Asli Tufan

Prevalence of potentially inappropriate prescribing among older adults: A comparison of the Beers 2012 and Screening Tool of Older Person's Prescriptions criteria version 2

To date, there is no study comparing the Beers 2012 and Screening Tool of Older Persons Prescriptions (STOPP) version 2 criteria, nor reporting a comparison of the prevalence of potentially inappropriate Prescribing (PIM) with STOPP version 2. We aimed to evaluate the prescriptions of patients admitted to a geriatric outpatient clinic with these tools, and to document the factors related to PIM use.

Low glomerular filtration rate as an associated risk factor for sarcopenic muscle strength: is creatinine or cystatin C-based estimation more relevant?

Abstract Introduction: We aimed to evaluate the association of a decreased glomerular-filtration-rate (GFR <60 ml/min/1.73 m2), estimated using Modification of Diet in Renal Disease (MDRD), creatinine- and cystatin C-based (CKDEPI-CR and CKDEPI-CC) Chronic Kidney Disease Epidemiology Collaboration equations with handgrip strength (HGS). Methods: Community-dwelling males aged ≥60 years admitted to outpatient clinic were included. We used MDRD, CKDEPI-CR, and CKDEPI-CC formulas for GFR estimation and corrected these for body surface area. Muscle strength was assessed by HGS. Results: 209 men (mean age 67.8 ± 6.4) were enrolled. Sixty-two patients (29.7%) had sarcopenic HGS. Subjects with sarcopenic HGS were older, had higher rate of a GFR < 60 ml/min/1.73 m2, had lower mid-upper arm circumference; tended to have lower creatine kinase, albumin, CKDEPI-CC-GFR levels; and higher BUN/creatinine ratio and cystatin C. Multivariate logistic regression analysis revealed a CKDEPI-CC lower than 60 ml/min/1.73 m2 as the only independent factor underlying sarcopenic HGS. Higher age tended to have an independent association. Only higher age was independently associated with low HGS when other estimations were used (p = 0.013 and p = 0.021 when MDRD and CKDEPI-CR were used, respectively). Conclusions: There is a strong association of a GFR level of <60 ml/min/1.73 m2 with sarcopenic HGS, when CKDEPI-CC formula is used.

Low skeletal muscle mass index is associated with function and nutritional status in residents in a Turkish nursing home.

Abstract Introduction: To determine the prevalence of low muscle mass (LMM) and the relationship between LMM with functional and nutritional status as defined using the LMM evaluation method of European Working Group on Sarcopenia in Older People (EWGSOP) criteria among male residents in a nursing home. Methods: Male residents aged >60 years of a nursing home located in Turkey were included in our study. Their body mass index (BMI) kg/m2, skeletal muscle mass (SMM-kg) and skeletal muscle mass index (SMMI-kg/m2) were calculated. The participants were regarded as having low SMMI if they had SMMI <9.2 kg/m2 according to our population specific cut-off point. Functional status was evaluated with Katz activities of daily living (ADL) and Lawton Instrumental Activities of Daily Living (IADL). Nutritional assessment was performed using the Mini Nutritional Assessment (MNA). The number of drugs taken and chronic diseases were recorded. Results: One hundred fifty-seven male residents were enrolled into the study. Their mean age was 73.1 ± 6.7 years with mean ADL score of 8.9 ± 2.0 and IADL score of 8.7 ± 4.6. One hundred twelve (71%) residents were aged >70 years. Thirty-five men (23%) had low SMMI in group aged >60 years, and twenty-eight subjects (25%) in the group aged >70 years. MNA scores were significantly lower in residents with low SMMI compared with having normal SMMI (17.1 ± 3.4 versus 19.6 ± 2.5, p = 0.005). BMI was significantly lower in the residents with low SMMI compared with normal SMMI (19.6 ± 2.7 versus 27.1 ± 4.1, p< 0.001). ADL scores were significantly different between residents with low SMMI and normal SMMI in those aged >70 years (8.1 ± 2.6 versus 9.1 ± 1.6, p = 0.014). In regression analyses, the only factor associated with better functional status was the lower age (p = 0.04) while the only factor associated with better nutrition was higher SMMI (p = 0.01). Conclusions: Low SMMI detected by LMM evaluation method of EWGSOP criteria is prevalent among male nursing home residents. There is association of low SMMI with nutritional status and probably with functional status within the nursing home setting using the EWGSOP criteria with Turkish normative reference cut-off value.

