Working Group on Functional Outcome Measures for Clinical Trials. Functional outcomes for clinical trials in frail older persons: time to be moving

Mortality Outcomes and Contributing Risk Factors in Patients with Hospital-Associated Disability

Background/Objectives: Hospital-associated disability (HAD), a functional decline following acute hospitalization, is a common complication associated with mortality and unfavorable prognoses in patients admitted to acute care hospitals. However, few studies have investigated mortality and associated factors in patients with HAD and have been limited by inconsistent HAD assessment tools and criteria. This study investigated mortality and risk factors in patients with HAD using specific criteria. Methods: This retrospective study evaluated patients referred to the Department of Rehabilitation Medicine with suspected HAD between June 2022 and March 2023. The collected data included medical histories, diagnostic tests for HAD (including muscle strength, balance, and modified Barthel Index), and bioelectrical impedance analysis (BIA). Multivariate logistic regression analysis was conducted to identify factors associated with mortality. Kaplan-Meier survival curves were constructed for mortality at 3 and 7 months. Results: A total of 455 patients were identified, among which 206 patients diagnosed with HAD (73.1 ± 12.5 years) were included in the analysis. The 3-month mortality rate was 27.2%. In the multivariate analysis, male sex (odds ratio (OR), 3.23; p < 0.01), a history of cancer (OR, 2.18; p < 0.05), and a low phase angle (OR, 0.69; p < 0.05) were significantly associated with mortality. A phase angle < 2.9° on BIA was associated with a significant increase in 3-month (hazard ratio (HR), 1.85; 95% confidence interval (CI), 1.06-3.23) and 7-month (HR, 2.80; 95% CI, 1.75-4.98) mortality. Conclusions: Patients with HAD had a high mortality rate, with several factors, particularly low BIA phase angles, associated with increased mortality.

Changes in real-world walking speed following 60-day bed-rest

The aim of this work was to explore whether real-world walking speed (RWS) would change as a consequence of 60-day bed-rest. The main hypothesis was that daily RWS would decrease after the bed-rest, with a subsequent recovery during the first days of re-ambulation. Moreover, an exploratory analysis was done in order to understand whether there is an agreement between the loss in RWS after bed-rest and the loss in the maximum oxygen uptake capacity (VO2max), or the loss in maximal vertical jump power (JUMP) respectively. Twenty-four subjects were randomly assigned to one of three groups: a continuous artificial gravity group, an intermittent artificial gravity group, or a control group. The fitted linear mixed effects model showed a significant decrease (p < 0.001) of RWS after the 60-day bed-rest and a subsequent increase (p < 0.001) of RWS during the 14-day recovery period in the study facility. No or little agreement was found between the loss in RWS and the loss in VO2max capacity or the loss in maximal vertical jumping power (RWS vs. VO2max: p = 0.81, RWS vs. JUMP: p = 0.173). Decreased RWS after bed-rest, with a follow-up recovery was observed for all three groups, regardless of the training intervention. This suggests that RWS, also in these settings, was able to reflect a de-conditioning and follow-up recovery process.

Inclusion of functional measures and frailty in the development and evaluation of medicines for older adults

The International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) E7, the guidance for the conduct of clinical trials in people older than age 65 years, dates from 1994. Since then, the inclusion of older people in clinical trials has hardly improved, particularly for the oldest old age group (individuals older than age 75 years), which is the fastest growing demographic bracket in the EU. Even though most medications are taken by this group, relevant endpoints and safety outcomes for this cohort are rarely included and reported, both in clinical trials and regulatory approval documents. To improve the critical appraisal and the regulatory review of medicines taken by frail older adults, eight recommendations are presented and discussed in this Health Policy. These recommendations are brought together from different perspectives and experience of the treatment of older patients. On one side, the perspective of medical practitioners from various clinical disciplines, with their direct experience of clinical decision making; on the other, the perspective of regulators assessing the data submitted in medicine registration dossiers, their relevance to the risk-benefit balance for older patients, and the communication of the findings in the product information. Efforts to improve the participation of older people in clinical trials have been in place for more than a decade, with little success. The recommendations presented here are relevant for stakeholders, authorities, pharmaceutical companies, and researchers alike, as the implementation of these measures is not under the capacity of a single entity. Improving the inclusion of frail older adults requires awareness, focus, and action on the part of those who can effect a much needed change.

In-Hospital Fall Risk Prediction by Objective Measurement of Lower Extremity Function in a High-Risk Population

OBJECTIVES

Limited data exist regarding association between physical performance and in-hospital falls. This study was performed to investigate the association between physical performance and in-hospital falls in a high-risk population.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The study population consisted of 1200 consecutive patients with a median age of 74 years (50.8% men) admitted to a ward with high incidence rates of falls, primarily in the departments of geriatrics and neurology, in a university hospital between January 2019 and December 2021.

METHODS

Short Physical Performance Battery (SPPB) was measured after treatment in the acute phase. As the primary end point of the study, the incidence of in-hospital falls was examined prospectively based on data from mandatory standardized incident report forms and electronic patient records.

RESULTS

SPPB assessment was performed at a median of 3 days after admission, and the study population had a median SPPB score of 3 points. Falls occurred in 101 patients (8.4%) over a median hospital stay of 15 days. SPPB score showed a significant inverse association with the incidence of in-hospital falls after adjusting for possible confounders (adjusted odds ratio for each 1-point decrease in SPPB: 1.19, 95% CI 1.10-1.28; P < .001), and an SPPB score ≤6 was significantly associated with increased risk of in-hospital falls. Inclusion of SPPB with previously identified risk factors significantly increased the area under the curve for in-hospital falls (0.683 vs. 0.740, P = .003).

CONCLUSION AND IMPLICATIONS

This study demonstrated an inverse association of SPPB score with risk of in-hospital falls in a high-risk population and showed that SPPB assessment is useful for accurate risk stratification in a hospital setting.

Effects of resistance training on muscular strength, endurance, body composition and functional performance among sarcopenic patients: a systematic review

Background

Sarcopenia, a gradual loss of muscle mass and strength associated with ageing, contributes to a decline in physical abilities, increase in disability and frailty and loss of functional independence. This functional deterioration which comes with ageing, can be slowed in pace with exercise.

Objective

The objective of the current review was to thoroughly search for literature assessing impact of RT on physical performance, body composition, muscle strength and endurance in sarcopenic elderly patients.

Methods

PubMed, Scopus, Web of Science, and PEDro databases were brought in use for a thorough search for articles published from 2010 to 2023. Two researchers independently retrieved data from studies that complied with the inclusion and exclusion criteria, while they also evaluated quality of the evidence.

Results

In total, 14 studies with 742 patients with mean age of 72.4 ± 9.22 years were included in the analysis for this review. Results indicate, RT improves body composition (p = 0.001), functional performance (p 0.001), postural stability (p = 0.005) and muscle strength (p 0.001) in elderly sarcopenic patients.

Conclusion

A promising intervention for the management of sarcopenia is RT. To yield RT's positive effects, a well-designed prescription is the need of the hour, just like it is with other treatment strategies.

Nutritional rehabilitation after acute illness among older patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Acute illness can lead to disability and reduced quality of life in older patients. The aim of this systematic review was to evaluate the effect of nutritional rehabilitation provided during and after hospitalisation for an acute event on functional status, muscle mass, discharge destination and quality of life of older patients.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42021264971). Articles were searched using Scopus, Medline, Google Scholar and Clinical.

TRIALS

gov. For studies included in the meta-analysis, Hedges'g standardized mean difference effect size was calculated and transformed in odds ratios.

RESULTS

We identified 7383 articles, of which 45 publications (41 trials, n = 8538 participants, mean age 80.35 ± 7.01 years.) were eligible for the systematic review. Patients were hospitalized for acute medical diseases (n = 6925) and fractures (n = 1063). The interventions included supplementation with a fixed amount of oral nutritional supplements (ONS, n = 17 trials), individualized diet plan (n = 3), combination of physical exercise with nutrition therapy (n = 14 trials), combination of anabolic agents with nutrition therapy (n = 5 trials). Overall nutritional rehabilitation improved functional status (Odds ratio 1.63 [1.15; 2.3], p = 0.003) and muscle mass (Odds ratio 2.61 [1.22; 5.5], p = 0.01), but not the quality of life or the discharge destination.

