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