Hyponatremia as a predictor of cognitive deterioration in hospitalized post-stroke patients

PURPOSE

Evidence is scarce regarding the association between hyponatremia and alterations in cognitive function among hospitalized older patients. We aimed to investigate the associations between hyponatremia and the baseline cognitive status, as well as the improvement in cognitive function, in hospitalized post-stroke patients.

METHODS

This retrospective cohort study included consecutive hospitalized post-stroke patients. Serum sodium concentrations were extracted from medical records based on blood tests performed within 24 h of admission, with hyponatremia defined as a serum sodium concentration < 135 mEq/L. The main outcomes included admission and discharge scores for cognitive levels, assessed through the cognitive domain of the Functional Independence Measure (FIM-cognition), as well as the score changes observed during the hospitalization period. Multivariate linear regression analyses were used to determine the association between hyponatremia and outcomes of interest, adjusted for potential confounders.

RESULTS

Data from 955 patients (mean age 73.2 years; 53.6 % men) were included in the analysis. The median baseline blood sodium level was 139 [137, 141], and 84 patients (8.8 %) exhibited hyponatremia. After full adjustment for confounders, the baseline hyponatremia was significantly and negatively associated with FIM-cognition values at admission (β = -0.009, p = 0.016), discharge (β = -0.038, p = 0.043), and the gain during hospital stay (β = -0.040, p = 0.011).

CONCLUSION

Baseline hyponatremia has demonstrated a correlation with decline in cognitive level over the course of rehabilitation in individuals after stroke. Assessing hyponatremia at the outset proves to be a pivotal prognostic indicator.

Prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia criteria in sarcopenic dysphagia: A retrospective cohort study

OBJECTIVE

The aim to examine the prevalence and prognosis of cachexia according to the Asian Working Group for Cachexia (AWGC) criteria in patients with sarcopenic dysphagia.

METHODS

A retrospective cohort study was conducted with 271 patients diagnosed with sarcopenic dysphagia out of 467 patients enrolled in the Japanese sarcopenic dysphagia database. Cachexia was diagnosed by the AWGC criteria. The AWGC criteria includes chronic diseases, either or both weight loss (2% or more over 3-6 mo) or low BMI (<21 kg/m2), and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>0.5 mg/dL). Outcomes were death, swallowing function as assessed by the Food Intake LEVEL Scale (FILS), and activities of daily living as assessed by the Barthel Index (BI) at follow-up.

RESULTS

The mean age was 84 (±8) y; 152 (56%) were female, and 97 (36%) had cachexia. In univariate analysis, death was significantly more common in the cachexia group (15% versus 2%, P ≤ 0.001). Logistic regression analysis showed that cachexia was independently associated with death (odds ratio: 3.557, 95% confidence interval: 1.010, 12.529). No significant differences were found in the presence or absence of cachexia in the FILS (7 versus 8, P = 0.849) and BI (55 versus 52.5, P = 0.892).

CONCLUSIONS

Cachexia was found in 36% of patients with sarcopenic dysphagia, and death was significantly higher in cachexia.

Associations between Baseline Hyponatremia and Activities of Daily Living and Muscle Health in Convalescent Stroke Patients

Objectives

Evidence is scarce regarding the association between hyponatremia and functional outcomes among older hospitalized patients. We aimed to evaluate the associations between baseline hyponatremia and improvement in activities of daily living (ADL) and muscle health in hospitalized post-stroke patients.

Methods

This retrospective cohort study included hospitalized post-stroke patients. Serum sodium concentrations were extracted from medical records based on blood tests performed within 24 h of admission, with hyponatremia defined as a serum sodium concentration below135 mEq/L. Primary outcome was the discharge ADL as assessed by the motor domain of the Functional Independence Measure (FIM-motor) and its corresponding gain during hospitalization. Other outcomes encompassed the discharge scores for skeletal muscle mass (SMI) and handgrip strength (HGS). Multivariate linear regression analyses were used to determine the association between hyponatremia and outcomes of interest, adjusted for potential confounders.

Results

Data from 955 patients (mean age 73.2 years; 53.6% men) were analyzed. The median baseline blood sodium level was 139 [interquartile range: 137, 141] mEq/L, and 84 patients (8.8%) exhibited hyponatremia. After full adjustment for confounders, baseline hyponatremia was significantly and negatively associated with FIM-motor at discharge (β=-0.036, P=0.033) and its gain during hospital stay (β=-0.051, P=0.033). Baseline hyponatremia exhibited an independent and negative association with discharge HGS (β=-0.031, P=0.027), whereas no significant association was found between baseline hyponatremia and discharge SMI (β=-0.015, P=0.244).

