C.C. Sieber

Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia

Sarcopenia, the age-associated loss of skeletal muscle mass and function, has considerable societal consequences for the development of frailty, disability, and health care planning. A group of geriatricians and scientists from academia and industry met in Rome, Italy, on November 18, 2009, to arrive at a consensus definition of sarcopenia. The current consensus definition was approved unanimously by the meeting participants and is as follows: Sarcopenia is defined as the age-associated loss of skeletal muscle mass and function. The causes of sarcopenia are multifactorial and can include disuse, altered endocrine function, chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. Although cachexia may be a component of sarcopenia, the 2 conditions are not the same. The diagnosis of sarcopenia should be considered in all older patients who present with observed declines in physical function, strength, or overall health. Sarcopenia should specifically be considered in patients who are bedridden, cannot independently rise from a chair, or who have a measured gait speed less that 1 m/s(-1). Patients who meet these criteria should further undergo body composition assessment using dual energy x-ray absorptiometry with sarcopenia being defined using currently validated definitions. A diagnosis of sarcopenia is consistent with a gait speed of less than 1 m·s(-1) and an objectively measured low muscle mass (eg, appendicular mass relative to ht(2) that is ≤ 7.23 kg/m(2) in men and ≤ 5.67 kg/m(2) in women). Sarcopenia is a highly prevalent condition in older persons that leads to disability, hospitalization, and death.

Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) "cachexia-anorexia in chronic wasting diseases" and "nutrition in geriatrics"

Chronic diseases as well as aging are frequently associated with deterioration of nutritional status, loss muscle mass and function (i.e. sarcopenia), impaired quality of life and increased risk for morbidity and mortality. Although simple and effective tools for the accurate screening, diagnosis and treatment of malnutrition have been developed during the recent years, its prevalence still remains disappointingly high and its impact on morbidity, mortality and quality of life clinically significant. Based on these premises, the Special Interest Group (SIG) on cachexia-anorexia in chronic wasting diseases was created within ESPEN with the aim of developing and spreading the knowledge on the basic and clinical aspects of cachexia and anorexia as well as of increasing the awareness of cachexia among health professionals and care givers. The definition, the assessment and the staging of cachexia, were identified as a priority by the SIG. This consensus paper reports the definition of cachexia, pre-cachexia and sarcopenia as well as the criteria for the differentiation between cachexia and other conditions associated with sarcopenia, which have been developed in cooperation with the ESPEN SIG on nutrition in geriatrics.

Evidence-Based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group

New evidence shows that older adults need more dietary protein than do younger adults to support good health, promote recovery from illness, and maintain functionality. Older people need to make up for age-related changes in protein metabolism, such as high splanchnic extraction and declining anabolic responses to ingested protein. They also need more protein to offset inflammatory and catabolic conditions associated with chronic and acute diseases that occur commonly with aging. With the goal of developing updated, evidence-based recommendations for optimal protein intake by older people, the European Union Geriatric Medicine Society (EUGMS), in cooperation with other scientific organizations, appointed an international study group to review dietary protein needs with aging (PROT-AGE Study Group). To help older people (>65 years) maintain and regain lean body mass and function, the PROT-AGE study group recommends average daily intake at least in the range of 1.0 to 1.2 g protein per kilogram of body weight per day. Both endurance- and resistance-type exercises are recommended at individualized levels that are safe and tolerated, and higher protein intake (ie, ≥ 1.2 g/kg body weight/d) is advised for those who are exercising and otherwise active. Most older adults who have acute or chronic diseases need even more dietary protein (ie, 1.2-1.5 g/kg body weight/d). Older people with severe kidney disease (ie, estimated GFR <30 mL/min/1.73 m(2)), but who are not on dialysis, are an exception to this rule; these individuals may need to limit protein intake. Protein quality, timing of ingestion, and intake of other nutritional supplements may be relevant, but evidence is not yet sufficient to support specific recommendations. Older people are vulnerable to losses in physical function capacity, and such losses predict loss of independence, falls, and even mortality. Thus, future studies aimed at pinpointing optimal protein intake in specific populations of older people need to include measures of physical function.