CONCLUSION

Nutritional rehabilitation was found to improve functional status and muscle mass. There is a need for larger studies involving older hospitalized patients.

Systematic review: the role of frailty in advanced chronic liver disease

BACKGROUND

Frailty is a known predictor of outcome and mortality in patients undergoing liver transplantation. However, most patients remain unsuitable transplant candidates. It is not yet known if the assessment of frailty in non-transplant candidates can aid prognostication.

AIM

To collate and interrogate the various frailty tools presently used to predict mortality in the non-transplant cirrhosis setting.

METHODS

A comprehensive review of MEDLINE and EMBASE databases for articles published from inception to March 2022 was undertaken, excluding those where patients underwent transplantation or had hepatocellular carcinoma.

RESULTS

We identified 12 observational cohort studies, featuring 9 frailty indices. These were from various global healthcare settings and of fair or good quality. Most were objective tools utilising clinician-based assessments. All frailty scores predicted prognosis, with variability in the method of application, and utilisation in long- or short-term mortality. Three studies directly compared different indices in the same population. There was some evidence that simple tools could perform as well, if not better, than more complex, time-consuming scores.

CONCLUSIONS

Various frailty tools can reproducibly evaluate mortality in patients with cirrhosis who are ineligible for transplant. However, further prospective head-to-head comparative studies are needed. In addition to determining model utility, studies should focus on important relative considerations which may limit widespread implementation including, ease of use and limited resources, given the global disparity of liver care provision. These tools may positively identify specific patient cohorts at risk of impending deterioration, thereby stratifying those patients likely to benefit from early integration with palliative care.

Effects of muscle mass and muscle quality estimated by phase angle on functional outcomes in older patients undergoing rehabilitation: A prospective cohort study

BACKGROUND

Both skeletal muscle mass and muscle quality are important predictors of poor prognosis in older patients. However, the effects of muscle mass and muscle quality estimated by the phase angle (PhA) on functional outcomes in older patients undergoing rehabilitation have yet to be reported. This study aimed to investigate whether appendicular skeletal muscle index (SMI) and muscle quality estimated by PhA were independently associated with activities of daily living (ADL) and physical function in older patients undergoing rehabilitation.

METHODS

This prospective cohort study included older patients in a subacute rehabilitation hospital (n = 443). Baseline SMI and PhA were measured using bioelectrical impedance analysis, and low SMI or low PhA were determined using each cutoff value. The primary outcomes were ADL abilities measured using the functional independence measure for motor function (FIM-M) score and physical function measured using the short physical performance battery (SPPB) score at hospital discharge. Association between low SMI and low PhA and FIM-M or SPPB scores at discharge were determined using multiple regression analysis adjusted for confounding factors.

RESULTS

There were significant differences between the normal- and low-PhA groups in the FIM-M and SPPB scores at discharge (P < 0.001). In multiple regression analysis, low PhA was independently associated with FIM-M (β = -0.109, P = 0.013) and SPPB scores (β = 0.535, P < 0.001) at discharge; however, low SMI was not independently associated with these functional outcomes.

CONCLUSION

Decreased muscle quality estimated by the PhA was independently associated with poor ADL abilities and poor physical function in older patients undergoing rehabilitation.

Effectiveness of a Supervised Group-Based Otago Exercise Program on Functional Performance in Frail Institutionalized Older Adults: A Multicenter Randomized Controlled Trial

BACKGROUND AND PURPOSE

Because of its high prevalence and association with negative health-related outcomes, frailty is considered one of the most important issues associated with human aging and its mitigation is among the essential public health goals for the 21st century. However, very few studies have focused on institutionalized older adults, despite the knowledge that frailty can be reversible when identified and treated from its earliest stages. Therefore, the objective of this study was to evaluate the effects of a supervised group-based multicomponent exercise program intervention with or without oral nutritional supplementation on functional performance in frail institutionalized older adults.

METHODS

This was a multicenter randomized controlled trial study with a 6-month intervention period. A total of 111 frail institutionalized older adults (75 years or older) who met at least 3 of the 5 Fried frailty criteria were randomly allocated to the control group (CG; n = 34, mean age = 87.3 ± 5.3 years), a supervised group-based multicomponent Otago Exercise Program group (OEP; n = 39, mean age = 86 ± 5.9 years), or a supervised group-based multicomponent exercise program intervention with oral nutritional supplementation (OEP+N; n = 38, mean age = 84.9 ± 6 years). Measurements included the Timed Up and Go test (TUG), Berg Balance Scale (BBS), Short Physical Performance Battery, repeated chair stand test (STS-5), handgrip strength (HGS), 10-m walking test, and 6-minute walking test, both at baseline and after the 6-month intervention period.

RESULTS AND DISCUSSION

The between-group analysis by 2-way analysis of covariance showed significant improvement in the TUG [{OEP vs CG: -8.2 seconds, 95% CI [-13.3 to -2.9]; P < .001}; {OEP vs OEP+N: -7.3 seconds, 95% CI [-12.4 to -2.2]; P = .002}], BBS [{OEP vs CG; 8.2 points, 95% CI [5.2 to 11.2]; P < .001}; [{OEP+N vs CG: 4.6 points, 95% CI [1.6 to 7.6]; P < .001}; {OEP vs OEP+N: 3.5 points, 95% CI [0.6 to 6.5]; P = .011}], and HGS [{OEP vs CG: 3.4 kg, 95% CI [1.5 to 5.3]; P < .001}; {OEP+N vs CG: 3.6 kg, 95% CI [1.7 to 5.5]; P < .001}]. Additionally, the within-group analysis showed a significant improvement in the TUG (-6.9 seconds, 95% CI [-9.8 to -4.0]; P < .001) and BBS (4.3 points, 95% CI [2.6 to 5.9]; P < .001) in the OEP group. A significant decrease in the BBS and HGS was shown in the CG.

CONCLUSIONS

A 6-month supervised group-based multicomponent exercise intervention improved the levels of mobility, functional balance, and HGS in frail institutionalized older adults. Further research will be required to evaluate the nutritional supplementation effects on functional performance to better determine its clinical applicability for tackling frailty.

The Effectiveness of Frailty Intervention for Older Patients with Frailty during Hospitalization

OBJECTIVES

This study aims to assess the effectiveness of a multidomain intervention program on the change in functional status of hospitalized older adults.

DESIGN

This single-arm, prospective, non-randomized interventional study investigates the efficacy of a multidomain interventional program including cognitive stimulation activity, simple exercises, frailty education, and nutrition counseling.

SETTING AND PARTICIPANTS

At a tertiary hospital in southern Taiwan, 352 eligible patients were sequentially enrolled. Included patients were aged ≥65 years (mean age, 79.6 ± 9.0 years; 62% male), scored 3-7 on the Clinical Frailty Scale (CFS), and were hospitalized in the geriatric acute ward.

INTERVENTION

Those receiving standard care (physical rehabilitation and nutrition counseling) during January-July 2019 composed the historical control group. Those receiving the multidomain intervention during August-December 2019 composed the intervention group.

MEASUREMENTS

The primary outcome was the change in activities of daily life (ADL) and frailty status, as assessed by Katz Index and Clinical Frailty Scale, with using the generalized estimating equation model. The length of hospital stay, medical costs, and re-admission rates were secondary outcomes.

RESULTS

Participants undergoing intervention (n = 101; 27.9%) showed greater improvements in the ADL and CFS during hospitalization (ADL adjusted estimate, 0.61; 95% CI, 0.11-1.11; p = 0.02; CFS adjusted estimate, -1.11; 95% CI, -1.42- -0.80; p < 0.01), shorter length of hospital stay (adjusted estimate, -5.00; 95% CI, -7.99- -2.47; p < 0.01), lower medical costs (adjusted estimate, 0.58; 95% CI, 0.49-0.69; p < 0.01), and lower 30- and 90-day readmission rates (30-day adjusted OR [aOR], 0.12; 95% CI, 0.27-0.50; p < 0.01; 60-day aOR, 0.04; 95% CI, 0.01-0.33; p < 0.01) than did controls.

CONCLUSIONS

Participation in the multidomain intervention program during hospitalization improved the functional status and decreased the hospital stay length, medical costs, and readmission rates of frail older people.

