High prevalence of geriatric syndromes in older adults

INTRODUCTION

The geriatric syndromes of frailty, sarcopenia, weight loss, and dementia are highly prevalent in elderly individuals across all care continuums. Despite their deleterious impact on quality of life, disability, and mortality in older adults, they are frequently under-recognized. At Saint Louis University, the Rapid Geriatric Assessment (RGA) was developed as a brief screening tool to identify these four geriatric syndromes.

MATERIALS AND METHODS

From 2015-2019, the RGA, comprised of the FRAIL, SARC-F, Simplified Nutritional Appetite Questionnaire (SNAQ), and Rapid Cognitive Screen (RCS) tools and a question on Advance Directives, was administered to 11,344 individuals ≥ 65 years of age across Missouri in community, office-based, hospital, Programs of All-Inclusive Care for the Elderly (PACE), and nursing home care settings. Standard statistical methods were used to calculate the prevalence of frailty, sarcopenia, weight loss, and dementia across the sample.

RESULTS

Among the 11,344 individuals screened by the RGA, 41.0% and 30.4% met the screening criteria for pre-frailty and frailty respectively, 42.9% met the screening criteria for sarcopenia, 29.3% were anorectic and at risk for weight loss, and 28.1% screened positive for dementia. The prevalence of frailty, risk for weight loss, sarcopenia, and dementia increased with age and decreased when hospitalized patients and those in the PACE program or nursing home were excluded.

CONCLUSIONS

Using the RGA as a valid screening tool, the prevalence of one or more of the geriatric syndromes of frailty, sarcopenia, weight loss, and dementia in older adults across all care continuums is quite high. Management approaches exist for each of these syndromes that can improve outcomes. It is suggested that the brief RGA screening tool be administered to persons 65 and older yearly as part of the Medicare Annual Wellness Visit.

Lewy Body Dementia

Dementia with Lewy bodies (DLB) is the second most common neurodegenerative dementia following Alzheimer disease. It stems from the formation of Lewy bodies, which contain aggregates of the misfolded protein, α-synuclein. These deposit in areas of the nervous system and brain, leading to neuronal cell death and causing clinically apparent symptoms. Because of its clinical overlap with other forms of dementia, DLB is often underdiagnosed and misdiagnosed. There is currently no cure for DLB and treatments are aimed at ameliorating specific symptoms.

Mild Cognitive Impairment

Mild cognitive impairment (MCI) occurs along a continuum from normal cognition to dementia. A roadblock to earlier diagnosis and potential treatment is the lack of consistency with screening for MCI. Universal screening would be ideal, but is limited. Once a diagnosis of MCI is made, it is important for the clinician to evaluate for reversible causes. At present time, there are no pharmacologic treatments proven to slow or cure progression of MCI to dementia; nonetheless, there is evidence that lifestyle modifications including diet, exercise, and cognitive stimulation may be effective.

Mild Cognitive Impairment

Mild cognitive impairment (MCI) occurs along a continuum from normal cognition to dementia. A roadblock to earlier diagnosis and potential treatment is the lack of consistency with screening for MCI. Universal screening would be ideal, but is limited. Once a diagnosis of MCI is made, it is important for the clinician to evaluate for reversible causes. At present time, there are no pharmacologic treatments proven to slow or cure progression of MCI to dementia; nonetheless, there is evidence that lifestyle modifications including diet, exercise, and cognitive stimulation may be effective.

Anorexia of aging and its role for frailty

PURPOSE OF REVIEW

The purpose of this review is to examine the concept of anorexia of aging, including its complex pathophysiology and the multifaceted interventions required to prevent adverse health consequences from this geriatric syndrome.

RECENT FINDINGS

Anorexia of aging is extremely common, occurring in up to 30% of elderly individuals; however, this diagnosis is frequently missed or erroneously attributed to a normal part of the aging process. With aging, impairments in smell and taste can limit the desire to eat. Alterations in stress hormones and inflammatory mediators can lead to excess catabolism, cachexia, and reduced appetite. In addition, mood disorders, such as anxiety and depression, are powerful inhibitors of appetite. Anorexia of aging, with its negative consequences on weight and muscle mass, is a risk factor for the development of frailty and is important to screen for, as early intervention is key to reversing this debilitating condition.