Prevalence of sarcopenia and its components in community-dwelling outpatient older adults and their relation with functionality

AIM Sarcopenia is recognized with its adverse functional outcomes. We aimed to report the prevalence of European Working Group on Sarcopenia in Older People (EWGSOP) defined sarcopenia and its individual components in community dwelling outpatient older adults and study the correlations of EWGSOP defined sarcopenia, muscle mass, muscle strength, and physical performance with functional status. MATERIAL AND METHODS The subjects were prospectively recruited from the geriatrics outpatient clinics of our university hospital. Body composition was assessed with bioimpedance analysis. Muscle strength was assessed by measurement of hand grip strength with hydraulic hand dynamometer, physical performance was assessed by 4 meter usual gait speed (UGS). Impaired muscle function was defined as presence of low muscle strength and or slow gait speed. As a measure of functionality, modified version of Katz activities of daily living (ADL) and Lawton instrumental activities of daily living (IADL) were assessed. RESULTS A total of 242 community dwelling outpatients with mean age of 79.4 ± 5.7 years were enrolled. 31.8% were male. Prevalence of low muscle mass was 2.1% and impaired muscle function was 71.1%. Prevalence of EWGSOP defined sarcopenia was 0.8% (1.3% in men and 0.6% in women). Most correlated parameter with ADL and IADL was the usual gait speed (r = 0.49, r = 0.63; p < .001, respectively). Grip strength was also correlated with ADL and IADL (r = 0.28, r = 0.35; p < .001). However, the skeletal muscle mass index (SMMI) was not correlated with ADL, IADL (p = .22, p = .22, respectively). In regression analysis, both ADL score and IADL scores were most related to UGS (beta = 0.5 and 0.6, p < .001), age (beta = -0.25 and -0.2, p < .001) and then sarcopenia (beta = 0.1 and 0.1, p < .05) but was not related to hand grip strength or SMMI. CONCLUSIONS The prevalence of sarcopenia was low as 0.8% albeit the presence of impaired muscle function in more than 2/3 of the cases. We have found that EWGSOP defined sarcopenia had association with ADL and IADL. The gait speed component of sarcopenia had the strongest associations with functional measures but SMMI component did not have any relation. We suggest that although low muscle mass may be a parameter related to worse functionality, it should not be regarded prerequisite for presence of sarcopenia analogous to low bone mineral density for osteoporosis.

Low Body Mass Index As a Risk Factor for Functional Dependency in Frail Individuals: Letter to the Editor

To the Editor: We read the article by Kosar and colleagues with great interest. The authors studied the effect of obesity on outcomes of older adults admitted to skilled nursing facilities for hip fracture postacute care. We have some comments and questions on this comprehensive article. First, we would like to ask whether the residents were examined for sarcopenia. Sarcopenia is a risk factor for falls. Rather than obesity, it may be that sarcopenic obesity was problematic in these individuals. The authors noted that obesity might be associated with weakness and poor lower extremity function. These are probably the consequences of lower extremity sarcopenia, which is in part due to lack of lower extremity use with knee and hip osteoarthritis. Hence, integration of sarcopenia analyses would add a substantial contribution to this important study. Otherwise, this lack should be noted as a limitation. Second, some studies have suggested that low body mass index (BMI) is a risk factor for functional dependency , especially in frail individuals . This was overlooked in the article. Also, the 1989 report of the American Committee on Diet and Health suggested that the optimal range of BMI for American older adults is 24.0 to 29.0 kg/m , but in the Kosar study, residents were divided into 4 BMI categories. The authors defined the first group as having a BMI between 18.5 and 29.9 kg/m and designated it as “nonobese.” This is a very heterogeneous group. Moreover, a BMI between 18.5 and 20.0 kg/m is regarded as borderline by ESPEN (The European Society for Clinical Nutrition and Metabolism) underweight and such individuals are at high risk of adverse outcomes and complications after fractures because of malnutrition . We suggest that the authors perform additional statistical analyses after excluding this group. In the results section, there were some parameters with wide standard deviations. Median scores should be given such that readers can have a better overview of the data. Another point is whether the authors had deep vein thrombosis, polypharmacy, and antipsychotic and opiate use data. These factors are important determinants of hospital re‐ admission, and some may be more prevalent in obese people. This analysis would contribute to the data interpretation, and if not present, it should be discussed as a limitation. Finally, the authors noted that they made regression models that were adjusted for age and age squared. This might cause multicollinearity, resulting from the repetition of the same kind of variable. Asli Tufan, MD Division of Geriatrics, Department of Internal Medicine, Marmara University Hospital, Istanbul, Turkey