Prevalence of and interventions for sarcopenia in ageing adults: a systematic review. Report of the International Sarcopenia Initiative (EWGSOP and IWGS)

Objective: to examine the clinical evidence reporting the prevalence of sarcopenia and the effect of nutrition and exercise interventions from studies using the consensus definition of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). Methods: PubMed and Dialog databases were searched (January 2000–October 2013) using pre-defined search terms. Prevalence studies and intervention studies investigating muscle mass plus strength or function outcome measures using the EWGSOP definition of sarcopenia, in well-defined populations of adults aged ≥50 years were selected. Results: prevalence of sarcopenia was, with regional and age-related variations, 1–29% in community-dwelling populations, 14–33% in long-term care populations and 10% in the only acute hospital-care population examined. Moderate quality evidence suggests that exercise interventions improve muscle strength and physical performance. The results of nutrition interventions are equivocal due to the low number of studies and heterogeneous study design. Essential amino acid (EAA) supplements, including ∼2.5 g of leucine, and β-hydroxy β-methylbutyric acid (HMB) supplements, show some effects in improving muscle mass and function parameters. Protein supplements have not shown consistent benefits on muscle mass and function. Conclusion: prevalence of sarcopenia is substantial in most geriatric settings. Well-designed, standardised studies evaluating exercise or nutrition interventions are needed before treatment guidelines can be developed. Physicians should screen for sarcopenia in both community and geriatric settings, with diagnosis based on muscle mass and function. Supervised resistance exercise is recommended for individuals with sarcopenia. EAA (with leucine) and HMB may improve muscle outcomes.

Frequency of Malnutrition in Older Adults: A Multinational Perspective Using the Mini Nutritional Assessment

OBJECTIVES: To provide pooled data on the prevalence of malnutrition in elderly people as evaluated using the Mini Nutritional Assessment (MNA).

Frailty and sarcopenia: definitions and outcome parameters

An operational definition of musculoskeletal decline in older people is needed to allow development of interventions for prevention or treatment, as was developed for the treatment of osteoporosis. Frailty and sarcopenia are linked, but distinct, correlates of musculoskeletal aging that have many causes, including age-related changes in body composition, inflammation, and hormonal imbalance. With the emergence of a number of exciting candidate therapies to retard the loss of muscle mass with aging, the derivation of a consensual definition of sarcopenia and physical frailty becomes an urgent priority. Although several consensual definitions have been proposed, these require clinical validation. An operational definition, which might provide a threshold for treatment/trial inclusion, should incorporate a loss of muscle mass as well as evidence of a decrease in muscle strength and/or physical activity. Evidence is required for a link between improvements in the measures of muscle strength and/or physical activity and clinical outcomes to allow development of interventions to improve clinical outcomes in frail older patients.

The Mini Nutritional Assessment®—Its History, Today's Practice, and Future Perspectives

In the early 1990s, the Mini Nutritional Assessment (MNA; Nestle Nutrition, Vevey, Switzerland) was developed for nutrition screening in the elderly. Since then, it became the most established and widespread screening tool for older persons and has been translated into many different languages. The MNA shows prognostic relevance with regard to functionality, morbidity, and mortality of the elderly in different settings. This article recalls the development of the MNA with its short form (MNA-SF) and reviews the literature, focusing on the most recent publications. Specific features of the application of the MNA in different settings (community, nursing home, hospital) are considered. Minor shortcomings of the tool, such as the resources and the cooperation necessary for completion of the MNA, are discussed. Future options for the adaptation of this valuable tool are briefly characterized.

Comparison of the Mini Nutritional Assessment, Subjective Global Assessment, and Nutritional Risk Screening (NRS 2002) for nutritional screening and assessment in geriatric hospital patients