Conclusions

Baseline hyponatremia demonstrated a correlation with compromised ADL and muscle health in individuals undergoing rehabilitation after stroke.

Malnutrition and cachexia may affect death but not functional improvement in patients with sarcopenic dysphagia

PURPOSE

To investigate whether two factors, malnutrition and cachexia, affect swallowing function, activities of daily living (ADL), and death in sarcopenic dysphagia.

METHODS

Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia Database, 271 met the study eligibility criteria in a retrospective cohort study. Patients were divided into four groups based on whether they had cachexia according to the Asian Working Group for Cachexia (AWGC) criteria and malnutrition according to the Global Leadership Initiative on Malnutrition (GLIM) criteria. Multivariate analyses were performed to investigate the differences in changes in the Food Intake LEVEL Scale (FILS) and Barthel Index (BI) and death after follow-up between the malnutrition and cachexia group and the other groups.

RESULTS

The mean age was 83.7 ± 8.3 years, 119 (44%) were men and 152 (56%) were women. The median FILS at baseline was 7 and the median BI was 25. A total of 120 (44%) had malnutrition only, 54 (20%) had neither cachexia nor malnutrition, 12 (4%) had cachexia only, and 85 (31%) had both cachexia and malnutrition. Multivariate analyses showed no significant difference between the change in BI (P = 0.688) and the change in FILS (P = 0.928) between the malnutrition and cachexia group and the other groups; however, death increased significantly (P = 0.010).

CONCLUSION

Some patients diagnosed with cachexia were not malnourished, although many patients with cachexia were malnourished. While patients with both cachexia and malnutrition did not show significant improvement in ADL and swallowing function compared with patients without both conditions, the number of deaths increased significantly.

Definition, diagnosis, and treatment of respiratory sarcopenia

PURPOSE OF REVIEW

Skeletal muscle weakness and wasting also occurs in the respiratory muscles, called respiratory sarcopenia. Respiratory sarcopenia may lead to worse clinical indicators and outcomes. We present a novel definition and diagnostic criteria for respiratory sarcopenia, summarize recent reports on the association between respiratory sarcopenia, physical and nutritional status, and clinical outcomes, and provide suggestions for the prevention and treatment of respiratory sarcopenia.

RECENT FINDINGS

Recently, a novel definition and diagnostic criteria for respiratory sarcopenia have been prepared. Respiratory sarcopenia is defined as a condition in which there is both low respiratory muscle strength and low respiratory muscle mass. Respiratory muscle strength, respiratory muscle mass, and appendicular skeletal muscle mass are used to diagnose respiratory sarcopenia. Currently, it is challenging to definitively diagnose respiratory sarcopenia due to the difficulty in accurately determining low respiratory muscle mass. Decreased respiratory muscle strength and respiratory muscle mass are associated with lower physical and nutritional status and poorer clinical outcomes. Exercise interventions, especially respiratory muscle training, nutritional interventions, and their combinations may effectively treat respiratory sarcopenia. Preventive interventions for respiratory sarcopenia are unclear.

SUMMARY

The novel definition and diagnostic criteria will contribute to promoting the assessment and intervention of respiratory sarcopenia.

Impaired oral status is associated with sarcopenic obesity in post-stroke patients

PURPOSE

Oral problems and muscle health are indeed significant concerns in ageing populations. However, there is limited evidence concerning the association between these issues. The study's focus was to investigate the association between oral problems and sarcopenic obesity, wherein sarcopenia and obesity coexist concurrently, in post-stroke patients.

METHODS

This retrospective, observational, cross-sectional study included patients hospitalised for post-stroke rehabilitation. Oral problems were assessed using the Revised Oral Assessment Guide (ROAG). Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. Multiple linear regression analysis was used to examine the association between the ROAG and sarcopenic obesity after adjusting for confounding factors.

RESULTS

A total of 760 patients were included, with a mean (SD) age of 71 (9) years, of whom 408 (54.7%) were male. The median (interquartile range, 25th and 75th percentiles) ROAG was 11 [9, 13]. Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. Multivariate linear analysis showed that ROAG was significantly and positively associated with sarcopenic obesity (β = .091, P = .023), followed by obesity alone (β = .084, P = .044), and sarcopenia alone (β = .081, P = .037).

CONCLUSION

Oral problems were associated with sarcopenic obesity in post-stroke. Oral assessment and intervention may have a positive impact on ADL and QOL in post-stroke patients with sarcopenic obesity.