Physical and Quality of Life Changes in Elderly Patients after Laparoscopic Surgery for Colorectal Cancer-A Prospective Cohort Study

Background-The incidence of colorectal cancer is increasing among elderly people, where postoperative complications are frequent. Methods-We evaluated postoperative physical and quality of life changes in elderly patients undergoing laparoscopic surgery for colorectal cancer. A prospective cohort study was performed in 31 colorectal cancer patients ≥60 years who were scheduled for laparoscopic surgery due to colorectal cancer. Outcomes were measured one month preoperative (T1), three days postoperative (T2) and one month postoperative (T3). Results-The largest early postoperative (from T1 to T2) declines were observed for isometric knee extension strength (33.1%), 30 s Chair Stand Test (27.9%) and handgrip strength (16.9%). Significant reductions in quality of life measured with the QLQ-C30 summary score and the EQ 5D index score were found between T1-T3 and T1-T2, respectively. Conclusions-A decline in isometric knee extension strength, 30 s Chair Stand Test, handgrip strength and quality of life is evident in elderly patients in the days following laparoscopic surgery for colorectal cancer. Preoperative values are recovered one month after surgery for all the outcomes, except for isometric knee extension, which should receive especial attention.

Use of handgrip strength measurement as an alternative for assessing chewing function in people with dementia

Background

Chewing ability and handgrip strength can be independent explanatory factors of physical fitness. The usability of measurement procedures for assessing chewing function in people with dementia seems to be limited. This study aimed to show an association between handgrip strength and chewing function to enable the use of handgrip strength measurement as an alternative for determining chewing parameters in people with dementia. 

Methods

The data analysed here are part of the OrBiD (Oral Health, Bite Force and Dementia) pilot study. A total of 120 participants were assigned to five evaluation groups based on their cognitive abilities using the Mini-Mental State Examination (MMSE). The MMSE groups in this data analysis were “no dementia” (noDem, MMSE 28–30), “mild cognitive impairment” (mCI, MMSE 25–27), and “mild dementia” (mDem, MMSE 18–24). Handgrip strength, maximum occlusal force, and chewing efficiency were measured. 

Results

The Mini-Mental State Examination scores among all participants (n = 71) resulted in a median of 27 and a range of 18–30. An association between maximum handgrip strength and the cognitive impairment of the participants was shown. Nevertheless, the use of handgrip strength measurement as an alternative for determining chewing function was not verified in this study.

Conclusions

The feasibility and reliability of chewing function measurements in people with dementia should be investigated. Existing measurement procedures may need to be adapted or new assessments may need to be developed to be usable in people with dementia.

Trial registration

ClinicalTrials.gov NCT03775772.

Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial

Background

Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as ‘Potentially Inappropriate Medications’ (PIMs) and ‘Potential Prescribing Omissions’ (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established.

Methods

As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the ‘Screening Tool of Older Persons’ Prescription Criteria / Screening Tool To Alert to Right Treatment’ (STOPP/START) Version 2, with functional disability assessed using the ‘World Health Organization Disability Assessment Schedule 2.0’ (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity.

Results

Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis.

Conclusions

The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.

Prevalence of sarcopenia in patients with gynecological cancer

BACKGROUND

The aim of the study was to investigate a prevalence of sarcopenia in patients with gynecological cancer in accordance with current diagnostic criteria of sarcopenia.

METHODS

A series of 513 patients with gynecological cancer who were intended to newly receive initial or salvage treatment were recruited in a prospective study. Eligible patients were examined with dual energy X-ray absorptiometry and underwent handgrip strength test and the Short Physical Performance Battery before treatment. Sarcopenia was defined as both low skeletal muscle mass (skeletal muscle mass index) and low muscle strength (handgrip strength of <18.0 kg) or both low skeletal muscle mass index and low physical performance (Short Physical Performance Battery score of ≤9).

RESULTS

A total of 475 patients (92.6%) were completely assessed in this study. Eligible patients' median age was 60 years (range: 29-89 years). Frequencies of patients with low skeletal muscle mass index, low hand grip strength and low Short Physical Performance Battery were 118 (24.8%), 70 (14.7%) and 80 (16.8%), respectively. Sarcopenia was finally identified in 45 patients (9.5%), which accounted for 38.1% of patients with low skeletal muscle mass index, 64.3% of the patients with low hand grip strength and 56.3% of the patients with low physical performance, respectively.

CONCLUSIONS

The prevalence of sarcopenia of 9.5% in patients with gynecological malignancy who were scheduled to newly receive an initial or a salvage treatment. A large-scale, nation-wide study might be planned to elucidate an accurate prevalence of sarcopenia among gynecologic cancer patients.

Efficacy and Safety of Acute Phase Intensive Electrical Muscle Stimulation in Frail Older Patients with Acute Heart Failure: Results from the ACTIVE-EMS Trial

As frailty in older patients with acute heart failure (AHF) has an adverse effect on clinical outcomes, the addition of electrical muscle stimulation (EMS) to exercise-based early rehabilitation may improve the effects of treatment. Post hoc analysis was performed on a randomized controlled study for clinical outcomes and prespecified subgroups (ACTIVE-EMS: UMIN000019551). In this trial, 31 AHF patients aged ≥ 75 years with frailty (Short Physical Performance Battery [SPPB] score 4–9) were randomized 1:1 to receive treatment with an early rehabilitation program only (n = 16) or early rehabilitation with add-on EMS therapy (n = 15) for 2 weeks. Changes in physical function and cognitive function between baseline and after two weeks of treatment were assessed. There were no adverse events during the EMS period. The EMS group showed significantly greater changes in quadriceps’ isometric strength and SPPB compared to the control group, and EMS therapy showed uniform effects in the prespecified subgroups. There were no significant differences in the changes in other indexes of physical function and cognitive function between groups. There was no significant difference in the rate of heart failure hospitalization at 90 days between groups. In conclusion, older AHF patients with frailty showed greater improvement in lower extremity function with the addition of EMS therapy to early rehabilitation without adverse events.

The Aging Study of Pyeongchang Rural Area (ASPRA): Findings and Perspectives for Human Aging, Frailty, and Disability

The Aging Study of Pyeongchang Rural Area (ASPRA) is a population-based, prospective cohort study of older adults in Pyeongchang, South Korea. Since the initial enrollment of 382 participants, the ASPRA has been maintained and has conducted comprehensive geriatric assessments annually, gradually expanding its population and coverage area. As a cohort study of aging-related conditions and their functional consequences, the ASPRA leveraged Pyeongchang's relatively low annual population movement rate and its healthcare delivery system, which was largely maintained by community health posts. Since its establishment, the ASPRA has reported numerous observational and multicomponent intervention studies on functional decline, geriatric syndrome, and frailty. Here, we discuss the findings and perspectives of ASPRA studies. We hope that the ASPRA enables the further implementation of a longitudinal study design on geriatric parameters and the development of public health strategies targeting aging-related conditions, especially in resource-limited community settings.

Muscle Thickness and Echo Intensity by Ultrasonography and Cognitive and Physical Dimensions in Older Adults

The purpose of the present study was to investigate the associations between muscle thickness and echo intensity with cognitive and physical dimensions like functional capacity measured in older people. This cross-sectional study involved 20 older adults (15 women and 5 men, mean age ± SD: 85 ± 7 years, body mass index: 25 ± 3 kg/m²) from a geriatric centre in Malaga (Spain). Anthropometric measurements, cognitive assessment with Pfeiffer Short Portable Mental Status Questionnaire and Motor Memory test, Physical Performance with Short Physical Performance Battery, and muscle strength were tested. Additionally, using B-mode ultrasonography, images of wrist flexors, biceps brachii, rectus femoris, vastus lateralis, medial gastrocnemius, and tibialis anterior were captured, and muscle thickness and echo intensity variables were extracted. An association between muscle parameters assessed by ultrasonography and cognitive and physical dimensions were found in older people. Echo intensity was the best predictor in a set of regression models with different muscle parameters and a battery of cognitive and physical tests in older people. Echo intensity adjusted by handgrip strength could be a low cost and ambulatory index and an indirect and reversible indicator of functional capacity.

