Carla Task Force on Sarcopenia: propositions for clinical trials

The MUnich SArcopenia Registry (MUSAR) : Paving the way for increased visibility, more frequent diagnoses and innovative new treatment

BACKGROUND

The consensus definition of sarcopenia enables a clear diagnostic algorithm. The syndrome can now also be coded in Germany (International Classification of Diseases 10, ICD-10 GM 62.50). Compared to the estimated prevalence it is still significantly underdiagnosed. Current treatment options include resistance training and a protein-rich diet, while pharmacological options are still missing.

OBJECTIVE

The Munich Sarcopenia Registry (MUSAR) aims to raise awareness of the syndrome and affected individuals. Additionally, it seeks to gain insights into risk factors, causes and treatment approaches. This publication conducts an initial analysis of 90 patient datasets with varying degrees of sarcopenia and examines the cohort for key geriatric parameters.

MATERIAL AND METHODS

Since 2018 patients from the geriatric clinic of the Ludwig Maximilians University Munich have been able to contribute their data to the registry. Sociodemographic, anthropometric, functional, and laboratory data are collected in a web-based registry.

RESULTS

Compared to patients without sarcopenia, patients with sarcopenia are significantly older, have more comorbidities and show poorer functional performance as well as reduced quality of life.

DISCUSSION

The results highlight the urgent need for further research and the development of new forms of treatment to improve the quality of life and independence of these patients. Challenges such as difficult recruitment complicate this endeavor. The MUSAR aims to minimize these issues and provides a valuable basis for generating extensive data through the systematic collection of patient data during hospital stays.

Myosteatosis in Cirrhosis: A Review of Diagnosis, Pathophysiological Mechanisms and Potential Interventions

Myosteatosis, or pathological excess fat accumulation in muscle, has been widely defined as a lower mean skeletal muscle radiodensity on computed tomography (CT). It is reported in more than half of patients with cirrhosis, and preliminary studies have shown a possible association with reduced survival and increased risk of portal hypertension complications. Despite the clinical implications in cirrhosis, a standardized definition for myosteatosis has not yet been established. Currently, little data exist on the mechanisms by which excess lipid accumulates within the muscle in individuals with cirrhosis. Hyperammonemia may play an important role in the pathophysiology of myosteatosis in this setting. Insulin resistance, impaired mitochondrial oxidative phosphorylation, diminished lipid oxidation in muscle and age-related differentiation of muscle stem cells into adipocytes have been also been suggested as potential mechanisms contributing to myosteatosis. The metabolic consequence of ammonia-lowering treatments and omega-3 polyunsaturated fatty acids in reversing myosteatosis in cirrhosis remains uncertain. Factors including the population of interest, design and sample size, single/combined treatment, dosing and duration of treatment are important considerations for future trials aiming to prevent or treat myosteatosis in individuals with cirrhosis.

Muscle Mass and Direct Oral Anticoagulant Activity in Older Adults With Atrial Fibrillation

BACKGROUND

Direct oral anticoagulants (DOAC) are hydrophilic drugs with plasma levels inversely proportional to lean body mass. Sarcopenic patients with low muscle mass may be at risk for supra-therapeutic DOAC levels and bleeding complications. We therefore sought to examine the influence of lean body mass on DOAC levels in older adults with atrial fibrillation (AF).

METHODS

A prospective cohort study was conducted with patients 65 years of age or more receiving rivaroxaban or apixaban for AF. Appendicular lean mass (ALM) was measured using a bioimpedance device and a dual X-ray absorptiometry scanner. DOAC levels were measured using a standardized anti-Xa assay 4 hours after (peak) and 1 hour before (trough) ingestion.

RESULTS

The cohort consisted of 62 patients (47% female, 77.0 ± 6.1 years). The prescribed DOACs were apixaban 2.5 mg (21%), apixaban 5 mg (53%), and rivaroxaban 20 mg (26%). Overall, 16% had supra-therapeutic DOAC levels at trough and 25% at peak. In the multivariable logistic regression model, lower ALM was independently associated with supra-therapeutic DOAC levels at trough (odds ratio per ↓ 1-kg 1.23, 95% confidence interval 1.02 to 1.49) and peak (odds ratio per ↓ 1-kg 1.18, 95% confidence interval 1.02 to 1.37). Addition of ALM to a model consisting of age, total body weight, and renal function resulted in improved discrimination for supra-therapeutic DOAC levels.