Herpes Simplex Virus Encephalitis in Geriatric Patients

Purpose of ReviewHerpes simplex virus encephalitis (HSVE) is a rare, devastating infectious disease of the brain. We reviewed published case series to determine whether epidemiology, clinical characteristics, and prognosis of HSVE differed in geriatric patients.Recent FindingsGeriatric patients have a higher incidence of HSVE and a worse prognosis than the rest of the adult population.SummaryThe gold standard to confirm HSVE diagnosis is to demonstrate HSV DNA in cerebrospinal fluid using polymerase chain reaction. Antiviral treatment with acyclovir prevents HSVE-related morbidity and mortality if started on time. Diagnosis and treatment of HSVE pose specific challenges due to comorbidities and medical conditions presenting with similar signs and symptoms commonly encountered in geriatric medicine. Thus, timely empirical treatment and confirmation of diagnosis in this patient population relies largely on astuteness of the clinician.

Suggestions on sarcopenia-related trials

We read the article by Reginster et al. [1] on recommendations for the conduct of clinical trials for drugs to treat or prevent sarcopenia with great, special interest. The authors successfully suggested a set of potential end-points and target population definitions to stimulate debate and progress within the medico-scientific and regulatory communities, which is an essential step towards sarcopenia treatment/prevention. We have some comments on this well-designed position paper. Among the operational definitions of sarcopenia, the authors mentioned the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, whose use they advocated in the screening (diagnostic) process to recruit patients for studies, and they also discussed the related measures of muscle mass or function as gait speed, hand grip strength (HGS), and appendicular lean mass (ALM). However, it should be noted that in the EWGSOP consensus, the appendicular muscle mass and absolute muscle mass were introduced and recommended as measures of muscle mass for which they also outlined suggested cut-off thresholds [2]. Furthermore, the authors only mentioned dual-energy X-ray absorptiometry (DXA) as an assessment tool for body composition–muscle mass, but bioimpedance analysis (BIA) is also suggested in both research and clinical practice. BIA is a good portable alternative to DXA and its easier use should be considered, which will ease and trigger further much-needed research in sarcopenia. An additional point is that the authors noted the relevant low strength values of HGS suggested in EWGSOP as \30 kg for men and\20 kg for women. However, these thresholds were from an Italian population [3]. EWGSOP recommends use of normative healthy young adults’ data of the study population rather than other predictive reference populations. A very recent such threshold to be mentioned was reported by our group from Turkey as\32 and 22 kg for men and women, respectively [4]. Finally, the authors suggested use of EWGSOP criteria using the presence of both low muscle mass and low muscle function (strength or performance) in the screening (diagnostic) process to recruit patients and also suggested prevention of sarcopenia in high-risk pre-sarcopenic individuals, who are characterised by the existence of low muscle mass alone. However, as it is also noted in the paper, low muscle strength (frequently referred to as dynapenia) is generally more strongly associated with poor function and disability than low muscle mass. Hence, the presented suggestion for recruiting patients in sarcopenia-related research would not recruit individuals with isolated low muscle strength (dynapenia). We suggest that individuals with isolated dynapenia should also be candidates for such therapy and therefore should be recruited in such research.

Queries raised about MNA for frail older hospital patients

In recent issue of Clinical Nutrition, we have read with a great interest the article by Slee et al. entitled “A comparison of the malnutrition screening tools, MUST, MNA and bioelectrical impedance assessment in frail older hospital patients” [1]. They show the potential ability of the MNA-SF and BIA to accurately assess malnutrition risk over MUST in frail older hospital patients. ESPEN recommends subjects at risk of malnutrition are identified by validated screening tools like NRS-2002, MNA-SF and MUST. They use different criteria and cut-offs, and were designed for different purposes and populations [2]. There were some queries raised about MNA esp for frail older hospital patients.