Gateway Geriatric
Education Center
Saint Louis University
Division of Geriatric Medicine
From Sarcopenia
to Frailty
Olga Kotelko 1.5m Women’s high school 6.9m Women’s world 7.5m
MacDonald Critchley
first described
age related
wasting of hands and feet
Irwin Rosenberg
was first to use
the term
Sarcopenia
SARCOPENIA: Age Related Loss of Muscle Mass
(poverty of flesh)
Clean and jerk
world weightlifting
records
0
50
100
150
200
250
<30 35-
39
40-
44
45-
49
50-
54
55-
59
60-
64
65-
69
70-
74
75-
80
80+
0
20
40
60
80
100
120
140
160
180
<30 35-
39
40-
44
45-
49
50-
54
55-
59
60-
64
65+
Male Female
AGING, EXERCISE AND MUSCLE INJURY
CONTRACTION
Muscle
MGF
Satellite Cells
(Mauro, 1961)
IGF1-Ea Type II Fiber Atrophy
Protein
Synthesis/ Degradation
Mechano Receptors
Titin
Dystroglycon
MUSCLE INJURY
MUSCLE REGENERATION
FUNCTION
Motor Units
Strength Power
Growth Factors
Fiber Number
< 5.75 kg/m2 3.15 (1.84-5.40) 16.8 4.96
5.75-6.74 kg/m2 1.46 (1.00-2.15) 9.2 2.70
> 6.75 1.00
< 8.50 kg/m2 4.60 (2.07-10.20) 28.7 3.63
8.50-10.74 kg/m2 3.48 (1.84-6.57) 56.8 7.18
> 10.75 kg/m2 1.00
Women (n =2,276 )
Men (n =2,223 )
* Adjusted for age, race, health behaviors, comorbidity, body fat
Odds Ratios* for Any Disability Associated with Sarcopenia
SM/Ht2 (kg/m2) Cutpoints established by ROC Analysis Janssen et al. Am J Epi 2004; JAGS 2004;53:80-85
Total Cost 18.4
Odds Ratio % PAR Cost, billion $
Old muscle shows fiber size heterogeneity
And fiber grouping
ALS
Invrease in muscles with
MYOSIN HEAVY CHAIN
with aging and denervation
©2012The American College of Sports Medicine. Published by Lippincott Williams & Wi lkins, Inc. 2
Reduced Satellite Cell Numbers with Spinal Cord Injury and Aging in Humans. VERDIJK, LEX;
Medicine & Science in Sports & Exercise. 44(12):2322-2330, December 2012.
Cross Sectional Area
Satelite Cells
The Motor Unit Number Index (MUNIX) in sarcopenic patients Experimental Gerontology Volume 48, Issue 4 2013 381 - 384
Stefan Hettwer , Pius Dahinden , Stefan Kucsera , Carlo Farina , Shaheen Ahmed , Ruggero Fariello , Michael Drey ...
Elevated levels of a C-terminal agrin fragment identifies a new subset of sarcopenia patients
Experimental Gerontology Volume 48, Issue 1 2013 69 - 75
Old muscles show fiber size variability
whereas cancer cells do not
(Example: Mouse Muscle)
NORMAL CANCER
OLD
2
Inclusion Body Myositis
Inclusion body myositis. Greenberg, Steven
Current Opinion in Rheumatology. 23(6):574-578, November 2011.
A slow degenerative, inflammatory
muscle disease
in persons over 50 years of age
The age-related loss of muscle strength is weakly associated with the loss of muscle mass.
Manini T M , Clark B C J Gerontol A Biol Sci Med Sci
2011;gerona.glr010
© The Author 2011. Published by Oxford University Press on behalf of The Gerontological Society of America.
Relative risk of poor physical performance, functional limitation, or physical disability in older
adults with dynapenia (low muscle strength), or sarcopenia (low muscle mass).
Manini T M , Clark B C J Gerontol A Biol Sci Med Sci
2011;gerona.glr010
© The Author 2011. Published by Oxford University Press on behalf of The Gerontological Society of America.