CONCLUSION

Our proof-of-concept study has identified an association between ALM and DOAC levels in older adults with AF. Further research is needed to determine the impact of ALM on bleeding complications and the potential role of ALM-guided dosing for sarcopenic patients.

Virtual Reality Balance Games Provide Little Muscular Challenge to Prevent Muscle Weakness in Healthy Older Adults

Objective: Muscle weakness is an important risk factor for falls in older adults. Intensity and duration of muscle activity are important determinants of exercise effectiveness in combating muscle weakness. The aim of this article was to assess the intensity and duration of muscle activity in virtual reality (VR) balance games. Materials and Methods: Thirty young and 30 healthy older adults played seven different VR balance games. Muscle activity of the vastus lateralis, vastus medialis, soleus, and gluteus medius was obtained using surface electromyography (EMG). The processed EMG signals were divided into 200-ms blocks, after which each block was categorized by its average normalized EMG activity, that is, >80%, 60%-80%, 40%-60%, or <40% of maximum voluntary contraction (MVC). We calculated the total number of blocks in each category to score intensity, as well as the maximal number of consecutive 200-ms blocks (MCBs) >40% MVC, to identify prolonged muscle activity. Results: Muscle activity during game play was mostly <40% MVC and prolonged activation was lacking. Only the games that included more dynamic movements showed activation blocks of higher intensity and resulted in more MCBs. Conclusion: Our method allowed us to analyze the overall muscle activity and the distribution of activity over a trial. Although the activation levels during these VR games were low in general, we identified game elements that could potentially provide a strength training stimulus. Future research should aim to implement these elements, such that the intensity, prolonged activity, and rest are optimized to sufficiently challenge lower limb muscles in VR training.

Critical appraisal of papers reporting recommendation on sarcopenia using the AGREE II tool: a EuroAIM initiative

BACKGROUND/OBJECTIVES

The growing interest of medical community about sarcopenia resulted in the production of several clinical practice guidelines (CPGs), with an unavoidable variability in terms of the overall quality of those publications. Our aim is to evaluate the quality of CPGs on sarcopenia using the AGREE II instrument.

SUBJECTS/METHODS

We performed an online literature search for sarcopenia CPGs using different databases. Four independent reviewers evaluated the quality of CPGs using the AGREE II instrument. To classify the quality of each guideline, we defined specific thresholds of final score: high-quality if five or more domains scored >60%; average-quality if three or four domains scored >60%; low-quality if ≤2 domains scored >60%.

RESULTS

Our literature search yielded 315 articles, and after applying exclusion criteria our final analysis included 19 CPGs. The overall quality of CPGs was remarkable, as 13/19 (68.4%) were considered of "high-quality" CPGs, with more than four domains reached a score higher than 60%. "Scope and Purpose" and "Clarity of Presentations" had the best domain results (78.4% and 73.8%, respectively), while the two domains with the lowest scores were "Rigor of Development" and "Applicability" (61.5% and 58.7%, respectively). Interobserver variability ranged between moderate (0.624) and fair (0.275).

CONCLUSIONS

Our study showed that the overall quality of CPGs about sarcopenia was noteworthy, as more than two-third of paper obtained a "high-quality" score. The domain "applicability" had the lowest score, suggesting that emphasis should be put on possible strategies for helping other doctors to implement guideline recommendations in clinical practice.

Get a grip: individual variations in grip strength are a marker of brain health

Demonstrations that grip strength has predictive power in relation to a range of health conditions-even when these are assessed decades later-has motivated claims that hand-grip dynamometry has the potential to serve as a "vital sign" for middle-aged and older adults. Central to this belief has been the assumption that grip strength is a simple measure of physical performance that provides a marker of muscle status in general, and sarcopenia in particular. It is now evident that while differences in grip strength between individuals are influenced by musculoskeletal factors, "lifespan" changes in grip strength within individuals are exquisitely sensitive to integrity of neural systems that mediate the control of coordinated movement. The close and pervasive relationships between age-related declines in maximum grip strength and expressions of cognitive dysfunction can therefore be understood in terms of the convergent functional and structural mediation of cognitive and motor processes by the human brain. In the context of aging, maximum grip strength is a discriminating measure of neurological function and brain health.