Cutoff value of the geniohyoid muscle mass to identify sarcopenic dysphagia by ultrasonography

PURPOSE

Determining the strength and area of the swallowing muscles is important in patients with sarcopenic dysphagia. Although the normative data on the strength of the swallowing muscles have been reported, those of the area of the geniohyoid muscle are poorly investigated. We investigated the cross-sectional area of the geniohyoid muscle in Japanese subjects without dysphagia using ultrasonography to determine the normative and cut-off values.

METHODS

142 subjects without dysphagia were included. The older group (age ≥ 65 years) included 36 (women 27/men 9) subjects, and the younger group (age ≤ 39 years) included 106 (women 54/men 52) subjects. The cross-sectional area of the geniohyoid muscle was measured by ultrasound. The mean of the younger group-2 standard deviation (SD) was calculated and used as a cut-off value for low swallowing muscle mass.

RESULTS

The mean (SD) of the area of the geniohyoid muscle of each group was as follows: older women group 167.2 (32.6) mm2, older men group 193.2 (49.5) mm2, younger women group 247.3 (37.4) mm2, younger men group 313.1 (59.2) mm2. The mean 2SD of the geniohyoid muscle area in the younger women group was 172.5 mm2 and in the younger men group 194.7 mm2.

CONCLUSION

We found that the cut-off value of the ultrasonographic cross-sectional area of the geniohyoid muscle was 172.5 mm2 for women and 194.7 mm2 for men. These values could be used as cut-off values for the mass of the geniohyoid muscle to identify patients with sarcopenic dysphagia.

Impact of Motivation for Eating Habits, Appetite and Food Satisfaction, and Food Consciousness on Food Intake and Weight Loss in Older Nursing Home Patients

BACKGROUND

This study analyzed data from the Long-term care Information system For Evidence (LIFE) database to examine the effects of motivation to eat, appetite and food satisfaction, and food consciousness on food intake and weight loss.

METHODS

Of the 748 nursing home residents enrolled in the LIFE database, 336 met the eligibility criteria for this cross-sectional study. Motivation to eat, appetite and food satisfaction, and food consciousness were rated on five-point Likert scales (e.g., good, fair, normal, not so good, and not good). We applied Spearman rank correlation coefficient and multiple regression analyses to analyze the relationships between these three items, daily energy and protein intake, and body weight loss over 6 months.

RESULTS

The mean participant age was 87.4±8.1 years and 259 (77%) were female. The required levels of care included-level 1, 1 (0%); level 2, 4 (1%); level 3, 107 (32%); level 4, 135 (40%); and level 5, 89 (27%). The mean daily energy intake was 28.2±7.8 kcal/kg. The mean daily protein intake was 1.1±0.3 g/kg. The mean weight loss over six months was 1.2±0.7 kg. We observed strong positive correlations among motivation to eat, appetite and food satisfaction, and food consciousness (r>0.8). These three items were significantly associated with higher daily energy intake but not with daily protein intake. Only appetite and food satisfaction were significantly associated with lower weight loss over six months.

CONCLUSION

The observed associations of appetite and food satisfaction suggest that these factors may be more important to assess than motivation to eat or food consciousness among older adult residents of long-term care facilities.

Polypharmacy, Potentially Inappropriate Medications, and Dysphagia in Older Inpatients: A Multi-Center Cohort Study

BACKGROUND

Although the relationship between medication status, symptomatology, and outcomes has been evaluated, data on the prevalence of polypharmacy and potentially inappropriate medications (PIMs) and the association of polypharmacy and PIMs with swallowing function during follow-up are limited among hospitalized patients aged ≥65 years with dysphagia.

METHODS

In this 19-center cohort study, we registered 467 inpatients aged ≥65 years and evaluated those with the Food Intake LEVEL Scale (FILS) scores ≤8 between November 2019 and March 2021. Polypharmacy was defined as prescribing ≥5 medications and PIMs were identified based on the 2023 Updated Beers Criteria. We applied a generalized linear regression model to examine the association of polypharmacy and PIMs with FILS score at discharge.

RESULTS

We analyzed 399 participants (median age, 83.0 years; males, 49.8%). The median follow-up was 51.0 days (interquartile range, 22.0-84.0 days). Polypharmacy and PIMs were present in 67.7% of and 56.1% of patients, respectively. After adjusting for covariates, neither polypharmacy (β = 0.05; 95% confidence interval [CI], -0.04-0.13, p=0.30) nor non-steroidal anti-inflammatory medications (β = 0.09; 95% CI, -0.02-0.19; p=0.10) were significantly associated with FILS score at discharge.

CONCLUSION

The results of this study indicated a high proportion of polypharmacy and PIMs among inpatients aged ≥65 years with dysphagia. Although these prescribed conditions were not significantly associated with swallowing function at discharge, our findings suggest the importance of regularly reviewing medications to ensure the appropriateness of prescriptions when managing older inpatients.