Sarcopenia
Kratopenia
(Thinamopenia)
Dynapenia
Frailty
Disability
Loss of muscle mass; not due to cachexia or PVD
Loss of power; Force X velocity
Fatigue Resistance Aerobic Illness Loss of Weight
Loss of ADLs
Loss of force ie strength
18.9
52.1
8
56.9
0
25
50
75
Intact Lacking Intact Lacking
6-month
mortality
6-month
Nursing Home
•Transfer
•Toilet
•Bathe
•Dress
•Eat
•Continence
ADL’s and Outcome
ESPEN SIG - CACHEXIA
Age Ageing. 2013 Mar;42(2):203-9. doi: 10.1093/ageing/afs194. Epub 2013
Jan 15.
Sarcopenia and mortality risk in frail older persons aged 80 years and
older: results from ilSIRENTE study.
Landi F, Cruz-Jentoft AJ, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E, Bernabei R, Onder G.
After adjusting for potential confounders including age,
gender, education, activities of daily living (ADL)
impairment, body mass index, hypertension, congestive
heart failure, chronic obstructive pulmonary disease,
number of diseases, TNF-α, participants with
sarcopenia had a higher risk of death for all
causes compared with non-sarcopenic
subjects (HR: 2.32, 95% CI: 1.01-5.43).
Francesco Landi , Rosa Liperoti , Domenico Fusco , Simona Mastropaolo , Davide Quattrociocchi , Anna
Proia , Matte...
Sarcopenia and Mortality among Older Nursing Home Residents
Journal of the American Medical Directors Association Volume 13, Issue 2 2012 121 - 126
Sarcopenia Prevalence and Associated Factors
in an Elderly Taiwanese Metropolitan
Population Journal of the American Geriatrics Society
Volume 61, Issue 3, pages 459–462, March 2013
• Sarcopenia was present in 14.4% of a
Taiwanese population aged 65 and older
in a metropolitan area.
• Factors associated with sarcopenia were
no regular exercise (OR = 2.62, 95%
CI = 1.61–4.26), and fall history
(OR = 1.72, 95% CI = 1.03–2.90).
Sarcopenia with limited
Mobility
A position paper from the Society on Sarcopenia, Cachexia and Wasting
Disorders Trialist Workshop, Washigton DC, December, 2010
JAMDA , June 2011
Sarcopenia with limited mobility:
Definition
A person with muscle loss whose walking
speed is equal to or less than 1 m/s or
who walks less than 400 m during a six minute walk. The person should also have
a lean appendicular mass corrected for
height squared of more than two standard
deviations below that of healthy persons
between 20 to 30 years of age of the same ehtnic group. Sarcopenia is
generally believed to be age-associated and its prevalence increases with age.
Sarcopenia with limited mobility:
Clinically significant interventions
An increase in the 6 minute walk of 50 meters
An increase of gait speed of 0.1 m/sec
NOTE: The 50 meter criteria was used for approval by the FDA of drugs for peripheral vascular disease and
Sarcopenia with limited mobility:
Conclusion
It is believed that this definition clearly defines a syndrome whose treatment should delay the onset of disability and as such provides a
clearly defined entity which can be subjected to therapeutic intervention and for which there is an acceptable defined response which should
allow the development of pharmaceutical products that can be approved by regulatory
agencies
LOW ASM +LIMITED MOBILITY
predicts 6 year loss of ADLs, IADLs and frailty but low
ASM does not
Comparison of Sarcopenia
Definitions Definition Screen Definition
IANA Sarcopenia Task Force
Gait Speed <1.0m/s Low appendicular lean mass (<7.23 kg/m2 in men;5.67 in women
EWGSOP Gait Speed <0.8m/s Low muscle mass (not defined)
SIG: Cachexia-Anorexia in Chronic Wasting Diseases
Gait Speed <0.8m/s, OR Other Physival Performance Measure
Low muscle mass(2SD)
Sarcopenia with Limited Mobility (SCWD)
6 min walk <400m OR Gait Speed <1.0m/s
Low appendicular lean mass 2SD 20-30 sex ethnicity
Definitions have much in common Sarcopenia is histologically different from cachexia with a different set of causes.