Training load does not affect detraining's effect on muscle volume, muscle strength and functional capacity among older adults

Research underlines the potential of low-load resistance exercise in older adults. However, while the effects of detraining from high-load protocols have been established, it is not known whether gains from low-load training would be better/worse maintained. The current study evaluated the effects of 24weeks of detraining that followed 12weeks of high- and low-load resistance exercise in older adults. Fifty-six older adults (68.0±5.0years) were randomly assigned to leg press and leg extension training at either HIGH load (2×10-15 repetitions at 80% of one-repetition maximum (1-RM)), LOW load (1×80-100 repetitions at 20% of 1-RM), or LOW+ load (1×60 repetitions at 20% of 1-RM, immediately followed by 1×10-20 repetitions at 40% 1-RM). All protocols ended with volitional fatigue. The main outcome measures included mid-thigh muscle volume, leg press 1-RM, leg extension isometric and isokinetic strength, and functional performance. Tests were performed at baseline, post-intervention and after 24weeks of detraining. Results show no effect of load on preservation of muscle volume, which returned to baseline after detraining. Training-induced gains in functional capacity and isometric strength were maintained, independent of load. HIGH and LOW+ were more beneficial than LOW for long-lasting gains in training-specific 1-RM. To conclude, gains in muscle volume are reversed after 24weeks of detraining, independent of load. This emphasises the need for long-term resistance exercise adherence. The magnitude of detraining in neuromuscular and functional adaptations was similar between groups. These findings underline the value of low-load resistance exercise in older age. Clinical Trial Registration NCT01707017.

The energy intake through regular nontherapeutic meals provision in long-term care: impact on nutritional status and related Geriatric Nutritional Risk Index

To investigate how the energy intake of institutionalized long-term-care patients through the regular nontherapeutic meals provision is associated with the nutritional status and the Geriatric Nutritional Risk Index (GNRI). A 9 month longitudinal, observational study. Long-term-care Hospital. 66 long-term-care patients with multiple medical conditions and solely oral food-intake. 47 (71 %) patients, predominantly women (n = 39/47), with a mean age of 83.04 (±9.58) years completed study time and 19 (29 %) deceased. At week 1 and week 36 of observation time energy intake was measured by means of three-days-weighing-records. Body composition was assessed with bioelectrical impedance analysis. Serum albumin, body weight and body height were taken from the medical report. Albumin content, body weight and height were used to calculate the Geriatric Nutritional Risk Index: GNRI = [1.489 × albumin (g/L)] + [41.7 × (weight/ideal body weight)]. Energy intake was significantly below 24 kcal/kg body weight per day. The GNRI of the deceased patients was significantly (p = 0.002) lower than the GNRI of the completers. During observation time energy-intake p < 0.001, body fat (p = 0.001) and phase angle (PA) of bio impedance measurement (p = 0.018) and likewise the GNRI (p = 0.021) of the completers decreased significantly. At the beginning and at the end of observation time energy intake correlated significantly with PA (p = 0.028/p < 0.001) and GNRI (p = 0.436/p = 0.004). Also GNRI and PA correlated significantly at the beginning (p = 0.001) and at the end (p < 0.001) of observation time. The energy intake through non therapeutic meals provision was too low for sustaining the nutritional status and likewise the GNRI. The malnourishment and the nutrition related clinical risk of the geriatric patients aggrevated during observation time.

Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older

In this study, we compare the extent to which seven available definitions of sarcopenia and two related definitions predict the rate of falling. Our results suggest that the definitions of Baumgartner and Cruz-Jentoft best predict the rate of falls among sarcopenic versus non-sarcopenic community-dwelling seniors.

INTRODUCTION

The purpose of the study is to compare the extent to which seven available definitions of sarcopenia and two related definitions predict the prospective rate of falling.

METHODS

We studied a cohort of 445 seniors (mean age 71 years, 45 % men) living in the community who were followed with a detailed fall assessment for 3 years. For comparing the rate of falls in sarcopenic versus non-sarcopenic individuals, we used multivariate Poisson regression analyses adjusting for gender and treatment (original intervention tested vitamin D plus calcium against placebo). Of the seven available definitions, three were based on low lean mass alone (Baumgartner, Delmonico 1 and 2) and four required both low muscle mass and decreased performance in a functional test (Fielding, Cruz-Jentoft, Morley, Muscaritoli). The two related definitions were based on low lean mass alone (Studenski 1) and low lean mass contributing to weakness (Studenski 2).

RESULTS

Among 445 participants, 231 fell, sustaining 514 falls over the 3-year follow-up. The prospective rate of falls in sarcopenic versus non-sarcopenic individuals was best predicted by the Baumgartner definition based on low lean mass alone (RR = 1.54; 95 % CI 1.09-2.18) with 11 % prevalence of sarcopenia and the Cruz-Jentoft definition based on low lean mass plus decreased functional performance (RR = 1.82; 95 % CI 1.24-2.69) with 7.1 % prevalence of sarcopenia. Consistently, fall rate was non-significantly higher in sarcopenic versus non-sarcopenic individuals based on the definitions of Delmonico 1, Fielding, and Morley.

