Dolores Sánchez-Rodríguez

Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit

Sarcopenia is the loss of muscle mass and strength, which in the elderly can result in disability and affect functional outcomes after hospitalization. The aim of this study was to evaluate the functional outcomes and mortality during hospitalization and at three months post-discharge, according to the presence of sarcopenia. Prospective study of 99 patients (38.4% men, aged 84.6) admitted in a subacute geriatric care unit who underwent a rehabilitation intervention. Main outcomes were mortality and functional improvement at discharge and at three-month follow-up. Sarcopenia was assessed by handgrip strength (hydraulic dynamometer) and by body composition bioimpedance. Forty-six (46.5%) patients met diagnostic criteria of sarcopenia. Patients with sarcopenia had a worse prior functional status than those without the condition (Barthel Index: 64.2±22.8 vs 73.3±21.8; p=0.04) but both groups had similar functional decline at admission (Barthel Index: 24±15.1 vs 28.5±15.2; p=0.1) and achieved similar functional improvement at discharge (20.4±18.3 vs 27.4±21; p=0.08). Barthel Index at discharge remained comparatively worse in patients with sarcopenia (44.2±26.6 vs 55.9±26.7; p=0.03). After completing a 3-month at-home rehabilitation program, no changes in functional capacity were observed in patients with sarcopenia; their peers improved their Barthel Index scores (45.5±24.8 vs 61.6±26.6; p=0.007). Mortality rates at 3-month follow-up did not differ between groups. In conclusion, patients with sarcopenia had a worse functional status, similar functional improvement during hospitalization and a lack of recovery after returning home. Further studies are needed to establish long-terms effects on mortality.

Does gait speed contribute to sarcopenia case-finding in a postacute rehabilitation setting?

OBJECTIVE The European Working Group of Sarcopenia in Older People (EWGSOP) has developed an algorithm based on gait speed measurement to begin sarcopenia case-finding in clinical practice, in which a cut-off point of <0.8m/s identifies risk for sarcopenia in community-dwelling older people. The objective of this study was to assess the application of the EWGSOP algorithm in hospitalised elderly patients with impaired functional capacity. METHODS One hundred in-patients (aged 84.1 SD 8.5, 62% women) were prospectively studied in a postacute care geriatric unit focused on rehabilitation. Sarcopenia was assessed by corporal composition (electrical bioimpedance), handgrip strength, and physical performance (gait speed). Other measurements were Charlson index, length of stay, and functional gain at discharge and 3-month follow-up. All patients were screened by the EWGSOP algorithm and sarcopenia was confirmed according to diagnostic criteria. RESULTS Gait speed was <0.8m/s in all cases and 58 patients had low muscle mass, which, according to the EWGSOP-algorithm, would indicate a diagnosis of sarcopenia. No differences were observed in functional capacity between these patients and those with normal muscle mass. When decreased handgrip strength was considered, 47 of these patients met the EWGSOP criteria for severe sarcopenia. In this group, differences in functional capacity were observed at discharge (Barthel 45.2 vs. 56.3, p=0.042) and 3-month follow-up (48.3 vs. 59.8, p=0.047). CONCLUSION The application of the EWGSOP algorithm in hospitalised, postacute, elderly patients with low gait speed suggested that muscle strength should be considered before confirming or discarding a sarcopenia diagnosis.

Prognostic Value of the ESPEN Consensus and Guidelines for Malnutrition: Prediction of Post-Discharge Clinical Outcomes in Older Inpatients

INTRODUCTION Our study aimed to determine whether malnutrition and nutrition-related conditions using the European Society for Clinical Nutrition and Metabolism (ESPEN) consensus were associated with functional status, institutionalization, readmissions, and mortality in older patients at 3-month follow-up. METHODS A cohort of 102 consecutive deconditioned patients was assessed at 3 months postdischarge from postacute geriatric care. Inclusion criteria were age ≥70 years, scores of Mini-Mental Status Examination ≥21/30, and being admitted for rehabilitation after an acute non-disabling disease. Malnutrition as defined by ESPEN consensus and nutrition-related conditions (such as frailty, sarcopenia, overweight/obesity, nutrient deficiency, and cachexia) was assessed, and related to postdischarge clinical outcomes at 3-month follow-up. RESULTS Of 95 included patients (84.5 ± 6.5 years; 63.2% women), 31 had unintentional weight loss and 19 fulfilled malnutrition criteria defined by the ESPEN consensus. Nutrition-related conditions were frequent: 94 patients had frailty, 44 sarcopenia, 58 overweight/obesity, and 59 nutrient deficiency. Sarcopenia reduced functional status at 3-month follow-up (median difference: -25.5; 95% confidence interval (CI) -46.4 - -4.3, P = 0.008). Institutionalization was related to unintentional weight loss in univariate analysis (odds ratio (OR) = 3.9; 95%CI 1.3 - 12.4, P = 0.018). Meeting the basic ESPEN definition of malnutrition was related to institutionalization in univariate (OR = 3.4; 95%CI 1.0 to 11.3, P = 0.042) but not multivariate analysis, and was not significantly associated with readmissions or mortality at 3-month follow-up. CONCLUSIONS Further research is needed on the potential value of the ESPEN consensus and guidelines for malnutrition to identify older patients at risk of worse functional status, institutionalization, readmissions, and mortality at 3-month follow-up postdischarge.