Sarcopenia is a syndrome
Loss of muscle mass is insufficient
Definitions include limited strength (grip strength) or mobility
Need acceptance from NIH/AGS
? Possible to use a simple questionnaire instead eg SARC-F ?
SARCOPENIC OBESITY
“Fat Frail”
0
5
10
15
20
25
30
35
<70y 70 to 74y 75 to 79y 80+y
Sarcopenia
Sarco Obese
Age
Morley et al J Clin Med 2001; 137:231-43
Per
cent
Pre
val
ence
In the New Mexico Aging
Process Study we found obese
sarcopenia to be longitudinally
the best predictor of future
disability and mortality.
EPIDOS STUDY
Sarcopenic-Obese
Odds of climbing stairs 2.60
Odds of going down stairs 2.35
Similarities in Acquired Factors Related to
Postmenopausal Osteoporosis and Sarcopenia
Joonas Sirola1,2 and Heikki Kröger1,2
Sarco-osteoporsosis
Similarities and comparisons between the
sarcopenia field and that of osteoporosis have
always been and continue to be inescapable. A younger term and a younger field of clinical investigation,
sarcopenia seems to parallel the development of
osteoporosis. Not unlike the case of sarcopenia, a
working definition of osteoporosis was not universally
reached for decades. Looking back and learning from
where the osteoporosis field started and where it is
now, one cannot be but optimistic that the emerging sarcopenia field will follow a similar course.
Sarcopenia: What's in a Name?
Dragos Roman, MD, , Karen Mahoney, MD, Ali Mohamadi, MD
Division of Metabolism and Endocrinology Drug Products, Center for Drug
Evaluation and Research, Food and Drug Administration, Silver Spring, MD
WHO Fracture Risk Assessment
(FRAX)
www.shef.ac.uk/FRAX/
Previous fracture
Parent fractured hip
Current smoking
Glucocorticoids
Secondary osteoporosis
Alcohol >3 units/day
Femoral neck BMD
FRAX
Questions
vs BMD
Lowest T-score < -2.5
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.730 (0.725-0.736)
Hip AUC 0.735 (0.730-0.740)
Prior spine of hip fracture
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.826 (0.818-0.835)
Hip AUC 0.770 (0.760-0.780)
Major probability with BMD >20%
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.951 (0.948-0.953)
Hip AUC 0.931 (0.928-0.934)
Hip probability with BMD >3%
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.915 (0.912-0.918)
Hip AUC 0.935 (0.933-0.938)
Any of the above (without hip >3%)
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.765 (0.760-0.770)
Hip AUC 0.761 (0.756-0.766)
Any of the above (with hip >3%)
1-Specificity
0.0 0.2 0.4 0.6 0.8 1.0
Se
nsitiv
ity
0.0
0.2
0.4
0.6
0.8
1.0
Major AUC 0.829 (0.825-0.833)
Hip AUC 0.836 (0.832-0.841)
Leslie et al, Osteoporosis Int
SARC-F
Strength: difficulty in lifting or carrying 10 lbs Assistance with walking Rise from a chair Climb stairs Falls
6-Year Outcomes Males and Females
O dds Ratio (95% CI ) P -Value
Incident ADLs > 1* 4.46 (2 .68-7.42) <.001
Incident IADLs > 1* 2.52 (1 .56-4.07) <.001
Hospitalized overnight past year** 2.43 (1 .46-4.05) <.001
Gait Speed < 0.8 m/s** 2.46 (1 .13-5.34) .023
Mortality* 1.87 (1 .17-2.98) .009
Males and Females
SA RC-F Scores > 4
Yes (n=93) No (n=483) P -Value
Chair stands** 16.00±7.1 11.76±5.1 .004
Grip strength** 28.11±12.0 31.53±11.2 .549
Males
O dds Ratio (95% CI ) P -Value
Incident ADLs > 1*** 3.32 (1 .28-8.61) .014
Incident IADLs > 1*** 2.28 (0 .93-5.61) .073