CONCLUSION

Among the definitions investigated, the Baumgartner definition and the Cruz-Jentoft definition had the highest validity for predicting the rate of falls.

Does Sarcopenia Impact Complications and Overall Survival in Patients Undergoing Radical Nephrectomy for Stage III and IV Kidney Cancer?

PURPOSE

To investigate the association of sarcopenia (muscle mass wasting) with complications and survival in patients undergoing radical nephrectomy for advanced kidney cancer.

PATIENTS AND METHODS

We identified 137 patients with stage III and IV kidney cancer who underwent radical nephrectomy between 2008 and 2012. Preoperative cross-sectional imaging was used to measure total psoas area (TPA) at the level of L3 and controlled for height (m(2)). Sarcopenia was identified as TPA in the lowest gender-specific quartile. Patient characteristics and postoperative complications were compared between sarcopenic and nonsarcopenic patients. Kaplan-Meier survival curve estimates were generated for overall and gender-specific survival.

RESULTS

Preoperative cross-sectional imaging was available for 128 patients (93%, 85 men and 43 women). Mean TPA for men was 5.49 cm(2)/m(2) versus 4.27 cm(2)/m(2) for women (P < 0.05). Sarcopenia was associated with risk of Clavien grade III or higher complication (P = 0.03) and node-positive disease (P = 0.01). Median follow-up was 48.3 months. Kaplan-Meier estimates of overall and gender-specific survival were similar between sarcopenic and nonsarcopenic patients.

CONCLUSION

Sarcopenia appears to be associated with risk of major complication after radical nephrectomy for advanced kidney cancer. It was not related to overall survival, however. This preoperative imaging tool may be helpful in preoperative counseling and preparation.

Evaluation and Management of the Geriatric Urologic Oncology Patient

The geriatric population presents a unique set of challenges in urologic oncology. In addition to the known natural history of disease, providers must also consider patient factors such as functional and nutritional status, comorbidities and social support when determining the treatment plan. The development of frailty measures and biomarkers to estimate surgical risk shows promise, with several assessment tools predictive of surgical complications. Decreased dependence on chronologic age is important when assessing surgical fitness, as age cutoffs prevent appropriate treatment of many elderly patients who would benefit from surgery. Within bladder, kidney and prostate cancers, continued refinement of surgical techniques offers a broader array of options for the geriatric patient than previously available.

Strength and function response to clinical interventions of older women categorized by weakness and low lean mass using classifications from the Foundation for the National Institute of Health sarcopenia project

BACKGROUND

The Foundation for the National Institutes of Health Sarcopenia Project developed data-driven cut-points for clinically meaningful weakness and low lean body mass. This analysis describes strength and function response to interventions based on these classifications.

METHODS

In data from four intervention studies, 378 postmenopausal women with baseline and 6-month data were evaluated for change in grip strength, appendicular lean mass corrected for body mass index, leg strength and power, and short physical performance battery (SPPB). Clinical interventions included hormones, exercise, and nutritional supplementation. Differences in outcomes were evaluated between (i) those with and without weakness and (ii) those with weakness and low lean mass or with one but not the other. We stratified analyses by slowness (walking speed ≤ 0.8 m/s) and by treatment assignment.

RESULTS

The women (72±7 years; body mass index of 26±5kg/m(2)) were weak (33%), had low lean mass (14%), or both (6%). Those with weakness increased grip strength, lost less leg power, and gained SPPB score (p < .05) compared with nonweak participants. Stratified analyses were similar for grip strength and SPPB. With lean mass in the analysis, individuals with weakness had larger gains in grip strength and SPPB scores regardless of low lean mass (p < .01).

CONCLUSIONS

Older women with clinically meaningful muscle weakness increased grip strength and SPPB, regardless of the presence of low lean mass following treatment with interventions for frailty. Thus, results suggest that muscle weakness, as defined by the Foundation for the National Institutes of Health Sarcopenia Project, appears to be a treatable symptom.