The barriers to interprofessional care for cancer cachexia among Japanese healthcare providers: A nationwide survey

BACKGROUND

Cancer cachexia is a severe complication of advanced malignancy, with few therapeutic options. To promote interprofessional care for cancer cachexia, healthcare providers' needs should be addressed in detail. This pre-planned subgroup analysis of the Global Educational Needs Evaluation: a systemic interprofessional study in cancer cachexia (GENESIS-CC) survey aimed to identify barriers to interprofessional care of cancer cachexia in Japan.

METHODS

A nationwide survey was electronically conducted for healthcare providers in oncological or general healthcare facilities from January to March 2021 in Japan. The Japanese Regional Advisory Board developed a barrier scoring system with 33 from the 58 original survey items to quantify six domains of barriers: (1) lack of confidence, (2) lack of knowledge, (3) barriers in personal practice, (4) barriers in perception, (5) barriers in team practice and (6) barriers in education. The largest possible barrier score was set at 100 points. We compared the scores by profession.

RESULTS

A total of 1227 valid responses were obtained from 302 (24.6%) physicians, 252 (20.5%) pharmacists, 236 (19.2%) nurses, 218 (17.8%) dietitians, 193 (15.7%) rehabilitation therapists and 26 (2.0%) other professionals. Overall, 460 (37.5%) were not very or at all confident about cancer cachexia care, 791 (84.1%) agreed or strongly agreed that care was influenced by reimbursement availability and 774 (81.9%) did not have cancer cachexia as a mandatory curriculum. The largest mean barrier score (± standard deviation) was 63.7 ± 31.3 for education, followed by 55.6 ± 21.8 for team practice, 43.7 ± 32.5 for knowledge, 42.8 ± 17.7 for perception and 36.5 ± 16.7 for personal practice. There were statistically significant interprofessional differences in all domains (P < 0.05), especially for pharmacists and nurses with the highest or second highest scores in most domains.

CONCLUSIONS

There is a need to improve the educational system and team practices of cancer cachexia for most Japanese healthcare providers, especially pharmacists and nurses. Our study suggests the need to reform the mandatory educational curriculum and reimbursement system on cancer cachexia to promote interprofessional care for cancer cachexia in Japan.

Psychological aspects of rehabilitation nutrition: A position paper by the Japanese Association of Rehabilitation Nutrition (secondary publication)

Psychological aspects of rehabilitation nutrition affect physical, cognitive, and social rehabilitation nutrition. When depression is recognized, not only pharmacotherapy and psychotherapy, but also non-pharmacological therapies such as exercise, nutrition, psychosocial, and other interventions can be expected to improve depression. Therefore, accurate diagnosis and intervention without overlooking depression is important. Psychological aspects of preventive rehabilitation nutrition is also important because depression can be partially prevented by appropriate exercise and nutritional management. Even in the absence of psychological negatives, increasing more psychological positives from a positive psychology perspective can be useful for both patients and healthcare professionals. Positive rehabilitation nutrition interventions can increase more psychological positives, such as well-being, through cognitive-behavioral therapy and mindfulness on their own, as well as through interventions on environmental factors. Consequently, physical, cognitive, and social positives are also expected to be enhanced.

Impact of rehabilitation dose on body mass index change in older acute patients with stroke: a retrospective observational study

Background

It is established that a low body mass index (BMI) correlates with a diminished home discharge rate and a decline in activities of daily living (ADL) capacity among elderly stroke patients. Nevertheless, there exists a paucity of knowledge regarding strategies to mitigate BMI reduction during the acute phase. This investigation seeks to elucidate the impact of rehabilitation dose, as determined by both physical and occupational therapy, on BMI alterations, positing that a heightened rehabilitation dose could thwart BMI decline.

Methods

This retrospective, observational study was conducted in the stroke unit of a university hospital. Enrollees comprised individuals aged ≥65 years, hospitalized for stroke, and subsequently relocated to rehabilitation facilities between January 2019 and November 2020. The percentage change in BMI (%ΔBMI) was calculated based on BMI values at admission and discharge. Multivariate multiple regression analysis was employed to ascertain the influence of rehabilitation dose on %ΔBMI.

Results

A total of 187 patients were included in the analysis, of whom 94% experienced a reduction in BMI during acute hospitalization. Following adjustment for sociodemographic and clinical factors, multivariable analyzes revealed a positive association between rehabilitation dose and %ΔBMI (β = 0.338, p < 0.001).