Hospitalized overnight past year**** 3.11 (1 .25-7.70) .014
Gait speed < 0.8 m/s**** 1.43 (0 .38-5.40) .598
Mortality*** 1.10 (0 .50-2.46) .809
Males
SA RC-F Scores > 4
Yes (n=26) No (n=176) P -Value
Chair stands**** 13.60±6.4 11.37±4.1 .522
Grip strength**** 38.57±14.1 41.16±10.9 .273
Females
O dds Ratio (95% CI ) P -Value
Incident ADLs > 1*** 5.13 (2 .79-9.42) <.001
Incident IADLs > 1*** 2.63 (1 .49-4.47) <.001
Hospitalized overnight past year**** 2.20 (1 .18-4.09) .013
Gait speed < 0.8 m/s**** 3.23 (1 .22-8.56) .018
Mortality*** 2.57 (1 .43-4.61) .002
Females
Yes (n=67) No (n=307) P -Value
Chair stands**** 16.99±7.3 11.97±5.6 .004
Grip strength**** 23.15±6.8 26.06±6.9 .005
St Louis SARC-F Longitudinal
SARC-F in Baltimore
Longitudinal Study
60+ years
Odds Ratio
P-value
Gait Speed <0.8 m/s
9.41(2.51-35.27)
0.001
Mortality
3.07(1.60-5.73)
0.001
SARC-F in NHANES
199-2000
Outcomes
SARC-F Scores > 4*
Yes
No
P-Value
Knee extensor strength: average peak force (Newtons) 204.36 77.9 276.65 96.6 <.001
Timed 20 foot walk, seconds 9.97 4.2 6.90 3.0 <.001
Odds Ratio (95% CI ) P-Value
Hospitalized overnight past year 2.24 (1.54-3.27) <.001
Physical function as independent predictors of SARC-F ≥ 4 in multiple binary
logistic regression analysis
n B S.E. P OR 95% C.I. for OR
4m walking speed 202 -4.913 .851 .000 .007 0.001-0.039
TUG* completed 76 -4.018 .781 .000 .018 0.004-0.083
TUG time 25 .071 .022 .001 1.074 1.029-1.121
SPPB#
76 -.572 .084 .000 .565 0.479-0.665
Grip strength 28 -.139 .025 .000 .870 0.828-0.915
SARC-F CHENGDU
INCREASED
LEPTIN
DECREASED
CALORIE AND
PROTEIN
INTAKE
DECREASED
PHYSICAL
ACTIVITY
CYTOKINE
EXCESS
egTNFα
IL-6
DECREASED
ANABOLIC
HORMONES
TESTOSTERONE
DHEA
VITAMIN D
DEFICIENCY DECREASED
GROWTH
HORMONE AND
GHRELIN
DECREASED
CNTF
DECREASED
MOTOR UNITS
ATHEROSCLEROSIS
INCREASED
FAT
INFILTRATION
INSULIN
RESISTANCE
ADIPONECTIN
DECREASED
IGF-1Ea
MGF
GENETIC
Myostatin
ActivinIIR
Notch I
IGF-2
CNTF
MITOCHONDRIAL
ABNORMALITIES
Visceral
obesity
Hypertriglyceridemia
Hypoxia
VITAMIN D AND SARCOPENIA
Longitudinal Fall in
Vitamin D with Age
• Hypovitamin D is associated with
declines in muscular strength and
reported disability • Zamboni et al J. Gerontol 57:m7, 2002
• Low Vitamin D and High PTH are
associated with sarcopenia • Visser et al JCEM 88:5766, 2003
• Low Vitamin D is an independent
predictor of falls • Flicker et al Jags 51:1533, 2003
• Vitamin D supplementation with
calcium appears to improve strength
and performance only in older persons
with low vitamin D levels • Latham et al JAGS 51:1219, 2000
• Vitamin D supplementation (528 IU) is
associated with decreased mortality
(0.93; 0.87-0.99) • Autier & Gandini Arch Intern Med 2007 167:1730
Effects of High-Intensity Progressive Resistance Training
and Targeted Multidisciplinary Treatment of Frailty on
Mortality and Nursing Home Admissions after Hip Fracture:
A Randomized Controlled Trial Singh et al JAMDA , Jan 2012
• Comprehensive Geriatric Assessment and
12 months resistance training twice weekly
• Mortality OR 0.19 (0.04 – 0.91)
• Nursing Home OR 0.16 (0.04 – 0.64)
• ADL’s p <0.02
• Assistive Device p<0.01
Treatment for SARCOPENIA is
RESISTANCE EXERCISE
-1000
-500
0
500
Bed Rest
Young
(30 days)
Old
(10 Days)
Old
1.25 protein/kg/day
Old
3 day_hospital