Sarcopenia as a predictor of complications and survival following radical cystectomy

PURPOSE

Patients undergoing radical cystectomy face substantial but highly variable risks of major complications. Risk stratification may be enhanced by objective measures such as sarcopenia. Sarcopenia (loss of skeletal muscle mass) has emerged as a novel biomarker associated with adverse outcomes in many clinical contexts relevant to cystectomy. Based on these data we hypothesized that sarcopenia would be associated with increased 30-day major complications and mortality after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

We performed a retrospective study of patients treated with radical cystectomy at our institution from 2008 to 2011. Sarcopenia was assessed by measuring cross-sectional area of the psoas muscle (total psoas area) on preoperative computerized tomography. Cutoff points were developed and evaluated using ROC curves to determine predictive ability in men and women for outcomes of major complications and survival.

RESULTS

Of 224 patients with bladder cancer 200 underwent preoperative computerized tomography within 1 month of surgery. Total psoas area was calculated with a mean score of 712 and 571 cm2/m2 in men and women, respectively. A clear association was noted between major complications and lower total psoas area in women using a cutoff of 523 cm2/m2 to define sarcopenia (AUC 0.70). Sarcopenia was not significantly associated with complications in men. There was a nonsignificant trend of sarcopenia with worse 2-year survival.

CONCLUSIONS

Sarcopenia in women was a predictor of major complications after radical cystectomy. Further research confirming sarcopenia as a useful predictor of complications would support the development of targeted interventions to mitigate the untoward effects of sarcopenia before cancer surgery.

Vitamin D Deficiency Treatment Patterns in Academic Urban Medical Center

OBJECTIVE

Assess racial/ethnic and sex differences in treatment of vitamin D deficiency with high dose ergocalciferol ('vitamin D2') or other forms of vitamin D in a northeastern U.S. ambulatory clinic of an academic urban medical center.

STUDY DESIGN

Cross-sectional observational review of electronic medication prescribing records of patients with 25-hydroxyvitamin D (25OHD) deficiency (25OHD < 20 ng/ml) from 2004-2008.

METHODS

Using multivariable logistic regression adjusting for patients' demographics, and Elixhauser comorbidity score, we examined the association of sex and race/ethnicity with prescription for at least one dose of vitamin D.

RESULTS

Among 2,140 patients without renal disease and tested for 25OHD deficiency (25OHD < 20 ng/ml), 66.2% received no vitamin D prescription for vitamin D deficiency. Blacks and Hispanics received vitamin D prescriptions at a higher frequency than whites, 37.8% 38.4% and 30.9%, respectively, p=0.003. The vitamin D prescription rate for women versus men was 26.3% and 7.5%, respectively, p=0.04. In a fully adjusted model, no difference in prescription likelihood for blacks and whites [OR=1.18 95% CI, 0.88-1.58; p=0.29] or Hispanics and whites was noted [OR=1.01 95% CI, 0.70-1.45;p=0.73]. Similarly, fully adjusted model showed no difference in prescription likelihood for females and males [OR=1.23 95% CI, 0.93-1.63; p=0.12].

CONCLUSIONS

Among primary care patients with vitamin D deficiency, vitamin D supplementation was low and white patients were less likely to receive vitamin D treatment than blacks or Hispanics. Interventions to correct the high prevalence of vitamin D deficiency should address the markedly low rate of vitamin D prescribing when 25OHD levels are measured.

The impact of sarcopenia on a physical activity intervention: the Lifestyle Interventions and Independence for Elders Pilot Study (LIFE-P)

OBJECTIVE

To determine if sarcopenia modulates the response to a physical activity intervention in functionally limited older adults.

DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Three academic centers.

PARTICIPANTS

Elders aged 70 to 89 years at risk for mobility disability who underwent dual-energy x-ray absorptiometry (DXA) for body composition at enrollment and follow-up at twelve months (N = 177).

INTERVENTION

Subjects participated in a physical activity program (PA) featuring aerobic, strength, balance, and flexibility training, or a successful aging (SA) educational program about healthy aging.

MEASUREMENTS

Sarcopenia as determined by measuring appendicular lean mass and adjusting for height and total body fat mass (residuals method), Short Physical Performance Battery score (SPPB), and gait speed determined on 400 meter course.

RESULTS

At twelve months, sarcopenic and non-sarcopenic subjects in PA tended to have higher mean SPPB scores (8.7±0.5 and 8.7±0.2 points) compared to sarcopenic and non-sarcopenic subjects in SA (8.3±0.5 and 8.4±0.2 points, p = 0.24 and 0.10), although the differences were not statistically significant. At twelve months, faster mean gait speeds were observed in PA: 0.93±0.4 and 0.95±0.03 meters/second in sarcopenic and non-sarcopenic PA subjects, and 0.89±0.4 and 0.91±0.03 meters/second in sarcopenic and non-sarcopenic SA subjects (p = 0.98 and 0.26), although not statistically significant. There was no difference between the sarcopenic and non-sarcopenic groups in intervention adherence or number of adverse events.