Muscle Strength and Physical Performance Are Associated with Reaction Time Performance in Older People

Background: Functional mobility and muscle strength are well known risk factors for sarcopenia. Furthermore, possible associations have been suggested between predisposing factors of sarcopenia and reaction time among the elderly. This study aims to analyze possible associations of functional mobility and muscle strength and reaction times in a population of people aged >60 years. Methods: A total of 290 older people (69.35 ± 5.55 years) participated in this study. The following parameters were assessed: optoacoustic lower-limb reaction time (OALLRT); acoustic lower-limb reaction time (ALLRT); optic lower-limb reaction time (OLLRT, using an optical detection system), functional mobility (through the timed up-and-go test) and muscle strength (using a dynamometer). Results: Our results show that lower values of muscle strength were associated with increased reaction times in OALLRT (β = −0.170; 95% confidence interval −0.011–0.000; R² = 0.237; p = 0.035) and in ALLRT (β = −0.228; 95% confidence interval −0.011–0.002; R² = 0.199; p = 0.006). Conclusion: Increased muscle strength (which at low values are risk factors for sarcopenia) was associated with decreased reaction times in people >60 years of age.

Impact of current or past physical activity level on functional capacities and body composition among elderly people: a cross-sectional analysis from the YMCA study

Background

Physical activity (PA) is recognized as important predictor of healthy aging. However, the influence of the type of voluntary PA as well as age or sex in this relationship is unclear. Thus, we assess the association between current and past PA level and physical performances among voluntary active older adults.

Methods

Functional capacities (timed Up and Go, sit-to-stand, alternate step test, unipodal balance, grip strength, knee extension strength, estimated muscle power and VO2 max) as well as body composition (DXA: total and appendicular lean masses (LM; kg), fat mass (FM; %)) were measured. Current and last 5-years PA level (time spent on total, aerobic, resistance and body & mind activities) were assessed using an interview. Multiple regressions, adjusted on age, sex and BMI, were performed to assess the relationship between current or past PA level and physical performances. Sub-group analysis, according to the sex (men/women) or age (< 65 yrs. vs. ≥65 yrs) were performed.

Results

525 subjects (age:61.7 ± 8.1 yrs.; women:68.9%; BMI:26.4 ± 4.8 kg/m²) were enrolled in this study. After adjustment on confounding factors, total current PA level has positive impact on total FM (β = − 2.09, p = 0004) and balance (β = 0.10; p = 0.05). Moreover, current body & mind activities influence total LBM (β = − 0.22, p = 0.02) and balance (β = 0.17; p = 0.001) whereas resistance activities influence total LBM (β = 0.17; p = 0.05), FM (β = − 0.16; p = 0.04) and sit-to-stand capacities (β = − 0.10; p = 0.05). Globally, these results were more pronounced in women than in men and among people aged over 65 years. Past level of PA has low impact on functional capacities and body composition, regardless of sex. Among people < 65 years, there is no relationship between time spent on total PA and functional capacities or body composition. However, a significant correlation was found between past total PA and balance (r=` 0.19; p = 0.01), alternate-step test (r = 0.24; p = 0.02) and VO2max (r = 0.19; p = 0.02) in people aged over 65 years. More precisely, the past time spent on aerobic and resistance activities influence balance (r = 0.16; p = 0.03 and r = 0.15; p = 0.04, respectively) after 65 yrs. old.

Conclusion

Even if physical activity history has little influence on physical aging process, being active is associated with body composition and functional capacities, especially among women aged 65 years and over.

Characteristics of the Electrophysiological Properties of Neuromuscular Motor Units and Its Adaptive Strategy Response in Lower Extremity Muscles for Seniors with Pre-Sarcopenia: A Preliminary Study

Older adults with sarcopenia, which is an aging-related phenomenon of muscle mass loss, usually suffer from decreases in both strength and functional performance. However, the causality between function loss and physiological changes is unclear. This study aimed to explore the motor unit characteristics of the neurological factors between normal subjects and those with sarcopenia. Five risk-sarcopenia (age: 66.20 ± 4.44), five healthy (age: 69.00 ± 2.35), and twelve young (age: 21.33 ± 1.15) participants were selected. Each participant performed knee extension exercises at a 50% level of maximal voluntary isometric contraction. Next, electromyogram (EMG) signals were collected, and information on each parameter—e.g., motor unit number, recruitment threshold, the slope of the mean firing rate to recruitment threshold, y-intercept, firing rate per unit force, and mean motor unit firing rate (MFR)—was extracted to analyze muscle fiber discrimination (MFD). Meanwhile, force variance was used to observe the stability between two muscle groups. The results suggested that there was no difference between the three groups for motor unit number, recruitment threshold, y-intercept, mean firing rate, and motor unit discrimination (p > 0.05). However, the slope of MFR and firing rate per unit force in the risk-sarcopenia group were significantly higher than in the young group (p < 0.05). Regarding muscle performance, the force variance in the non-sarcopenia group was significantly higher than the young group (p < 0.05), while the risk-sarcopenia group showed a higher trend than the young group. This study demonstrated some neuromuscular characters between sarcopenia and healthy elderly and young people when performing the same level of leg exercise tasks. This difference may provide some hints for discovering aging-related strength and function loss. Future studies should consider combining the in vivo measurement of muscle fiber type to clarify whether this EMG difference is related to the loss of muscle strength or mass before recruiting symptomatic elderly participants for further investigation.

Construct Validity, Test-Retest Reliability, Sensitivity to Change, and Feasibility of the Patient-Specific Functional Scale in Acutely Hospitalized Older Patients With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

The Patient-Specific Functional Scale (PSFS) as an individualized patient-reported outcome measure may allow to assess limitations and changes in self-determined functional activities most important to an older patient in the acute care setting. However, its clinimetric properties have not yet been evaluated in these patients. The study aimed to investigate the construct validity, test-retest reliability, sensitivity to change, and feasibility of the PSFS in acutely hospitalized older patients with and without cognitive impairment (CI).

METHODS

The clinimetric properties of the PSFS were investigated by secondary data analysis from a prospective observational cohort study examining physical activity and mobility in acutely hospitalized older patients. In this analysis, 120 older patients-83.0 (6.4) years-with (Mini-Mental State Examination [MMSE] 18-23, n = 52) and without CI (MMSE ≥24, n = 68) receiving early multidisciplinary geriatric rehabilitation in acute care were included. Construct validity was assessed by Spearman correlations (rs) with the Activity-specific Balance Confidence Scale (ABC-6), Short Falls Efficacy Scale-International (Short FES-I), EuroQoL-5 Dimensions (EQ-5D), Short Physical Performance Battery (SPPB), de Morton Mobility Index (DEMMI), and Barthel Index (BI); test-retest reliability within 24 hours by intraclass correlation coefficients (ICCs); sensitivity to change by standardized response means (SRMs) calculated for treatment effects, and feasibility by completion rates/times and floor/ceiling effects.

RESULTS

The PSFS showed fair to moderate correlations with all construct variables in patients with CI (rs = 0.31 to 0.53). In patients without CI, correlations were fair for the ABC-6, FES-I, EQ-5D, and BI (rs = |0.27 to 0.36|), but low for the SPPB and DEMMI (rs = -0.04 to 0.14). Test-retest reliability (both: ICC = 0.76) and sensitivity to change (CI: SRM = 1.10, non-CI: SRM = 0.89) were excellent in both subgroups. Excellent feasibility was documented by high completion rates (>94%), brief completion times (<8 min), and no floor/ceiling effects in both subgroups.

CONCLUSIONS

The PSFS has adequate clinimetric properties for assessing patient-specific functional limitations and changes in acutely hospitalized older patients with and without CI. It might be an appropriate complement to traditional functional scales to enhance patient-centeredness in clinical geriatric assessment.

Using the Updated EWGSOP2 Definition in Diagnosing Sarcopenia in Spanish Older Adults: Clinical Approach

Recently the European Working Group on Sarcopenia in Older People (EWGSOP2) has updated diagnostic criteria for sarcopenia, which consist of one or more measures of muscle strength, muscle mass, and physical performance, plus an initial screening test called SARC-F. The main objective was to compare the number of cases of sarcopenia, using the different measurements and screening options. A cross-sectional study was conducted on Spanish older adults (n = 272, 72% women). Combining the different measures proposed by the steps described in the EWGSOP2 algorithm, 12 options were obtained (A-L). These options were studied in each of the three models: (1) using SARC-F as initial screening; (2) not using SARC-F; and (3) using SARC-CalF instead of SARC-F. A χ2 independence test was statistically significant (χ2(6) = 88.41, p < 0.001), and the association between the algorithm used and the classification of sarcopenia was moderate (Cramer's V = 0.226). We conclude that the different EWGSOP2 measurement options imply case-finding differences in the studied population. Moreover, when applying the SARC-F, the number of people classified as sarcopenic decreases. Finally, when SARC-CalF is used as screening, case finding of sarcopenic people decreases. Thus, clinical settings should consider these outcomes, since these steps can make preventive and therapeutic interventions on sarcopenia vary widely.