Bed Rest leads to 3x rate of muscle loss in 1/3 time
Increased protein Intake stops muscle loss and decreases strength loss
Hospitalization accelerates muscle loss
HIGHER DIETARY PROTEIN INTAKE TO
COUNTERACT
MUSCLE LOSS IN ELDERLY
Houston et al., 2008 (Health ABC cohort)
HIGH PROTEIN ONS IMPROVES
HANDGRIP STRENGTH
Michael Tieland , Ondine van de Rest , Marlou L. Dirks , Nikita van der Zwaluw , Marco Mensink , Luc J.C. van Loon...
Protein Supplementation Improves Physical Performance in Frail Elderly People: A Randomized, Double-Blind, Placebo-Controlled Trial
Journal of the American Medical Directors Association Volume 13, Issue 8 2012 720 - 726
http://dx.doi.org/10.1016/j.jamda.2012.07.005
Effects of Exercise and Amino Acid Supplementation on Body Composition and Physical Function
in Community‐Dwelling Elderly Japanese Sarcopenic Women: A Randomized Controlled Trial
Journal of the American Geriatrics Society
Volume 60, Issue 1, pages 16-23, 5 DEC 2011 DOI: 10.1111/ j.1532-5415.2011.03776.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2011.03776.x/full#jgs3776-fig -0002
PROT-AGE
• PROT-AGE recommendations for dietary protein intake in
healthy older adults
• • To maintain and regain muscle, older people need more dietary
protein than do younger people; older people should consume an
average daily intake in the range of 1.0 to 1.2 g/kg BW/d.
• • The per-meal anabolic threshold of dietary protein/amino acid
intake is higher in older individuals (ie, 25 to 30 g protein per meal,
containing about 2.5 to 2.8 g leucine) in comparison with young
adults.
• • Protein source, timing of intake, and amino acid supplementation
may be considered when making recommendations for dietary
protein intake by older adults.
• • More research studies with better methodologies are desired to
fine tune protein needs in older adults.
An International Consensus
and
Assessment for Frailty
FRAILTY DEFINITIONS
“Occurs when under stressful conditions the person has
diminished ability to carry out important practiced
social activities of daily living.It needs to be distinguished
from disability”
Renoir, 1915
Blonde a la rosa
0 10 20 30 40 50 60 70 80 90 100
Age (years)
VO
2 m
ax
Car
dia
c outp
ut
Bal
ance
Musc
le s
tren
gth
Frailty
Threshold
FRAILTY DEFINITION
OBJECTIVE
Fried et al J Gerontol 56A M146,2001
•Weight Loss(10 lbs in 1 year)
•Exhaustion(self-report)
•Weakness (grip strength;lowest 20%)
•Walking speed(15 feet; slowest 20%)
•Low Physical Activity(Kcals/week;lowest 20%)
Female >
Male
6.9%
Frailty predicts 10 year disability
and mortality in Mexican Americans J Rehab Med 2001;41:892; Gerontol 2009; 55:64
ADLs Mortality
Prefrail 1.32 1.25
Frail 2.42 1.81
HISPANIC EPESE
Rockwood Deficit Scale
10 year outcomes
Deficits added >0.25 = Frail
Content
Validity
Construct
Validity
Criterion
Mortality
Criterion
ADLs
CHS Y Y Y Y
SOF Y Y Y Y
Deficit Model Y Y Y Y
SHARE-FI Y Y Y
FRAIL Y Y Y Y
Kihon-Checklist Y Y Y
VES-13 Y Y Y
Sherbrooke
postal
questionnaire
Y Y Y
Tilburg Y Y Y
Fatigue
Resistance (Climb 1 flight stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
FRAILTY (IANA)
SIX VALIDATIONS Australia(2) Hong Kong St Louis Europe (2)
Kaplan-Meier survival curves showing association between FRAIL
scale at W2 and subsequent all-cause mortality.