CONCLUSION

These data suggest that older adults with sarcopenia, who represent a vulnerable segment of the elder population, are capable of improvements in physical performance after a physical activity intervention.

Effects of whey proteins and carbohydrates on the efficacy of resistance training in elderly people: double blind, randomised controlled trial

BACKGROUND/OBJECTIVES

A few previous studies indicate that protein supplementation increases gains in muscle mass and strength during a resistance exercise program. The purpose of this study was to investigate whether whey protein supplementation results in greater increases in lean body mass, muscle strength and physical function in elderly individuals during 12 weeks of resistance exercise when compared to isocaloric carbohydrate supplementation.

SUBJECTS/METHODS

A total of 161 men and women, 65-91 years old, participated in a randomized, controlled, double-blind intervention study, involving dietary supplementation and a 12-week resistance exercise program, designed to increase muscle mass and strength of all major muscle groups. Participants exercised three times a week and received either 20 g of whey protein (n=83) or isocaloric carbohydrate (n=78) in liquid form immediately after each workout. Data were obtained at baseline and end point.

RESULTS

The primary outcomes, lean body mass, strength and physical function increased significantly during the course of the study. Type of dietary supplementation did not influence gains in lean body mass (P=0.365), quadriceps strength (P=0.776) or performance during a 6-min walk (P=0.726) or a timed up-and-go test (P=0.151). Twenty participants discontinued the intervention.

CONCLUSIONS

Ingestion of 20 g of whey protein immediately after resistance exercise three times per week, does not lead to greater gains in lean body mass, strength and physical function in elderly people with sufficient energy and protein intakes when compared to isocaloric carbohydrate.

Temporal relationship between handgrip strength and cognitive performance in oldest old people

BACKGROUND

cognitive decline and muscle weakness are prevalent health conditions in elderly people. We hypothesised that cognitive decline precedes muscle weakness.

OBJECTIVE

to analyse the temporal relationship between cognitive performance and handgrip strength in oldest old people.

DESIGN

prospective population-based 4-year follow-up study.

SUBJECTS

a total of 555 subjects, all aged 85 years at baseline, were included into the study.

METHODS

handgrip strength measured at age 85 and 89 years. Neuropsychological test battery to assess global cognitive performance, attention, processing speed and memory at baseline and repeated at age 89 years. Associations between handgrip strength and cognitive performance were analysed by repeated linear regression analysis adjusted for common confounders.

RESULTS

at age 85 and 89 years, better cognitive performance was associated with higher handgrip strength (all, P<0.03), except for attention. There was no longitudinal association between baseline handgrip strength and cognitive decline (all, P>0.10), except for global cognitive performance (P=0.007). Better cognitive performance at age 85 years was associated with slower decline in handgrip strength (all, P<0.01) after adjustment for common confounders.

CONCLUSION

baseline cognitive performance was associated with decline in handgrip strength, whereas baseline handgrip strength was not associated with cognitive decline. Our results suggest that cognitive decline precedes the onset of muscle weakness in oldest old people.

Diabetes and frailty: an emerging issue. Part 2: Linking factors

Diabetes and frailty may be causally related and operate through each of the key components of the frailty phenotype or via the associated medical co-morbidities. The presence of frailty in a setting of diabetes increases the level of disability and leads to poorer clinical outcomes. The vascular complications of diabetes (both macro- and microvascular) are implicated in this aetiopathogenesis of frailty and any associated mood disturbance or cognitive impairments worsen the outcome. Research into exploring this relationship further is needed and this may lead to more effective interventional strategies.

The frailty syndrome: a comprehensive review

The frailty syndrome is defined as unintentional weight and muscle loss, exhaustion, and declines in grip strength, gait speed, and activity. Evidence with respect to the clinical definition, epidemiology, mechanisms, interactions, assessment, prevention, and treatment of frailty in the older adult is reviewed.