SummaryThe Mini Nutritional Assessment (MNA), the Subjective Global Assessment (SGA) and the Nutritional Risk Screening (NRS) are screening and assessment tools aimed at detecting malnourished individuals and those at risk for malnutrition. In our study we tested their applicability in geriatric hospital patients and compared the results of the three tools.We examined prospectively all patients of two acute geriatric wards by the MNA, the SGA and the NRS. 121 patients were included in the study. The MNA could be completed in 66.1% of all patients, the SGA in 99.2% and the NRS in 98.3%. There was a significant association of all three tools with the BMI (p<0.01). With regard to serum albumin and to length of hospital stay (p<0.05), only a significant association could be shown for the MNA (p<0.05). Although the categories of the results were not completely identical for the three tools there were more patients at risk or malnourished according to the MNA (70%) than according to the SGA (45%) or the NRS (40.3%). The direct comparison of the NRS with the MNA and the SGA demonstrated significant differences, especially for the latter (p<0.001).In a relevant percentage of those tested, MNA, SGA, and NRS identify different individuals as malnourished or at risk for malnutrition. Because of its association with relevant prognostic parameters, the MNA is still the first choice for geriatric hospital patients. For those patients to whom the MNA cannot be applied, the NRS is recommended.ZusammenfassungScreening- und Assessmentverfahren wie das Mini Nutritional Assessment (MNA), das Subjective Global Assessment (SGA) sowie des Nutritional Risk Screening (NRS) dienen der Erkennung einer manifesten Malnutrition sowie der Identifikation einer diesbezüglicher Risikopopulation. Ziel der vorliegenden Arbeit war es, bei akutgeriatrischen Krankenhauspatienten die Anwendbarkeit der drei Verfahren sowie die durch sie ermittelten Resultate zu vergleichen.Es wurden die Patienten zweier akutgeriatrischer Krankenhausstationen prospektiv mit MNA, SGA und NRS untersucht. 121 stationäre Patienten wurden in die Studie eingeschlossen. Das MNA konnte bei 66,1% durchgeführt werden, das SGA bei 99,2% und das NRS bei 98,3%. Die Ergebnisse aller drei Verfahren besaßen eine signifikante Beziehung zum Body Mass Index (p<0,01). Bezüglich des Serumalbumins sowie der Krankenhausverweildauer zeigte sich jeweils allein für das MNA ein signifikanter Zusammenhang (p<0,05). Auch wenn die Ergebniskategorien der drei Testverfahren nicht vollständig identisch sind, befanden sich laut MNA deutlich mehr Patienten in der Risikogruppe für eine Malnutrition beziehungsweise wiesen eine Malnutrition auf (70%), als dies nach dem SGA (45%) oder dem NRS (40,3%) der Fall war. Beim direkten Vergleich des NRS mit dem MNA bzw. des NRS mit dem SGA fanden sich signifikante Unterschiede, wobei diese für den letzteren Vergleich besonders deutlich ausfielen (p<0,001).MNA, SGA und NRS ermitteln in einem relevanten Prozentsatz unterschiedliche Patienten als Risikopatienten für eine Mangelernährung beziehungsweise als manifest mangelernährt. Aufgrund seiner Beziehung zu prognoserelevanten Parametern sollte bei geriatrischen Krankenhauspatienten primär das MNA eingesetzt werden. Für Patienten, welche nicht mit dem MNA untersucht werden können, empfiehlt sich das NRS.

ESPEN guidelines on definitions and terminology of clinical nutrition

BACKGROUND A lack of agreement on definitions and terminology used for nutrition-related concepts and procedures limits the development of clinical nutrition practice and research. OBJECTIVE This initiative aimed to reach a consensus for terminology for core nutritional concepts and procedures. METHODS The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed a consensus group of clinical scientists to perform a modified Delphi process that encompassed e-mail communication, face-to-face meetings, in-group ballots and an electronic ESPEN membership Delphi round. RESULTS Five key areas related to clinical nutrition were identified: concepts; procedures; organisation; delivery; and products. One core concept of clinical nutrition is malnutrition/undernutrition, which includes disease-related malnutrition (DRM) with (eq. cachexia) and without inflammation, and malnutrition/undernutrition without disease, e.g. hunger-related malnutrition. Over-nutrition (overweight and obesity) is another core concept. Sarcopenia and frailty were agreed to be separate conditions often associated with malnutrition. Examples of nutritional procedures identified include screening for subjects at nutritional risk followed by a complete nutritional assessment. Hospital and care facility catering are the basic organizational forms for providing nutrition. Oral nutritional supplementation is the preferred way of nutrition therapy but if inadequate then other forms of medical nutrition therapy, i.e. enteral tube feeding and parenteral (intravenous) nutrition, becomes the major way of nutrient delivery. CONCLUSION An agreement of basic nutritional terminology to be used in clinical practice, research, and the ESPEN guideline developments has been established. This terminology consensus may help to support future global consensus efforts and updates of classification systems such as the International Classification of Disease (ICD). The continuous growth of knowledge in all areas addressed in this statement will provide the foundation for future revisions.

Sarcopenia and frailty in geriatric patients: implications for training and prevention.