4 to 8 year follow up
Hyde Z et al. JCEM 2010;95:3165-3172
Frailty (3+) predicted
ADL deficit
P<0.0001
Specificity of Scales in Hong Kong Study
MALE MALE FEMALE FEMALE
MORTALITY Physical Limit MORTALITY Physical Limit
Rockwood 96.4% 98.4% 93.8% 98%
CHS 99.2% 100% 99.4% 99.9%
FRAIL 99.1% 99.4% 99.9% 100%
Hubbard 98% 99.6% 96.1% 95.1%
9-year OR of ADL deficit or Mortality
in persons not lacking ADLs ADLs
PreFra
il
Frail p
FRAIL 2.74 20.76 .001
SOF 3.09 3.48 .001
CHS 2.40 6.47 .001
Rockwood 2.36 5.65 .001
MORTALITY
PreFrail Frail p
1.58 3.99 .001
1.47 1.40 NS
1.35 2.42 .01
2.50 2.66 .001
The ability of three different models of frailty to predict all-cause mortality: Results from the
European Male Aging Study (EMAS) • We used a frailty index (FI), frailty phenotype (FP), and FRAIL
scale (FS) to predict mortality in the EMAS. Participants were aged 40–79 years (n = 2929) at baseline and 6.6% (n = 193) died over a median 4.3 years of follow-up.. The mean FI increased linearly with age (r2 = 0.21) and in Cox regression models adjusted for age, center, smoking and partner status the hazard ratio (HR) for death for each unit increase of the FI was 1.49.
• Compared to robust men, those who were FP frail at baseline had a HR for death of 3.84, while those who were FS frail had a HR of 3.87.
• Our data suggest that the choice of frailty model may not be of paramount importance when predicting future risk of death, enabling flexibility in the approach used.
Operationalization of Frailty Using Eight Commonly Used Scales and Comparison of Their Ability
to Predict All‐Cause Mortality
Journal of the American Geriatrics Society
Volume 61, Issue 9, pages 1537-1551, 26 AUG 2013 DOI: 10.1111/jgs.12420
http://onlinelibrary.wiley.com/doi/10.1111/jgs.12420/full#jgs12420-fig-0001
ROC for FRAIL at 2 years was 0.70
Prevalence of Frailty
Excluding baseline ADL deficits
Frailty Consensus Conference
Orlando, Florida
December
IAGG Definition
Physical frailty is an important medical
syndrome. The group defined physical frailty
as “a medical syndrome with multiple causes
and contributors that is characterized by
diminished strength, endurance, and reduced
physiologic function that increases an
individual’s vulnerability for developing
increased dependency and/or death.”
IAGG Recommendations
Physical frailty can potentially be
prevented or treated with specific
modalities, such as
exercise, protein-calorie
supplementation, vitamin D, and
reduction of polypharmacy.
.
IAGG Recommendations
For the purposes of optimally managing
individuals with physical frailty, all persons
older than 70 years and all individuals with
significant weight loss (5%) due to chronic
disease should be screened for frailty.