Longitudinal Association Between Energy Regulation and Fatigability in Mid-to-Late Life

BACKGROUND

Deficits in energy production and utilization have been linked to higher fatigue and functional decline with aging. Lesser known is whether individuals with a combination of low peak energy capacity and high energy costs for mobility (eg, impaired energy regulation) are more likely to experience the onset and progression of high fatigability with aging.

METHODS

Participants in the Baltimore Longitudinal Study of Aging (n = 651, 49.0% male, mean age 71.9, range 50-94) with ≥2 visits who completed fatigability (Borg rating of perceived exertion [RPE] after a 5-minute 1.5 mph treadmill walk), slow walking energy expenditure (VO2 mL/kg/min), and peak walking energy expenditure (VO2 mL/kg/min), testing between 2007 and 2018. The longitudinal association between each measure of energy expenditure, a ratio of energy cost-to-capacity, and perceived fatigability was modeled using mixed effects models adjusted for age, body composition, and comorbidities. Time to higher perceived fatigability (RPE ≥ 10) was modeled using Cox proportional hazards models.

RESULTS

In continuous analyses, higher slow walking energy expenditure (p < .05) and a higher cost ratio (p ≤ .001) were associated with greater perceived fatigability over time. Cox proportional hazards models using tertiles of the cost ratio suggest that, compared to those in the lowest tertile, those in the middle and highest tertiles had 1.89 (95% confidence interval [CI]: 1.57-5.16) and 2.85 (95% CI: 1.05-3.40) times greater risk of developing higher fatigability, respectively.

CONCLUSION

Findings suggest that strategies to prevent fatigability should consider methods to improve energy regulation by targeting both the independent and combined effects of declining peak capacity and rising energy costs for mobility with aging.

Ability of SARC-F to Find Probable Sarcopenia Cases in Older Adults

BACKGROUND/OBJECTIVE

In 2018 EWGSOP2 has suggested low muscle strength as the primary parameter of sarcopenia. The consensus has recommended SARC-F questionnaire as a screening test to find cases with low muscle strength which has been designated as probable sarcopenia. We aimed to study the ability of SARC-F to find probable sarcopenia cases in older patients.

DESIGN

Retrospective, cross-sectional.

SETTING

Istanbul University Istanbul Faculty of Medicine.

PARTICIPANTS

A total of 456 older adults (71.1% female, mean age: 74.6±6.6 years).

MEASUREMENTS

We diagnosed probable sarcopenia by EWGSOP 2 criteria, i.e., presence of low handgrip strength (HGS). SARC-F questionnaire was performed by all participants. We used a receiver operating characteristics curve to obtain SARC-F cut-off values to detect probable sarcopenia and calculated the area under the curve and 95% confidence interval (CI).

RESULTS

We included 456 participants (71.1% female; mean age: 74.6 ± 6.6 years). Probable sarcopenia was present in 58 (12.7%). SARC-F cut-off ≥ 2 presented the best balance between sensitivity and specificity (sensitivity: 64.9% vs specificity: 67.9%) to detect probable sarcopenia [the area under the receiver operating characteristics curve (AUC) = 0.710; 95% Cl: 0.660-0.752, p< 0.001]. SARC-F with a cut-off point ≥ 1 had sensitivity 84.2% and specificity 40.5% and SARC-F ≥ 4 had high specificity 88.2% with 40.3% sensitivity.

CONCLUSION

SARC-F is a good screening tool for sarcopenia in practice. Our findings suggest SARC-F ≥ 1 cut-off point to be used as the probable sarcopenia screening tool regarding its high sensitivity. Consequently, SARC-F ≥ 4 cut-off is better to be used if one prefers to exclude probable sarcopenia.

Functional and Clinical Characteristics for Predicting Sarcopenia in Institutionalised Older Adults: Identifying Tools for Clinical Screening

BACKGROUND

Recently, the European Working Group on Sarcopenia in Older People (EWGSOP2) has updated the sarcopenia definition based on objective evaluation of muscle strength, mass and physical performance. The aim of this study was to analyse the relationship between sarcopenia and clinical aspects such as functionality, comorbidity, polypharmacy, hospitalisations and falls in order to support sarcopenia screening in institutionalised older adults, as well as to estimate the prevalence of sarcopenia in this population using the EWGSOP2 new algorithm.

METHODS

A multicentre cross-sectional study was conducted on institutionalised older adults (n = 132, 77.7% female, mean age 82 years). Application of the EWGSOP2 algorithm consisted of the SARC-F questionnaire, handgrip strength (HG), appendicular skeletal muscle mass index (ASMI) and Short Physical Performance Battery (SPPB). Clinical study variables were: Barthel Index (BI), Abbreviated Charlson's Comorbidity Index (ACCI), number of medications, hospital stays and falls.

RESULTS

Age, BI and ACCI were shown to be predictors of the EWGSOP2 sarcopenia definition (Nagelkerke's R-square = 0.34), highlighting the ACCI. Sarcopenia was more prevalent in older adults aged over 85 (p = 0.005), but no differences were found according to gender (p = 0.512).

CONCLUSION

BI and the ACCI can be considered predictors that guide healthcare professionals in early sarcopenia identification and therapeutic approach.

Incorporation of frailty estimated by gait speed within MELD-Na and the predictive potential for mortality in cirrhosis

Background:

The 5 m gait speed (5MGS), a simple and reliable performance metric and surrogate indicator of frailty, consistently predicts adverse events in elders. Additionally, MELD-Na (model for end-stage liver disease-sodium) scores fail to capture nutritional and functional decline of cirrhotic patients that may confer excess mortality. We hypothesized that 5MGS might be associated with all-cause mortality, and that inclusion of frailty assessment within MELD-Na could improve the prediction of mortality in cirrhosis.

Methods:

5MGS was measured at baseline in 113 hospitalized cirrhotic patients. Survival status over 2 years and cirrhosis-related complications were recorded. We evaluated the prognostic value of 5MGS (as a continuous variable and as a dichotomous variable). The definition of slow versus preserved 5MGS was 0.8 ms⁻¹ based on previous publication. Using Cox proportional hazards regression, a novel MELDNa-5MGS score was derived. Receiver operating characteristics (ROC) curves estimated discrimination between the new score model and established prognostic indices.

Results:

The continuous 5MGS and slow 5MGS were independent predictors of all-cause mortality [5MGS: hazard ratio (HR) 0.133 (0.047–0.347), p < 0.001; slow 5MGS: HR 4.805 (1.536–15.026), p < 0.007]. The equation derived from Cox regression analysis was as follows: MELDNa-5MGS: MELD-Na score + 11 × slow 5MGS. The 2-year mortality in patients with high MELDNa-5MGS score was significantly higher (p < 0.001). Discriminatory power was significantly better for MELDNa-5MGS than MELD-Na score (AUC: 0.802 versus 0.724, p = 0.014 for 1 year; 0.773 versus 0.709, p = 0.044 for 2 years).

Conclusion:

In cirrhotic patients, 5GMS is an independent risk factor of mortality. Modification of MELD-Na to include frailty estimated by low 5GMS is related to improved prognostication of mortality.

Malnutrition among elderly patients with severe aortic stenosis

BACKGROUND

Most patients with aortic stenosis (AS) are elderly. To achieve favorable outcomes after interventional treatments, careful management including adequate nutritional support is required. However, there has been a lack of knowledge about the prevalence of malnutrition and factors related to it.

AIMS

To explore the prevalence of malnutrition and its related factors in patients with severe AS.

METHODS

This was a single-institution, cross-sectional study. A total of 300 consecutive older patients (mean age, 83.8 ± 0.5 years) with AS were prospectively enrolled. Nutritional status was evaluated with the Mini Nutritional Assessment-Short Form (MNA-SF). Cardiac, kidney, physical, cognitive functions, instrumental activities of daily living (IADL) as measured with the Frenchay Activities Index (FAI), medical history, and comorbidities were evaluated as potentially related factors. Multiple logistic regression analysis was performed to identify factors that were significantly associated with the MNA-SF.