The International Registry of patients with sarcopenia: applying research in sarcopenia to clinical practice

Sarcopenia has been recently recognized as a disease for the purposes of coding (ICD-10-CM M62.84) and reimbursement [1, 2]. This acknowledgement has important implications for researchers, as this disease is related to malnutrition and frailty [3], functional decline, high rate of hospitalization, loss of quality of life [4] and increased mortality [5], but the definitive diagnostic [6] and therapeutic strategies [2] to counteract this reversible condition remain a challenge [7]. The European Geriatric Medicine Society (EuGMS) is a leader in activities around sarcopenia in Europe and promoted the European Working Group on Sarcopenia in Older People (EWGSOP), which has proposed the most widely used algorithm for sarcopenia case finding and recommends assessment of sarcopenia in all geriatric patients and every healthcare setting [7]. The EuGMS founded the Special Interest Group (SIG) on Sarcopenia in September 2015, and published the first special issue on sarcopenia in European Geriatric Medicine in 2016 [8]; since then, the number of formal members of this interest group has increased to 74, making it the most extensive SIG of the EuGMS. Staying in the lead of cutting-edge translational activities around sarcopenia, the EuGMS and the SIG on Sarcopenia are now launching the International Registry of patients with sarcopenia, among other initiatives, in an effort to bridge the gaps between research and clinical settings; and in line with the report from the International Conference on Frailty and Sarcopenia Research Task Force [2] and the World Health Organization’s strategy to enhance initiatives towards optimal aging [9]. To the best of our knowledge, this EuGMS initiative is the first registry of patients with sarcopenia. In Geriatric medicine, there are very few registries. For example, the EURECCA International Comparison is an European registry on treatment and survival of older patients with colon cancer, involving six European countries and 50,000 patients in its first decade [10]; in Italy, the “Syncope and Dementia registry” is a prospective, observational multicenter study assessing the transient loss of consciousness in patients with dementia in usual care [11]. Other fields of medicine have a higher number of registries, with a wide range of policies on research access. A systematic review in nephrology identified 144 renal registries, of which 22 provided public access for publications or reports and only 13 made anonymized patient data available to the external researchers, either by application and review of the proposed data usage or by user fees [12]. In surgery, 18 clinical registries that focus on the surgical quality have been described [13]. In rheumatology [14], the main topic of registries is rare diseases; a systematic review identified 48 clinical registries about 23 different diseases, most of them classified as rare but they also include more common ones, such as psoriasis. In dermatology, 11 registries on survival after skin cancer, with a focus on the clinical adverse outcomes, have been described [15]. The ultimate goal of the International Registry of patients with sarcopenia is to unify the efforts and observations of clinicians and researchers worldwide, [2] and provide ready access to the data for research purposes. However, the registry also has intermediate objectives:

Application of ultrasound for muscle assessment in sarcopenia: towards standardized measurements

PurposeMeasurement of muscle mass is paramount in the screening and diagnosis of sarcopenia. Besides muscle quantity however, also quality assessment is important. Ultrasonography (US) has the advantage over dual-energy X-ray absorptiometry (DEXA) and bio-impedance analysis (BIA) to give both quantitative and qualitative information on muscle. However, before its use in clinical practice, several methodological aspects still need to be addressed. Both standardization in measurement techniques and the availability of reference values are currently lacking. This review aims to provide an evidence-based standardization of assessing appendicular muscle with the use of US.MethodsA systematic review was performed for ultrasonography to assess muscle in older people. Pubmed, SCOPUS and Web of Sciences were searched. All articles regarding the use of US in assessing appendicular muscle were used. Description of US-specific parameters and localization of the measurement were retrieved.ResultsThrough this process, five items of muscle assessment were identified in the evaluated articles: thickness, cross-sectional area, echogenicity, fascicle length and pennation angle. Different techniques for measurement and location of measurement used were noted, as also the different muscles in which this was evaluated. Then, a translation for a clinical setting in a standardized way was proposed.ConclusionsThe results of this review provide thus an evidence base for an ultrasound protocol in the assessment of skeletal muscle. This standardization of measurements is the first step in creating conditions to further test the applicability of US for use on a large scale as a routine assessment and follow-up tool for appendicular muscle.

Sarcopenia: revised European consensus on definition and diagnosis

Abstract Background in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions EWGSOP2s updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.