Conclusion

The findings of this study suggest that, in the context of acute stroke treatment, an augmented rehabilitation dose is associated with a diminished decrease in BMI.

Impact of registered dietitian and dental hygienist involvement on functional outcomes in patients with dysphagia: triad of rehabilitation, nutrition, and oral management

PURPOSE

To investigate whether the involvement of both registered dietitians and dental hygienists results in greater improvement in swallowing function and activities of daily living (ADL) in patients with dysphagia undergoing rehabilitation.

METHODS

Of 467 patients enrolled in the Japanese Sarcopenic Dysphagia database, 433 met the study eligibility criteria in a retrospective cohort study. Patients were divided into two groups based on whether or not they received intervention by both registered dietitians and dental hygienists. Outcomes were changes in the Food Intake Level Scale (FILS) and the Barthel Index (BI) at initial and follow-up assessments. Multiple regression analyses adjusted for age, sex, sarcopenia, dwelling, Charlson comorbidity index, malnutrition diagnosed by the Global Leadership Initiative on Malnutrition, and initial FILS or BI were conducted to examine the relationship between the involvement of both registered dietitians and dental hygienists.

RESULTS

The mean age was 80.5 and ± 10.7 years, and 222 were female. Both registered dietitians and dental hygienists were involved in 242 (57%) patients. Median and interquartile range changes in FILS and BI were 1 (0, 2) and 15 (0, 32.5), respectively. In multiple regression analyses, the change in the FILS was significantly higher in the involvement of both registered dietitians and dental hygienists (standardized coefficient = 0.075, P = 0.033), however, the change in the BI was not significantly different between the groups.

CONCLUSION

The involvement of both registered dietitians and dental hygienists improved swallowing function, but not ADL. Triad of rehabilitation, nutrition, and oral management may be useful for patients with dysphagia.

Impact of Poor Oral Health Status on Swallowing Function Improvement in Older Dysphagic Patients

Background This study aimed to explore the relationship between poor oral health status and improvement in swallowing function in older patients with dysphagia across various clinical settings, including acute and post-acute care environments. Methods This retrospective cohort study encompassed patients aged 65 years and older with dysphagia. Oral health status was assessed using the oral health assessment tool (OHAT) or the revised oral assessment guide (ROAG). In this study, an OHAT score of ≥3 or an ROAG score of ≥13 indicated poor oral health status. The primary outcome measured was the change in the food intake level scale (FILS) score, which reflects swallowing function, during the observation period. The association between changes in FILS score and poor oral health status was analyzed using a multivariable linear regression model. Results The study included 361 older patients with dysphagia (mean age 82.7 ± 7.7 years; 47.3% male), of whom 82.5% had poor oral health. A negative association was found between poor oral health status and improvement in FILS score at the endpoint (partial regression coefficient: -0.523, 95% confidence interval: -0.99 to -0.06, P=0.026). Conclusions Our findings underscore the negative impact of poor oral health status on the improvement of swallowing function and emphasize the importance of oral health interventions for older patients. Further study on oral health interventions' effects on improving swallowing function in older patients with dysphagia is warranted.

Change in phase angle is associated with improvement in activities of daily living and muscle function in patients with acute stroke

PURPOSE

The phase angle (PhA) is a simple index that reflects nutritional status and muscle quality. This study aimed to investigate the association between PhA changes and activities of daily living (ADL), muscle strength, and muscle mass in patients with acute stroke.

METHODS

This retrospective, observational, cross-sectional study included patients hospitalized for acute stroke. The primary outcome was functional independence measure (FIM) of motor gain. The secondary outcomes were changes in handgrip strength and skeletal muscle mass index (SMI) during hospitalization. Multivariate analysis was used to examine whether PhA changes were associated with outcomes, after adjusting for potential confounders.

RESULTS

Hundred and sixty one subjects (mean age 74.6 years, 92 men) were included in the study. Multivariate analysis showed that PhA change was significantly and positively correlated with the gain in FIM motor scores, both for men (β = 0.634, p < 0.001) and women (β = 0.660, p < 0.001). Furthermore, there were significant associations between PhA change and changes in handgrip strength for men (β = 0.222, p = 0.030) and women (β = 0.491, p < 0.001), as well as SMI for men (β = 0.556, p < 0.001) and women (β = 0.290, p = 0.025).

CONCLUSIONS

An increased phase angle was positively associated with ADL, muscle strength, and muscle mass at discharge in patients with acute stroke.

Impact of body mass index on outcomes of inpatients with vertebral compression fractures in Japan: A retrospective cohort study

AIM

The present study examined the relationship between body mass index and the ability to perform the activities of daily living in patients with vertebral compression fractures.