RESULTS

The mean (SD) score of the MNA-SF was 10.9 (2.5). 34 patients (11.3%) and 127 patients (42.3%) met the criteria for malnutrition and at risk of malnutrition, respectively. On multiple logistic regression analysis, female sex (OR 3.455, 95% CI 1.045-11.42, P = 0.042), NYHA class (OR 3.625, 95% CI 1.627-8.074, P = 0.002), left ventricular ejection fraction (/10%) (OR 0.961, 95% CI 0.932-0.991, P = 0.010), and FAI score (/10 points) (OR 0.911, 95% CI 0.864-0.961, P < 0.001) were significantly related to malnutrition.

CONCLUSIONS

The prevalence of malnutrition was high among older persons with severe AS, and female sex, poor cardiac function, and lower IADL were independently related to it.

Effect of Protein Supplementation on Physical Performance in Older People With Sarcopenia-A Randomized Controlled Trial

OBJECTIVES

To test the long-term effects of whey-enriched protein supplementation on muscle and physical performance.

DESIGN

A 12-month randomized controlled double blind trial with a 43-month of post-trial follow-up.

SETTING

Porvoo, Finland.

PARTICIPANTS

A total of 218 older (>74 years of age) community-dwelling people with sarcopenia.

INTERVENTION

(1) Control with no supplementation; (2) isocaloric placebo; and (3) 20 g × 2 whey-enriched protein supplementation. All participants were given instructions on home-based exercise, dietary protein, and vitamin D supplementation of 20 μg/d.

MEASUREMENTS

Physical performance was assessed by short physical performance battery and continuous summary physical performance scores. Hand grip strength and calf intracellular resistance based skeletal muscle index were measured by bioimpedance spectroscopy. The measurements were performed at 0, 6, and 12 months. The post-trial follow-up was performed by a postal questionnaire and national census record data.

RESULTS

The participants were older (75-96 years of age) and mostly women (68%). The test supplements had no significant effects on physical performance; the 12-month changes for short physical performance battery were -0.55, -.05, and 0.03 points in control, isocaloric, and protein groups (P = .17), respectively. The changes in continuous summary physical performance scores were similar between the intervention groups (P = .76). The hand grip strength decreased significantly in all intervention groups, and the 12-month changes in calf intracellular resistance-based skeletal muscle index were minor and there were no differences between the intervention groups. One-half of the patients (56%) in both supplement groups reported mild gastrointestinal adverse effects. Differences were found neither in the all-cause mortality nor physical functioning in the post-trial follow-up.

CONCLUSIONS

The whey-enriched protein supplementation in combination with low intensity home-based physical exercise did not attenuate the deterioration of muscle and physical performance in community-dwelling older people with sarcopenia.

Assessment and significance of sarcopenia in liver transplantation

Sarcopenia frequently occurs in cirrhotic patients who are waiting for liver transplantation (LT). This disease is associated with increased morbidity and mortality rates during the LT period. Recently, the careful assessment of nutritional status for end-stage liver disease patients has received a great deal of attention; hence, numerous methods of evaluating sarcopenia have been proposed. However, most of the methods have limitations, including a lack of objectivity, reproducibility, and ability to discriminate prognoses. In addition, many reports suggest that sarcopenia be used as an adjustment factor for the selection criteria of LT and that sarcopenia be incorporated into the selection criteria for living donor LT in our center. In this article, based on a literature review, we aim to identify the current definition of sarcopenia, the available methods of measurement, the potential novel interventions for the treatment of malnutrition and the significance of sarcopenia in LT.

The association between apathy, decline in physical performance, and falls in older persons

BACKGROUND

Symptoms of apathy are common in older persons. Negative effects on physical performance and fall risk are plausible, considering the pathophysiology of apathy. However, literature is scarce.

AIM

To longitudinally assess the association between apathy and (1) decline of physical performance and (2) the number of falls in older community-dwelling persons.

METHODS

The 'B vitamins for the PRevention Of Osteoporotic Fractures' study provided data on 2919 older persons over a period of 2 years. Apathy was assessed using the Geriatric Depression Scale 3. A physical performance score (PPS) was calculated using three performance tests. Falls were registered prospectively. We calculated adjusted odds ratios (ORs), Incidence Rate Ratios (IRRs), and their 95% confidence intervals. Effect modification by age and gender was investigated. We also investigated mediation by baseline PPS for the association between apathy and the number of falls.

RESULTS

Apathy and decline of PPS were independently associated. After stratification, the effect only remained in men. Age was an effect modifier; higher ORs for decreasing age. Apathy was also independently associated with the number of falls. After stratification, women had higher IRRs than men. Age modified the association in the opposite direction: higher IRRs for increasing age. Baseline PPS was a mediator in the association.

CONCLUSION

The impact of apathy on physical performance and fall incidents varied with age and gender. Potentially, in older individuals with apathy, fall risk is preceded by a decline in physical performance. In clinical practice, identifying apathy in older persons might be useful to target mobility preserving interventions.

Fixed Handheld Dynamometry Provides Reliable and Valid Values for Quadriceps Isometric Strength in People With Chronic Obstructive Pulmonary Disease: A Multicenter Study

BACKGROUND

Quadriceps weakness is associated with poor clinical outcomes in chronic obstructive pulmonary disease (COPD). However, quadriceps isometric strength assessment has not been routinely adopted in clinical practice because of the lack of homogeneity in the devices and protocols and the lack of reliability studies.

OBJECTIVE

The objectives of this study were to determine the test-retest reliability and the criterion validity of a commercially available handheld dynamometer for evaluating the quadriceps isometric maximal voluntary contraction (iMVCquad) using a standardized protocol and to investigate the relationship between iMVCquad and functional capacity in people with COPD.

DESIGN

This was a prospective, observational, multicenter trial.

METHODS

Participants with mild to severe COPD from 4 Canadian sites were tested on 2 separate days. Five iMVCquad measurements were obtained following a standardized procedure with a fixed handheld dynamometer (iMVCquad-HHD), and then 5 iMVCquad measurements were obtained with a computerized dynamometer (iMVCquad-CD; the gold standard). Functional capacity was assessed with the Short Physical Performance Battery. Intraclass correlation coefficients, standard errors of measurement, Bland-Altman plots, and Spearman correlation coefficients were used for analyses.

RESULTS

Sixty-five participants (mean age = 69 years [SD = 8]; forced expiratory volume in 1 second = 48% of predicted value [SD = 21]) completed the study. The mean iMVCquad-HHD values on visits 1 and 2 were 102.7 (SD = 51.6) and 105.6 (SD = 58.8) N·m, respectively; the standard error of measurement was 11.4 N·m. The between-visits intraclass correlation coefficient for iMVCquad-HHD was 0.95 (95% confidence interval  = 0.92-0.97), with a mean bias of 2.0 (Bland-Altman plot). There was a strong correlation between iMVCquad-HHD and iMVCquad-CD (Spearman correlation coefficient = 0.86). There was no correlation between iMVCquad-HHD and Short Physical Performance Battery total score.

LIMITATIONS

Participants had stable COPD with few comorbidities and were more physically active than the general population of people with COPD; results might not be applicable to patients with acute exacerbations of the disease or more comorbidities. Assessment order between handheld and computerized dynamometers has not been randomized, but analyses did not highlight any systematic bias or learning effect.

CONCLUSIONS

Quadriceps strength assessment can be implemented in a reliable and valid way in people with COPD using a fixed handheld dynamometer and standardized procedure. This protocol should be established in clinical practice to facilitate the assessment of muscle strength in people with COPD.

Early inpatient rehabilitation for acutely hospitalized older patients: a systematic review of outcome measures

Background

Selecting appropriate outcome measures for vulnerable, multimorbid, older patients with acute and chronic impairments poses specific challenges, which may have caused inconsistent findings of previous intervention trials on early inpatient rehabilitation in acutely hospitalized older patients. The aim of this review was to describe primary outcome measures that have been used in randomized controlled trials (RCTs) on early rehabilitation in acutely hospitalized older patients, to analyze their matching, and to evaluate the effects of matching on the main findings of these RCTs.