Nutrition and sarcopenia: evidence for an interaction

Nutritional interventions that might influence sarcopenia, as indicated by literature reporting on sarcopenia per se as well as dynapenia and frailty, are reviewed in relation to potential physiological aetiological factors, i.e. inactivity, anabolic resistance, inflammation, acidosis and vitamin D deficiency. As sarcopenia occurs in physically active and presumably well-nourished populations, it is argued that a simple nutritional aetiology is unlikely and unequivocal evidence for any nutritional influence is extremely limited. Dietary protein is probably the most widely researched nutrient but only for frailty is there one study showing evidence of an aetiological influence and most intervention studies with protein or amino acids have proved ineffective with only a very few exceptions. Fish oil has been shown to attenuate anabolic resistance of muscle protein synthesis in one study. There is limited evidence for a protective influence of antioxidants and inducers of phase 2 proteins on sarcopenia, dynapenia and anabolic resistance in human and animal studies. Also fruit and vegetables may protect against acidosis-induced sarcopenia through their provision of dietary potassium. While severe vitamin D deficiency is associated with dynapenia and sarcopenia, the evidence for a beneficial influence of increasing vitamin D status above the severe deficiency level is limited and controversial, especially in men. On this basis there is insufficient evidence for any more specific nutritional advice than that contained in the general healthy lifestyle–healthy diet message: i.e. avoiding inactivity and low intakes of food energy and nutrients and maintain an active lifestyle with a diet providing a rich supply of fruit and vegetables and frequent oily fish.

Force-velocity characteristics of the knee extensors: an indication of the risk for physical frailty in elderly women

OBJECTIVES

To examine the relationship between muscle strength, speed of movement, muscle mass (MM), and functional performance in elderly women and to determine optimal threshold values below which physical frailty occurs.

DESIGN

Survey.

SETTING

University-based laboratory.

PARTICIPANTS

Institutionalized women (N=123; mean age, 79.67 ± 5.2y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Force-velocity characteristics of the knee extensors were evaluated by using isometric, isokinetic, and ballistic tests on a motor-driven dynamometer. Isometric (ISOM) strength, dynamic strength, maximal speed of movement (SoM, unloaded), and speed of movement with standardized resistance of 20% (S(20)), 40% (S(40)), and 60% (S(60)) of the isometric maximum were recorded. MM of the upper leg was determined by using computed tomography. The modified Physical Performance Test (mPPT) was used to assess functional performance.

RESULTS

Force-velocity characteristics (r varied from .31-.68) and MM (r=.41) correlated significantly with functional performance (P<.05). In a forward stepwise regression model, only SoM and ISOM strength remained independently associated with mPPT score (R(2)=.49), with SoM accounting for most of the variance. The threshold value that optimally differentiates between women with mild (mPPT score, 25-31) or without (mPPT score ≥32) physical frailty was 350°/s for SoM and 1.46N m/kg for ISOM strength. Sensitivity and specificity ranged from 74% to 77% and 71% to 77%, respectively.

CONCLUSIONS

SoM is a key component in the onset of functional difficulties in elderly women. Exercise interventions specifically targeting muscle power (by including exercises at high velocities) thus might be crucial to prevent functional decline.

Designing Phase II B trials in sarcopenia: the best target population

Despite the existing limitations and controversies regarding the definition of sarcopenia and its clinical consequences, the current scientific evidence strongly suggests that muscle decline is a primary determinant of the disabling process (and likely of other major health-related events). In fact, the muscle loss (in terms of mass as well as strength) occurring with aging has been growingly associated with mobility impairment and disability in older persons. Unfortunately, current evidence is mainly from observational studies. Times are mature to begin testing interventions aimed at modifying the sarcopenia process through the design and development of specific clinical trials. Considering the emergence of many promising interventions towards this age-related condition (e.g., physical exercise [in particular, resistance training], testosterone, antioxidant supplementations), the need for Phase II trial designs is high. In the present report, we discuss which are the major issues related to the design of Phase II clinical trials on sarcopenia with particular focus on the participant's characteristics to be considered as possible inclusion and exclusion criteria.

Clinical trials on sarcopenia: methodological issues regarding phase 3 trials

Phase 3 trials estimate the effectiveness of an intervention to prevent, delay the onset of, or treat sarcopenia. Participants should have sarcopenia or present a sarcopenia risk profile. Control group should be characterized by the best standard of clinical care. This article further develops issues on sarcopenia definition, target population, primary and secondary end points, duration of the trials, muscle mass assessment, strength and physical performance assessment, and control of possible confounders. The challenges to conduct phase 3 trials in the elderly should not offset the opportunities for the development of new strategies to counteract sarcopenia and prevent late-life disability.