METHODS

A retrospective cohort analysis of patients aged >65 years hospitalized with a vertebral compression fracture was carried out using a nationwide database in Japan. Body mass index was categorized as underweight (<18.5 kg/m2 ), normal weight (18.5-22.9 kg/m2 ), overweight (23.0-27.4 kg/m2 ) and obese (≥27.5 kg/m2 ) according to the World Health Organization criteria for the Asia-Pacific region. The primary outcome was Barthel Index gain, namely, the change in the Barthel Index score at discharge from that at admission. Secondary outcomes were the length of hospital stay and readmission within 30 days of discharge.

RESULTS

Among 41 423 participants, 24.5% were classified as underweight, excluding those with missing body mass index data. The underweight group had a significantly lower Barthel Index gain than the normal, overweight and obese groups (median 20 vs 25 vs 30 vs 30, respectively, P < 0.001). The underweight group also had longer hospital stays and higher 30-day readmission rates than the other groups. A multivariable analysis showed that being underweight was independently associated with a Barthel Index gain -3.63 points (95% confidence interval -4.58 to -2.68) lower than normal weight. Furthermore, being underweight was an independent variable affecting the length of hospital stay and readmission within 30 days (P < 0.001).

CONCLUSIONS

In patients with vertebral compression fractures, being underweight leads to lower Barthel Index scores, longer hospital stays and increased readmissions within 30 days of discharge. Geriatr Gerontol Int 2023; 23: 788-794.

Sarcopenic Dysphagia and Simplified Rehabilitation Nutrition Care Process: An Update

Sarcopenic dysphagia is characterized by weakness of swallowing-related muscles associated with whole-body sarcopenia. As the number of patients with sarcopenia increases with the aging of the world, the number of patients with sarcopenic dysphagia is also increasing. The prevalence of sarcopenic dysphagia is high in the institutionalized older people and in patients hospitalized for pneumonia with dysphagia in acute care hospitals. Prevention, early detection and intervention of sarcopenic dysphagia with rehabilitation nutrition are essential. The diagnosis of sarcopenic dysphagia is based on skeletal and swallowing muscle strength and muscle mass. A reliable and validated diagnostic algorithm for sarcopenic dysphagia is used. Sarcopenic dysphagia is associated with malnutrition, which leads to mortality and Activities of Daily Living (ADL) decline. The rehabilitation nutrition approach improves swallowing function, nutrition status, and ADL. A combination of aggressive nutrition therapy to improve nutrition status, dysphagia rehabilitation, physical therapy, and other interventions can be effective for sarcopenic dysphagia. The rehabilitation nutrition care process is used to assess and problem solve the patient's pathology, sarcopenia, and nutrition status. The simplified rehabilitation nutrition care process consists of a nutrition cycle and a rehabilitation cycle, each with five steps: assessment, diagnosis, goal setting, intervention, and monitoring. Nutrition professionals and teams implement the nutrition cycle. Rehabilitation professionals and teams implement the rehabilitation cycle. Both cycles should be done simultaneously. The nutrition diagnosis of undernutrition, overnutrition/obesity, sarcopenia, and goal setting of rehabilitation and body weight are implemented collaboratively.

Ultrasound utilized by registered dietitians for body composition measurement, nutritional assessment, and nutritional management

BACKGROUND AND AIMS

Ultrasound has been used primarily as a tool for body composition measurement in the field of clinical nutrition. Although many recent reports have demonstrated that ultrasound could be a useful tool for nutritional assessment, it is not well incorporated into registered dietitians' (RDs) practice. The aim of this review was to summarize the usefulness of ultrasound in assessing body composition and nutritional status and in nutritional management by RDs.

METHODS

Studies on ultrasonography, nutritionists, body composition, nutritional assessment, and diet therapy was searched using the MEDLINE databases.

RESULTS

After reviewing the articles, we categorized them into the following topics; 1) principles of muscle measurement using the ultrasound, types of muscle that can be measured, 2) indices of muscle and muscle mass and quality as assessed using ultrasound and its relationship to nutritional indicator, 3) diagnosis of the Global Leadership Initiative on Malnutrition (GLIM) criteria malnutrition using ultrasound, 4) practical nutritional management using ultrasound and 5) education and issues for ultrasound implementation. Ultrasound can evaluate low body mass index, unintentional loss of body weight, low skeletal muscle mass index, decreased food intake/assimilation, and disease burden/inflammation, all which are essential items of the phenotypic and etiologic criteria of the GLIM.