Summary.Sarcopenia, the loss of muscle mass and strength, is a constant phenomenon in aging. Physiologic age-dependent changes (drop in growth hormone (GH), IGF-1, menopause/andropause) explain the impaired protein synthesis, the decline of muscle mass, strength, and bone density. Harmful consequences of sarcopenia in old age are loss of muscle strength, inducing itself loss of mobility, neuromuscular impairment, and homeostatic balance failure syndrome with gait and balance disorders. All these sarcopenia-induced disabilities are important factors for an increased rate of falls and fractures in old age. Both falls and fractures cause hospitalisation and immobilisation which again induces sarcopenia.Once the physiologial age-dependent decline of protein synthesis has started, some connected “vicious loops” occur in frail elderly patients, forming a typical pattern in geriatric medicine. There is a vicious loop between sarcopenia and immobilisation: sarcopenia → neuromuscular impairment → falls and fractures → immobilisation → sarcopenia. Another loop is the “nutritional” vicious loop between sarcopenia and malnutrition: sarcopenia → immobilisation → decline of nutrition skills (“empty refrigerator”) → malnutrition → impaired protein synthesis → sarcopenia. There is also a third “metabolic” vicious loop between sarcopenia and the decline of the protein reserve of the body: sarcopenia → decline of the protein reserve of the body → diminished capacity to meet the extra demand of protein synthesis associated with disease and injury → sarcopenia. Frailty, a term not precisely defined, results from these different “vicious loops” including sarcopenia, neuromuscular impairment, falls and fractures, immobilisation, malnutrition, impaired protein synthesis, and decreased protein reserve of the body.Implications for training: main possibilities for training and prevention (of sarcopenia and frailty) are: a) continuous neuromuscular training (including training of balance) b) mobilisation c) prevention of falls d) training of nutrition skills and improvement of nutrition e) improvement of the impaired protein synthesis (with hormones etc.), and f) avoidance of dangerous drugs (drugs which cause neuromusculair impairment).Zusammenfassung.Sarkopenie, der Verlust an Muskelmasse und Muskelstärke, ist ein mit dem Alter kontinuierlich zunehmender Prozess. Physiologische alternsabhängige Veränderungen (die Abnahme des Wachstumshormones (GH), von IGF-1, die Meno- und die Andropause) führen zu einer Verminderung der Proteinsynthese, zu einer Abnahme der Muskelmasse und -kraft sowie der Knochendichte. Eine schwerwiegende Konsequenz der Sarkopenie im Alter ist der Verlust an Muskelkraft, der seinerseits eine Einschränkung der Mobilität, eine Verschlechterung des neuromuskulären Status und Gleichgewichts- und Gangstörungen verursacht. Alle diese durch die Sarkopenie bedingten Einschränkungen sind wichtige Ursachen für die größere Häufigkeit von Stürzen und Frakturen bei älteren Patienten. Sowohl Stürze als auch Frakturen führen zu einer Krankenhauseinweisung und zu einer Immobilisation, welche ihrerseits wieder die Sarkopenie verstärkt.Sobald die physiologische alternsabhängige Abnahme der Proteinsynthese einmal begonnen hat, sind bei gebrechlichen älteren Patienten miteinander verbundene „Circuli vitiosi“ zu beobachten, die eine typische Struktur in der Geriatrie darstellen. So gibt es einen Circulus vitiosus zwischen Sarkopenie und Immobilisierung: Sarkopenie → Verschlechterung des neuromuskulären Status → Stürze und Frakturen → Immobilisierung → Sarkopenie. Ein anderer Circulus vitiosus ist der zwischen Sarkopenie und Malnutrition: Sarkopenie → Immobilisierung → Abnahme der Fähigkeit, selbst für eine ausreichende Ernährung zu sorgen („empty refrigerator“) → Malnutrition → Verminderung der Proteinsynthese → Sarkopenie. Es gibt noch einen dritten „metabolischen“ Circulus vitiosus zwischen Sarkopenie und der Abnahme der Proteinreserve des Körpers: Sarkopenie → Abnahme der Proteinreserve des Körpers → eine verminderte Kapazität, die durch Krankheit und Verletzungen gesteigerten Anforderungen an die Proteinsynthese zu kompensieren → Sarkopenie.Gebrechlichkeit (frailty), ein Begriff, der nicht exakt definiert ist, resultiert aus diesen verschiedenen Circuli vitiosi, welche Sarkopenie, Verschlechterung des neuromuskulären Status, Stürze und Frakturen, Immobilisierung, Malnutrition, Verminderung der Proteinsynthese und eine verminderte Proteinreserve einschließen.Implikationen für das Training und die Prävention: Sarkopenie und Gebrechlichkeit im Alter lassen sich verhindern oder in ihrem Fortschreiten zumindestens verlangsamen durch a) kontinuierliches neuromuskuläres Training einschließlich Training des Gleichgewichts b) Mobilisierung c) durch die Verhinderung von Stürzen d) durch eine Verbesserung der Ernährung e) durch eine Steigerung der verminderten Proteinsynthese (durch anabole Hormone etc.) und f) durch die Vermeidung von gefährlichen Medikamenten, insbesondere von Medikamenten, die eine Muskelschwäche und eine Einschränkung der Koordination verursachen.