Higher blood pressure is associated with higher handgrip strength in the oldest old

BACKGROUND

Aging is associated with progressive loss of muscle strength. Muscle tissue is vascularized by an elaborate vascular network. There is evidence that blood pressure (BP) is associated with muscle function in middle age. It is unknown how BP associates with muscle function in oldest old people. We studied the association between BP and handgrip strength in middle and old age.

METHOD

BP was measured automatically in middle-aged subjects and with a mercury sphygmomanometer in the oldest old. Handgrip strength was measured with a handgrip strength dynamometer. Cross-sectional measurements of handgrip strength and BP were available for 670 middle-aged subjects (mean 63.2 ± 6.6 years) and 550 oldest old subjects (all 85 years). Prospective data were available for oldest old subjects only with a 4-year follow-up at 89 years. The association between BP and handgrip strength was analyzed by linear regression analysis.

RESULTS

In middle-aged subjects, BP and handgrip strength were not statistically significantly associated. In oldest old subjects, higher systolic BP (SBP), mean arterial pressure (MAP), and pulse pressure (PP) were associated with higher handgrip strength after adjusting for comorbidity and medication use (all P < 0.02). Furthermore, in oldest old subjects, changes in SBP, MAP, and PP after 4 years was associated with declining handgrip strength (all, P < 0.05).

CONCLUSION

In oldest old, higher BP is associated with better muscle strength. Further study is necessary to investigate whether BP is a potential modifiable risk factor for prevention of age-associated decline in muscle strength.

Clinical practice in nursing homes as a key for progress

With the aging of the world's population there has become a major need for the development of nursing homes throughout the world. While some countries provide high quality care for the disabled elderly, in others this is not the case. Education of a medical director has been shown to improve the quality of the nursing home. Physicians need to have knowledge of how to implement continuous quality improvement and culture change. Key medical issues include moving to a restraint free environment, subsyndromal delirium, behavioral disturbances, weight loss, pain management, pressure ulcers, falls, hip fractures, polypharmacy, depression and frailty.

Nutritional recommendations for the management of sarcopenia

The Society for Sarcopenia, Cachexia, and Wasting Disease convened an expert panel to develop nutritional recommendations for prevention and management of sarcopenia. Exercise (both resistance and aerobic) in combination with adequate protein and energy intake is the key component of the prevention and management of sarcopenia. Adequate protein supplementation alone only slows loss of muscle mass. Adequate protein intake (leucine-enriched balanced amino acids and possibly creatine) may enhance muscle strength. Low 25(OH) vitamin D levels require vitamin D replacement.

Functional consequences of sarcopenia and dynapenia in the elderly

PURPOSE OF REVIEW

The economic burden due to the sequela of sarcopenia (muscle wasting in the elderly) are staggering and rank similarly to the costs associated with osteoporotic fractures. In this article, we discuss the societal burden and determinants of the loss of physical function with advancing age, the physiologic mechanisms underlying dynapenia (muscle weakness in the elderly), and provide perspectives on related critical issues to be addressed.

RECENT FINDINGS

Recent epidemiological findings from longitudinal aging studies suggest that dynapenia is highly associated with both mortality and physical disability even when adjusting for sarcopenia indicating that sarcopenia may be secondary to the effects of dynapenia. These findings are consistent with the physiologic underpinnings of muscle strength, as recent evidence demonstrates that alterations in muscle quantity, contractile quality and neural activation all collectively contribute to dynapenia.

SUMMARY

Although muscle mass is essential for regulation of whole body metabolic balance, overall neuromuscular function seems to be a critical factor for maintaining muscle strength and physical independence in the elderly. The relative contribution of physiologic factors contributing to muscle weakness are not fully understood and further research is needed to better elucidate these mechanisms between muscle groups and across populations.

Resistance Training During Weight Loss in Overweight and Obese Older Adults: What Are the Benefits?

Obesity and sarcopenia are important public health challenges that affect the healthy aging trajectory of older adults. Although weight loss is recommended for overweight and obese older adults to prevent chronic disease, exercise is an important additional weight management strategy to maximize fat mass loss while retaining lean mass and improving function. Resistance training (RT) is a well-known exercise modality to improve muscle function and lean mass and has been investigated in several recent studies as a potentially powerful strategy to employ along with weight loss in overweight and obese older adults. RT is an important exercise training strategy as outlined in the Physical Activity Guidelines for Americans and is recommended by the American College of Sports Medicine for older adults who are able to safely participate. This brief review will highlight some of the age-related consequences of sarcopenia and obesity and will summarize some of the published research findings of combined RT and weight loss in overweight and obese older adults.