Fatigue
Resistance (Climb 1 flight stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
Fatigue
Resistance (Climb 1 flight
stairs)
Aerobic (Walk one block)
Illnesses
Loss of weight
FRAILTY
(IANA)
Fatigue Syndrome (CFS; myalgic
encephalitis)
Anemia
Treatment excess eg hypotension,
chemotherapy
Illnesses eg vitamin B12 deficiency,
heart failure, renal failure, cancer
Gulf War Syndrome (? toxin
exposure)
Unhappy (Depression)
Endocrine (Hypothyroid, Addison’s,
Diabetes mellitus)
Sleep Disorders (Sleep apnea, restless
legs, insomnia)
Resistance and balance
exercises
And protein
Aerobic Exercise
And protein
Reduce polypharmacy
PROTEIN AND ENERGY SUPPLEMENTATION IN
ELDERLY MALNOURISHED
Cochrane Database,2009
62 Trials; n=10,187
.
Maximum duration of intervention was 18 months.
Weight change showed a benefit of supplementation of
2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42
trials.
Mortality results were statistically significant when limited
to trials in which participants (N = 2461) were defined as
undernourished (RR 0.79, 95% CI 0.64 to 0.97).
The risk of complications was reduced in 24 trials (RR
0.86, 95% CI 0.75 to 0.99)
Intercom Trial
Efficacy of nutritional intervention in early COPD over 24 months
Improved Weight
Fat free mass
Muscle strength
6 minute walk distance
Decreased hospitalization
Characteristic Intervention Group ∆ Control Group ∆ Difference (95%
confidence interval)
Functional limitation score
n = 47 n = 50
Total (n = 97) –0.4 (1.4) 0.2 (1.5) –0.6 (–1.2–[–0.0])
Physical performance score
n = 39 n = 34
Total (n = 73) 2.6 (4.2) 2.6 (5.8) 0.1 (–2.3–2.4)
Physical activity score n = 38 n = 36
Total (n = 74) 0.7 (1.4) 0.5 (1.7) 0.2 (–0.5–0.9)
Body weight in kg n = 49 n = 49
Total (n = 98) 2.6 (4.1) 0.4 (5.6) 2.2 (0.3–4.2)
Post-discharge nutritional support in malnourished elderly individuals improves functional limitations.
Neelemaat F, Bosmans JE, Thijs A, Seidell JC, van Bokhorst-de van der Schueren MA. J Am Med Dir Assoc. 2011 May;12(4):295-301
Nutritional Supplements
Are Cost Effective
The National Institute for Health and Clinical
Excellence (United Kingdom) calculated that
the cost for Quality Adjusted Life Years of
NUTRITIONAL SCREENING and ORAL
NUTRITIONAL SUPPLEMENTS was
equivalent to £13,251
(www.nice.org.uk)
Wilson MM, et al.. Amer J Clinical Nutrition. 75(5):944-7, 2002
0
200
400
600
800
1000
1200
Water Milk Grape Corn
Syrup
Immediate
After 60 Min.
Calo
ries * * *
*p<0.05
Effect of Time of Administration of
Oral Caloric Supplements
Medications
Emotional (depression)
Alcoholism,anorexia tardive, abuse (elder)
Late life paranoia
Swallowing problems
Oral problems
Nosocomial infections,no money (poverty)
Wandering/dementia
Hyperthyroidism,hypercalcemia,hypoadrenalism
Enteric problems (malabsorption)
Eating problems (eg. Tremor)
Low salt, low cholesterol diet
Shopping and meal preparation problems, Stones (cholecystitis)
Caloric Supplementation and treat the
Causes of Weight Loss
Morley JE, Silver AJ. Ann Intern Med 1995;123:850-859.
JAMDA
Journal of the American
Medical Directors
Association
Impact Factor : 4.645
IAGG Curriculum Over 1000 slides on line IAGG Certificate at GARN
Network http://www.garn-network.org/
Frailty is now objectively defined and
can be treated and
can be simply screened
for in the clinic by FRAIL
There appears to be some utility of a
psychosocial frail scale (SOCIAL)
Johanna Quaas
87 years old