CONCLUSION

Ultrasound may be useful for RDs to perform body composition measurement, nutritional assessment, and nutritional management. It will be important to identify the cutoff values for ultrasound-based measurements of muscle mass. In order for RDs to perform a body composition measurement, nutritional assessment, and nutritional management using ultrasound, educational issues need to be addressed.

Phase angle is associated with sarcopenic obesity in post-stroke patients

BACKGROUND & AIMS

Evidence is limited concerning the association between bioimpedance analysis-derived phase angle and sarcopenic obesity. This study examined this association in patients who underwent convalescent rehabilitation after stroke.

METHODS

This cross-sectional study included hospitalized patients with post-acute stroke. The phase angle was measured using a multifrequency bioimpedance analysis. Sarcopenic obesity was diagnosed according to the European Society of Clinical Nutrition and Metabolism/European Association for the Study of Obesity criteria. A multiple linear regression analysis was used to examine the association between the phase angle and sarcopenic obesity after adjusting for confounding factors. A receiver operating characteristic curve was used to calculate the optimal phase angle cutoff value for predicting sarcopenic obesity.

RESULTS

A total of 760 patients (median age 71 years; 352 women) were analyzed. The median (interquartile range, 25th and 75th percentiles) phase angle was 4.45° (4.10°, 4.88°). Sarcopenic obesity was diagnosed in 16 (3.9%) men, 18 (5.1%) women, and 34 (4.5%) patients overall. The multiple linear regression analysis showed that sarcopenic obesity (β = -0.185, p = 0.017) and sarcopenia (β = -0.121, p = 0.012) were significantly and negatively associated with the phase angle. Obesity was not significantly associated with the phase angle (β = -0.078, p = 0.094). The optimal cutoff value of the phase angle for diagnosing sarcopenic obesity was 4.29° (sensitivity 0.65, specificity 0.80, area under the curve [AUC] 0.79, 95% CI 0.77-0.87, p < 0.001) in men and 3.84° (sensitivity 0.67, specificity 0.84, AUC 0.81, 95% CI 0.79-0.86, p < 0.001) in women.

CONCLUSION

The phase angle was associated with sarcopenic obesity, and the cutoff values of the phase angle that could predict sarcopenic obesity were 4.29° for men and 3.84° for women. This simple and practical phase angle-based prediction of sarcopenic obesity can be useful in clinical practice.

Diagnosis and outcomes of cachexia in Asia: Working Consensus Report from the Asian Working Group for Cachexia

Chronic diseases often lead to metabolic disorders, causing anabolic resistance and increased energy consumption, which result in cachexia. Cachexia, in turn, can lead to major clinical consequences such as impaired quality of life, shortened life expectancy, and increased healthcare expenditure. Existing international diagnostic criteria for cachexia employ thresholds derived from Western populations, which may not apply to Asians due to differing body compositions. To address this issue, the Asian Working Group for Cachexia (AWGC) was initiated. The AWGC comprises experts in cachexia research and clinical practice from various Asian countries and aims to develop a consensus on diagnostic criteria and significant clinical outcomes for cachexia in Asia. The AWGC, composed of experts in cachexia research and clinical practice from several Asian countries, undertook three-round Delphi surveys and five meetings to reach a consensus. Discussions were held on etiological diseases, essential diagnostic items for cachexia, including subjective and objective symptoms and biomarkers, and significant clinical outcomes. The consensus highlighted the importance of multiple diagnostic factors for cachexia, including chronic diseases, either or both weight loss or low body mass index, and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>5 mg/L [0.5 mg/dL]). The AWGC proposed a significant weight change of 2% or more over a 3-6 month period and suggested a tentative cut-off value of 21 kg/m2 for low body mass index in diagnosing cachexia. Critical clinical outcomes were determined to be mortality, quality of life as assessed by tools such as EQ-5D or the Functional Assessment of Anorexia/Cachexia Therapy, and functional status as measured by the Clinical Frailty Scale or Barthel Index, with significant emphasis on patient-reported outcomes. The AWGC consensus offers a comprehensive definition and user-friendly diagnostic criteria for cachexia, tailored specifically for Asian populations. This consensus is set to stimulate future research and enhance the multidisciplinary approach to managing cachexia. With plans to develop further guidelines for the optimal treatment, prevention, and care of cachexia in Asians, the AWGC criteria are expected to drive research across chronic co-morbidities and cancer in Asia, leading to future refinement of diagnostic criteria.

The effect of anamorelin (ONO-7643) on cachexia in cancer patients: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Cachexia is associated with increased morbidity and mortality rates in patients with cancer. This meta-analysis aims to explore the effect of anamorelin on cancer cachexia markers.