Methods

A systematic literature search was conducted in PubMed, Cochrane CENTRAL, CINAHL, and PEDro databases. Additional studies were identified through reference and citation tracking. Inclusion criteria were: RCT, patients aged ≥65 years, admission to an acute hospital medical ward (but not to an intensive medical care unit), physical exercise intervention (also as part of multidisciplinary programs), and primary outcome measure during hospitalization. Two independent reviewers extracted the data, assessed the methodological quality, and analyzed the matching of primary outcome measures to the intervention, study sample, and setting. Main study findings were related to the results of the matching procedure.

Results

Twenty-eight articles reporting on 24 studies were included. A total of 33 different primary outcome measures were identified, which were grouped into six categories: functional status, mobility status, hospital outcomes, adverse clinical events, psychological status, and cognitive functioning. Outcome measures differed considerably within each category and showed a large heterogeneity in their matching to the intervention, study sample, and setting. Outcome measures that specifically matched the intervention contents were more likely to document intervention-induced benefits. Mobility instruments seemed to be the most sensitive outcome measures to reveal such benefits.

Conclusions

This review highlights that the selection of outcome measures has to be highly specific to the intervention contents as this is a key factor to reveal benefits attributable to early rehabilitation in acutely hospitalized older patients. Inappropriate selection of outcome measures may represent a major cause of inconsistent findings reported on the effectiveness of early rehabilitation in this setting.

Trial registration

PROSPERO CRD42017063978.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1201-4) contains supplementary material, which is available to authorized users.

Deterioration of Limb Muscle Function during Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Important features of both stable and acute exacerbation of chronic obstructive pulmonary disease (COPD) are skeletal muscle weakness and wasting. Limb muscle dysfunction during an exacerbation has been linked to various adverse outcomes, including prolonged hospitalization, readmission, and mortality. The contributing factors leading to muscle dysfunction are similar to those seen in stable COPD: disuse, nutrition/energy balance, hypercapnia, hypoxemia, electrolyte derangements, inflammation, and drugs (i.e., glucocorticoids). These factors may be the trigger for a downstream cascade of local inflammatory changes, pathway process alterations, and structural degradation. Ultimately, the clinical effects can be wide ranging and include reduced limb muscle strength. Current therapies, such as pulmonary/physical rehabilitation, have limited impact because of low participation rates. Recently, novel drugs have been developed in similar disorders, and learnings from these studies can be used as a foundation to facilitate discovery in patients hospitalized with a COPD exacerbation. Nevertheless, investigators should approach this patient population with knowledge of the limitations of each intervention. In this Concise Clinical Review, we provide an overview of acute muscle dysfunction in patients hospitalized with acute exacerbation of COPD and a strategic approach to drug development in this setting.

Short-Term Change in Gait Speed and Clinical Outcomes in Older Patients With Acute Heart Failure

BACKGROUND

Evidence for the prognostic value of gait speed is largely based on a single measure at baseline, so we investigated the prognostic significance of change in gait speed in hospitalized older acute heart failure (AHF) patients.Methods and Results:This retrospective study was performed in a cohort of 388 AHF patients ≥60 years old (mean age: 74.8±7.8 years, 228 men). Routine geriatric assessment included gait speed measurement at baseline and at discharge. The primary outcome of this study was all-cause death. Gait speed increased from 0.74±0.25 m/s to 0.98±0.27 m/s after 13.5±11.0 days. Older age, shorter height and lower hemoglobin level at admission, prior HF admission, and higher baseline gait speed were independently associated with lesser improvement in gait speed. A total of 80 patients died and 137 patients were readmitted for HF over a mean follow-up period of 2.1±1.9 years. In multivariate analyses, change in gait speed showed inverse associations with all-cause death (hazard ratio [HR] per 0.1 m/s increase: 0.83; 95% confidence interval [CI]: 0.73 to 0.95; P=0.006) and with risk of readmission for HF (HR: 0.91; 95% CI: 0.83 to 0.99; P=0.036).

CONCLUSIONS

Short-term improvement in gait speed during hospitalization was associated with reduced risks of death and readmission for HF in older patients with AHF.

Assessment of Muscle Function and Physical Performance in Daily Clinical Practice : A position paper endorsed by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

It is well recognized that poor muscle function and poor physical performance are strong predictors of clinically relevant adverse events in older people. Given the large number of approaches to measure muscle function and physical performance, clinicians often struggle to choose a tool that is appropriate and validated for the population of older people they deal with. In this paper, an overview of different methods available and applicable in clinical settings is proposed. This paper is based on literature reviews performed by members of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) working group on frailty and sarcopenia. Face-to-face meetings were organized afterwards where the whole group could amend and discuss the recommendations further. Several characteristics should be considered when choosing a tool: (1) purpose of the assessment (intervention, screening, diagnosis); (2) patient characteristics (population, settings, functional ability, etc.); (3) psychometric properties of the tool (test-retest reliability, inter-rater reliability, responsiveness, floor and ceiling effects, etc.); (4) applicability of the tool in clinical settings (overall cost, time required for the examination, level of training, equipment, patient acceptance, etc.); (5) prognostic reliability for relevant clinical outcomes. Based on these criteria and the available evidence, the expert group advises the use of grip strength to measure muscle strength and the use of 4-m gait speed or the Short Physical Performance Battery test to measure physical performance in daily practice. The tools proposed are relevant for the assessment of muscle weakness and physical performance. Subjects with low values should receive additional diagnostic workups to achieve a full diagnosis of the underlying condition responsible (sarcopenia, frailty or other).

Activities of daily living among elderly persons with severe aortic stenosis

PURPOSE

To determine the level of limitations in activities of daily living (ADL) and instrumental ADL, and identify related factors to instrumental ADL among elderly persons with severe aortic stenosis (AS).

MATERIALS AND METHODS

We prospectively enrolled 112 consecutive elderly persons (mean age, 84.6 ± 4.4 y) with severe AS. We assessed ADL and instrumental ADL using the Barthel index (BI) and the Frenchay activities index (FAI), respectively. Cardiac, physical, cognitive and kidney functions, nutritional status, medical histories, and comorbidities were assessed. A multiple logistic analysis was developed to explore related factors to the FAI.

RESULTS

The medians (ranges) of BI and FAI were 100 (15-100) and 21 (0-38), respectively. The multiple logistic analysis revealed that a history of heart failure (sβ = -0.189), a history of cerebrovascular disease (sβ = -0.233), the short physical performance battery score ≤ 8 (sβ = -0.272), the mini-mental state examination score ≤ 23 (sβ = -0.168) were significantly related to the FAI (p < 0.05).

CONCLUSIONS

Physical frailty, a history of heart failure, cerebrovascular disease, and cognitive decline were independently related to declined instrumental ADL. IMPLICATIONS FOR REHABILIATION Activities of daily living was well-preserved among elderly persons with severe aortic stenosis. Instrumental activities of daily living varied among patients with aortic stenosis and was sometimes impaired. Physical frailty, a history of heart failure, and a history of cerebrovascular disease were independently associated with instrumental activities of daily living in elderly persons with severe aortic stenosis.

Ultrasound Muscle Assessment and Nutritional Status in Institutionalized Older Adults: A Pilot Study

Muscle thickness, measured by ultrasonography, has been investigated for nutritional assessment in older adults, however the associations between muscle ultrasound parameters in the lower limb and nutritional status have not been studied. The aim of this study was to investigate the relationship between muscle thickness echo intensity (EI), and nutritional status in home care residents. A cross sectional study was conducted involving 19 older adults from a home care in Malaga (Spain). We evaluated lower leg muscles by ultrasound, anthropometric data, physical function (measured by gait speed and the Short Physical Performance Battery), strength (handgrip and knee extensors strength) and nutritional status across the Mini-Nutritional Assessment Short-Form (MNA-SF). We found that muscle thickness assessed by ultrasonography independently predicts nutritional status by MNA-SF and after adjusting for handgrip strength or age and sex. As secondary findings, we found relations between strength, functional capacity and the MNA-SF test. These results suggest that lower leg muscle ultrasound parameters could be used as a low-cost objective method for muscle evaluation in nutritional assessment in older adults.