SUMMARY

Anorexia of aging is a complex geriatric syndrome and a direct risk factor for frailty and thus should not be accepted as normal consequence of aging. Early diagnosis and formulating a plan for targeted interventions is critical to prevent disability and preserve function in elderly patients.

Caloric supplements for the elderly

PURPOSE OF REVIEW

Malnutrition and weight loss have serious consequences in older adults. The use of caloric supplementation may provide nutritional and functional benefits in this population. This article reviews the recent literature on oral nutritional supplementation (ONS) in the elderly.

RECENT FINDINGS

Inadequate caloric intake is a factor consistently associated with weight loss, and use of ONS can increase weight in community-dwelling as well as acute and chronically ill elders. ONS does not improve function or mortality in the general elderly population but has shown benefits in those who are frail or malnourished. Improvement in functional status and mortality was not seen in postacute, hip fracture, or demented populations.

SUMMARY

At this time, research does not clearly show that providing ONS to unselected groups of older adults results in functional or mortality benefits; however, a small increase in body weight is a likely outcome.

Severe nutritional risk predicts decreased long-term survival in geriatric patients undergoing pancreaticoduodenectomy for benign disease

BACKGROUND

Weight loss and malnutrition are poorly tolerated by geriatric patients, and pancreaticoduodenectomy (PD) can result in chronic malabsorption and weight loss. We sought to determine how preoperative severe nutritional risk (SNR), as defined by the American College of Surgeons National Surgical Quality Improvement Program/American Geriatric Society Best Practice Guidelines, affects long-term survival after PD for benign disease among geriatric and nongeriatric patients.

STUDY DESIGN

All patients undergoing PD for nonmalignant conditions at a single center between 1995 and 2013 were followed for survival, excluding patients who died within 90 days of surgery. Survival of geriatric (age ≥65 years) and nongeriatric (age <65 years) patients with and without SNR was compared using Kaplan Meier methods. Cox regression was performed.

RESULTS

There were 320 patients who underwent PD for benign disease. Over the course of the study, the proportion of geriatric patients undergoing PD for benign conditions increased from 25% to 46%. In addition to being older, geriatric patients undergoing PD for benign disease were significantly more likely to have coronary artery disease (CAD) and hypertension. Geriatric patients with preoperative SNR had significantly decreased long-term survival after PD for benign disease (p < 0.001), with roughly 1 in 3 patients dead at 5 years compared with 1 in 14 patients without SNR. Survival was not significantly different among nongeriatric patients with and without SNR. In geriatric patients, age, CAD, and SNR were significantly associated with decreased survival on both univariate and multivariate analysis.

CONCLUSIONS

Severe nutritional risk can be a useful predictor of long-term survival in geriatric patients undergoing PD, and could improve patient risk stratification preoperatively. Nonoperative management should be strongly considered in geriatric patients with SNR, when malignancy is not suspected.

Do nutrients play a role in delirium?

PURPOSE OF REVIEW

This study will review the biologic roles of thiamine, niacin, folic acid, cobalamin, antioxidants, lipids, glucose, and water and their implications as contributors or causal agents in the development of delirium, particularly if deficiencies or excesses exist.

RECENT FINDINGS

Knowledge on how overall nutritional status and individual nutrients predispose or directly lead to the development of delirium is currently very limited. Most studies in the area of nutrition and cognition still describe mental status changes using the term dementia and do not specifically address nutrition and delirium. However, as the brain pathophysiology that accompanies delirium has been furthered elucidated, it has become clear that nutritional imbalances can lead to these same physiologic changes in neuronal tissue.

SUMMARY

Delirium, characterized by an acute change in mental status along with diminished awareness and attention and disturbances in memory, language, or perception, confers high rates of morbidity and mortality and can be difficult to both diagnose and treat. Although the cause of delirium is often multifactorial, nutritional status and nutrients may play a role in predisposing or directly causing this acute cognitive dysfunction. Many nutritional deficiencies or excesses (i.e., B vitamins, antioxidants, glucose, water, lipids) have been shown to alter the way one thinks and restoring the balance in many of these nutrients can lead to resolution of delirium.