METHODS

We searched MEDLINE/PubMed, SCOPUS, and WOS from their inception until 5 June 2022. A systematic search was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. We included trials investigating the effect of anamorelin on body weight, lean body mass, fat mass, insulin-like growth factor 1 (IGF-1), handgrip, quality of life insulin-like growth factor-binding protein 3 (IGFBP-3), and in patients with cancer. A random-effects model was run to pooled results.

RESULTS

Five articles providing 1331 participants were analyzed in this study. Pooled analysis revealed a significant increase in body weight (weighted mean difference (WMD): 1.56 kg, 95% confidence interval (CI): 1.20, 1.92; I2= 0%), lean body mass (WMD: 1.36 kg, 95% CI: 0.85, 1.86; I2= 53.1%), fat mass (WMD: 1.02 kg, 95% CI: 0.51, 1.53; I2= 60.7%), IGF-1 (WMD: 51.16 ng/mL, 95% CI: 41.42, 60.90, I2= 0%), and IGFBP-3 (WMD: 0.43 μg/mL, 95% CI: 0.17, 0.68, I2= 98.6%). Results showed no significant increase in appetite when analysis run on all studies without considering different doses 0.29 (95% CI: -0.30, 0.89, I2= 73.8%), however, there was a significant increase in appetite without heterogeneity and inconsistency 0.59 (95% CI: 0.32, 0.86; I2= 0%) in the 100 mg/day group compared to anamorelin non-user.

CONCLUSIONS

Patients with cancer who receive anamorelin as a treatment for cachexia showed a significant increase in body weight, lean body mass, fat mass, IGF-1, and IGFBP-3.

Anamorelin in Japanese patients with cancer cachexia: an update

PURPOSE OF REVIEW

Anamorelin was approved for production and marketing in Japan on 22 January 2021 for cancer cachexia in non-small-cell lung cancer, gastric cancer, pancreatic cancer, and colorectal cancer. The authors describe the updates of anamorelin for cancer cachexia in Japan.

RECENT FINDINGS

Recent evidence showed that anamorelin improved lean body mass, body weight, and appetite in patients with cancer cachexia in clinical practice. Anamorelin does not increase body weight in the severe-weight-loss group in cachectic patients with pancreatic cancer. Several case reports showed that anamorelin can cause cardiac adverse drug reactions. Among the cardiac adverse reactions, fatal arrhythmias should be monitored carefully even if it is the first dose. Anamorelin combined with nutrition, physical activity, and exercise may be more useful than anamorelin alone for treating cancer cachexia. An interim analysis from post-marketing all-case surveillance was performed; however, details have not yet been published. When anamorelin cannot be used for cancer cachexia, Kampo medicines can be considered as an option.

SUMMARY

Anamorelin has changed the clinical practice of cancer cachexia in Japan. The authors hope that anamorelin is available for other disease-related cachexia along with appropriate multidisciplinary interventions.

Pre-existing sarcopenia and swallowing outcomes in acute stroke patients

BACKGROUND & AIMS

This study aimed to investigate the associations of pre-existing sarcopenia with swallowing function, oral intake level, and aspiration pneumonia in patients with acute stroke.

METHODS

This observational study included patients (≥60 years of age) with acute ischemic stroke or intracerebral hemorrhage within 7 days of onset who were screened for sarcopenia, malnutrition, and swallowing difficulties in a stroke-care unit within 48 h of admission. Sarcopenia was defined by the Asian Working Group on Sarcopenia 2019 as having a low calf circumference, handgrip strength, and appendicular muscle mass index. The primary outcome was impaired oral intake (functional oral intake scale <5 points) at 3, 7, and 14 days after admission, and the secondary outcome was aspiration pneumonia during hospitalization.

RESULTS

We enrolled 350 patients (median age of 77 years; 63% males) who underwent the aforementioned screening. Sarcopenia was diagnosed in 34% of patients, and malnutrition was found in 66% of patients with sarcopenia. When compared with the comparison group (defined as patients with either or both normal calf circumference and handgrip strength), the sarcopenia group had significantly lower tongue pressure and a higher prevalence of dysphagia. Sarcopenia was associated with functional oral intake scale <5 at 7 days (adjusted odds ratio [OR], 4.72; 95% confidence interval [CI], 1.91-11.71); p = 0.002) and 14 days (adjusted OR, 3.93; 95% CI, 1.47-10.53; p = 0.006) and with aspiration pneumonia during hospitalization (adjusted OR, 6.12; 95% CI, 1.63-22.94; p = 0.007).

CONCLUSION

Acute stroke patients with sarcopenia may have weakness of the swallowing-related muscles which may lead to impaired oral intake and aspiration pneumonia.