Gait speed and prognosis in patients with idiopathic pulmonary fibrosis: a prospective cohort study

The 4-m gait speed (4MGS), a simple physical performance measure and surrogate marker of frailty, consistently predicts adverse prognosis in older adults. We hypothesised that 4MGS could predict all-cause mortality and nonelective hospitalisation in patients with idiopathic pulmonary fibrosis (IPF).4MGS and lung function were measured at baseline in 130 outpatients newly diagnosed with IPF. Survival status and nonelective hospital admissions were recorded over 1 year. We assessed the predictive value of 4MGS (as a continuous variable and as a binary variable: slow versus preserved 4MGS) by calculating hazard ratios using Cox proportional regression, adjusting for potential confounding variables. Receiver operating characteristic curves assessed discrimination between the multivariable regression models and established prognostic indices.Continuous 4MGS and slow 4MGS were independent predictors of all-cause mortality (4MGS: HR 0.03, 95% CI 0.01-0.31; p=0.004; slow 4MGS: 2.63, 95% CI 1.01-6.87; p=0.049) and hospitalisation (4MGS: HR 0.02, 95% CI 0.01-0.14; p<0.001; slow 4MGS: 2.76, 95% CI 1.16-6.58; p=0.02). Multivariable models incorporating 4MGS or slow 4MGS had better discrimination for predicting mortality than either the gender, age and lung physiology index or Composite Physiologic Index.In patients with IPF, 4MGS is an independent predictor of all-cause mortality and nonelective hospitalisation.

Sarcopenia Indicators as Predictors of Functional Decline and Need for Care among Older People

OBJECTIVES

Sarcopenia is associated with poor health outcomes. We examined the relative roles of muscle mass, strength, physical performance and obesity as health predictors among older sarcopenic people.

DESIGN AND PARTICIPANTS

This prospective study examined community-dwelling people aged 75+ (N=262).

SETTING

Porvoo Sarcopenia and Nutrition Trial.

MEASUREMENTS

We collected demographic data and medical history by postal questionnaire including RAND-36 at baseline and at four years and measured BMI, Short Physical Performace Battery (SPPB), hand-grip strength, cognition and two surrogate measures of muscle mass; the Single Frequency Skeletal Muscle Index (SF-SMI) and the Calf Intracellular Resistance Skeletal Muscle Index (CRi-SMI).

RESULTS

Adjusted for age and gender, independent outdoors mobility was predicted positively by baseline physical functioning scores in RAND-36 (p<0.001), the SPPB (p<0.001), the two-minute step test (p<0.001), and grip strength (p=0.023), as well as CRi-SMI (p<0.001). However, the prediction was negative in BMI (p<0.001) and the Charlson co-morbidity Index (p= 0.004). Similar associations were found when the physical component RAND-36 was used as an outcome measure. The use of home care was predicted by high co-morbidity (p=0.057) and low scores in RAND-36 (p<0.001), SPPB (p<0.001) and the two-minute step test (p<0.001), and low CRi-SMI (p<0.001). CRi-SF was a more consistent predictor than SF-SMI, which was partly masked by BMI. Controlled for age, gender and comorbidity, a 10% difference in CRi-SMI was associated with a 4% higher probability (p=0.019) of independently living at home, whereas the respective figures for SF-SMI and BMI were -18% (p=0.098) and -14% (p=0.088).

CONCLUSIONS

In contrast to SF-SMI, high CRi-SMI appeared to indicate good prognosis and less need of care, independently of BMI.

Ratings of activities of daily living in nursing home residents: comparison of self- and proxy ratings with actual performance and the impact of cognitive status

This study was conducted to examine differences between self- and proxy ratings of activities in daily living (ADL) in nursing home residents and to compare them with actual performance. An impact of cognitive status on these ratings was also determined. Data were obtained from 164 dyads of nursing home residents (self-ratings) and their professional care providers (proxy ratings). Statistical procedures included t tests, intraclass correlations, Pearson's correlations, analysis of variance (ANOVA) and ROC curves. Paired t test provided evidence that residents in general overestimated their abilities for all ADLs (p < .01 in all cases), but a substantial subset of 54 residents, with mean MMSE of 18, agreed with their care providers. The mean MMSE score of those who overestimated their abilities was 13 (N = 57). The ANOVA revealed that greater rating differences were associated with more severe cognitive impairment (MMSE, F = 9.93, p < .001). Proxy ratings of walking were not significantly different from actual performances (p = .145), while self-ratings overestimated it (p < .001). Although residents in general overestimated their ADL abilities and results of comparison with actual performance indicated that proxies may be closer to the actual status in this population, a considerable number of those with milder cognitive impairment were able to assess their ADLs with reasonable accuracy.

Performance of SARC-F in Regard to Sarcopenia Definitions, Muscle Mass and Functional Measures

OBJECTIVE

To assess the reliability and validity of Turkish version of SARC-F in regard to screening with current definitions of sarcopenia, muscle mass and functional measures.

DESIGN

Cross-sectional study.

PARTICIPANTS

Community-dwelling older adults aged >=65 years admitting to a geriatric outpatient clinic.

MEASUREMENTS

Muscle mass (bioimpedance analysis), handgrip strength, usual gait speed, chair sit-to-stand test, functional reach test, short physical performance battery, SARC-F questionnaire, FRAIL questionnaire Sarcopenia was evaluated with 4 current different definitions: European Working Group on Sarcopenia in Older People's (EWGSOP); Foundation for the National Institutes of Health (FNIH), International Working Group on Sarcopenia (IWGS) and Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD).

RESULTS

After cross-cultural adaptation, 207 subjects were analysed in the clinical validation study. Mean age was 74.6±6.7 years, 67.6% were women. Against EWGSOP, FNIH, IWGS and SCWD definitions of sarcopenia, sensitivity of SARC-F were %25, 31.6%, 50% and 40%; specificity were 81.4%, 82.4%, 81.8% and 81.7%, respectively. Positive predictive values were between 5.1-15.4% and negative predictive values were 92.3-98.2%. Against parameters of low muscle mass, sensitivity were about 20% and specificity were about 81%. Against parameters of function; for low hand grip strength, sensitivity of SARC-F were 33.7% (for Turkish cut-off); 50% (for FNIH cut-off); specificity were 93.7% (for Turkish cut-off) and 85.8% (for FNIH cut-off). Against low UGS, poor performance in chair sit to stand test, functional reach test, SPPB and presence of positive frailty screening sensitivity were 58.3%, 39.2%, 59.1%, 55.2% and 52.1% while specificity were 97.3%, 97.8%, 88.1%, 99.3% and 91.2%, respectively.

CONCLUSION

The psychometric performance of Turkish SARC-F was similar to the original SARC-F. It revealed low sensitivity but high specificity with all sarcopenia definitions. Sensitivity and specificity were higher for muscle function tests reflecting its inquiry and input on functional measures. Our findings suggest that SARC-F is an excellent test to exclude muscle function impairment and sarcopenia. SARC-F is relatively a good screening test for functional measures.

Gait speed has comparable prognostic capability to six-minute walk distance in older patients with cardiovascular disease

Background

Although gait speed and six-minute walk distance are used to assess functional capacity in older patients with cardiovascular disease, their prognostic capabilities have not been directly compared.

Methods

The study population was identified from the Kitasato University Cardiac Rehabilitation Database and consisted of 1474 patients ≥60 years old with a mean age of 72.2 ± 7.1 years that underwent evaluation of both usual gait speed and six-minute walk distance in routine geriatric assessment between 1 June 2008–30 September 2015. Both gait speed and six-minute walk distance were determined on the same day at hospital discharge.

Results

Mean gait speed and six-minute walk distance in the whole population were 1.04 m/s and 381 m, respectively, and were strongly positively correlated ( r = 0.80, p < 0.001). A total of 180 deaths occurred during a follow-up of 2.3 ± 1.9 years. After adjusting for confounding factors, both gait speed (adjusted hazard ratio per 0.1 m/s increase: 0.87, 95% confidence interval: 0.81–0.93, p < 0.001) and six-minute walk distance (adjusted hazard ratio per 10-metre increase: 0.96, 95% confidence interval: 0.94–0.97, p < 0.001) were independent predictors of all-cause mortality. There was no significant difference in prognostic capability between gait speed and six-minute walk distance (c-index: 0.64 (95% confidence interval: 0.60–0.69) and 0.66 (95% confidence interval: 0.61–0.70), respectively, p = 0.357).

Conclusions

Gait speed and six-minute walk distance showed similar prognostic predictive ability for all-cause mortality in older cardiovascular disease patients, indicating the potential utility of gait speed as a simple risk stratification tool in older cardiovascular disease patients.