Jürgen M. Bauer

Sarcopenia: European consensus on definition and diagnosis Report of the European Working Group on Sarcopenia in Older People

The European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria for age-related sarcopenia. EWGSOP included representatives from four participant organisations, i.e. the European Geriatric Medicine Society, the European Society for Clinical Nutrition and Metabolism, the International Association of Gerontology and Geriatrics—European Region and the International Association of Nutrition and Aging. These organisations endorsed the findings in the final document. The group met and addressed the following questions, using the medical literature to build evidence-based answers: (i) What is sarcopenia? (ii) What parameters define sarcopenia? (iii) What variables reflect these parameters, and what measurement tools and cut-off points can be used? (iv) How does sarcopenia relate to cachexia, frailty and sarcopenic obesity? For the diagnosis of sarcopenia, EWGSOP recommends using the presence of both low muscle mass + low muscle function (strength or performance). EWGSOP variously applies these characteristics to further define conceptual stages as ‘presarcopenia’, ‘sarcopenia’ and ‘severe sarcopenia’. EWGSOP reviewed a wide range of tools that can be used to measure the specific variables of muscle mass, muscle strength and physical performance. Our paper summarises currently available data defining sarcopenia cut-off points by age and gender; suggests an algorithm for sarcopenia case finding in older individuals based on measurements of gait speed, grip strength and muscle mass; and presents a list of suggested primary and secondary outcome domains for research. Once an operational definition of sarcopenia is adopted and included in the mainstream of comprehensive geriatric assessment, the next steps are to define the natural course of sarcopenia and to develop and define effective treatment.

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.

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).

Sarcopenia: European consensus on definition and diagnosis

The European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria for age-related sarcopenia. EWGSOP included representatives from four participant organisations, i.e. the European Geriatric Medicine Society, the European Society for Clinical Nutrition and Metabolism, the International Association of Gerontology and Geriatrics—European Region and the International Association of Nutrition and Aging. These organisations endorsed the findings in the final document. The group met and addressed the following questions, using the medical literature to build evidence-based answers: (i) What is sarcopenia? (ii) What parameters define sarcopenia? (iii) What variables reflect these parameters, and what measurement tools and cut-off points can be used? (iv) How does sarcopenia relate to cachexia, frailty and sarcopenic obesity? For the diagnosis of sarcopenia, EWGSOP recommends using the presence of both low muscle mass + low muscle function (strength or performance). EWGSOP variously applies these characteristics to further define conceptual stages as ‘presarcopenia’, ‘sarcopenia’ and ‘severe sarcopenia’. EWGSOP reviewed a wide range of tools that can be used to measure the specific variables of muscle mass, muscle strength and physical performance. Our paper summarises currently available data defining sarcopenia cut-off points by age and gender; suggests an algorithm for sarcopenia case finding in older individuals based on measurements of gait speed, grip strength and muscle mass; and presents a list of suggested primary and secondary outcome domains for research. Once an operational definition of sarcopenia is adopted and included in the mainstream of comprehensive geriatric assessment, the next steps are to define the natural course of sarcopenia and to develop and define effective treatment.

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.

Nutritional status according to the mini nutritional assessment (MNA®) and frailty in community dwelling older persons: A close relationship

ObjectiveThis study investigates the association between MNA results and frailty status in community-dwelling older adults. In addition the relevance of singular MNA items and subscores in this regard was tested.DesignCross-sectional study.SettingCommunity-dwelling older adults were recruited in the region of Nürnberg, Germany.Participants206 volunteers aged 75 years or older without cognitive impairment (Mini Mental State Examination >24 points), 66.0% female.MeasurementsFrailty was defined according to Fried et al. as presence of three, pre-frailty as presence of one or two of the following criteria: weight loss, exhaustion, low physical activity, low handgrip strength and slow walking speed. Malnutrition (<17 points) and the risk of malnutrition (17–23.5 points) were determined by MNA®.Results15.1% of the participants were at risk of malnutrition, no participant was malnourished. 15.5 % were frail, 39.8% pre-frail and 44.7% non-frail. 46.9% of the frail, 12.2% of the pre-frail and 2.2% of the non-frail participants were at risk of malnutrition (p<0.001). Hence, 90% of those at risk of malnutrition were either pre-frail or frail. For the anthropometric, dietary, subjective and functional, but not for the general MNA subscore, frail participants scored significantly lower than pre-frail (p<0.01), and non-frail participants (p<0.01). Twelve of the 18 MNA items were also significantly associated with frailty (p<0.05).ConclusionsThese results underline the close association between frailty syndrome and nutritional status in older persons. A profound understanding of the interdependency of these two geriatric concepts will represent the basis for successful treatment strategies.

The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women : A consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

From 50 years of age, postmenopausal women are at an increased risk of developing sarcopenia and osteoporosis as a result of deterioration of musculoskeletal health. Both disorders increase the risk of falls and fractures. The risk of developing sarcopenia and osteoporosis may be attenuated through healthy lifestyle changes, which include adequate dietary protein, calcium and vitamin D intakes, and regular physical activity/exercise, besides hormone replacement therapy when appropriate. Protein intake and physical activity are the main anabolic stimuli for muscle protein synthesis. Exercise training leads to increased muscle mass and strength, and the combination of optimal protein intake and exercise produces a greater degree of muscle protein accretion than either intervention alone. Similarly, adequate dietary protein intake and resistance exercise are important contributors to the maintenance of bone strength. Vitamin D helps to maintain muscle mass and strength as well as bone health. These findings suggest that healthy lifestyle measures in women aged >50 years are essential to allow healthy ageing. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends optimal dietary protein intake of 1.0-1.2g/kgbodyweight/d with at least 20-25g of high-quality protein at each main meal, with adequate vitamin D intake at 800IU/d to maintain serum 25-hydroxyvitamin D levels >50nmol/L as well as calcium intake of 1000mg/d, alongside regular physical activity/exercise 3-5 times/week combined with protein intake in close proximity to exercise, in postmenopausal women for prevention of age-related deterioration of musculoskeletal health.

Prospective Validation of the Modified Mini Nutritional Assessment Short-Forms in the Community, Nursing Home, and Rehabilitation Setting

To validate the modified Mini Nutritional Assessment (MNA) short‐forms (MNA‐SFs) with respect to agreement with full MNA classification in the target populations of the MNA.

C-terminal Agrin Fragment as a potential marker for sarcopenia caused by degeneration of the neuromuscular junction

INTRODUCTION Sarcopenia is considered to be an enormous burden for both the individuals affected and for society at large. A multifactorial aetiology of this geriatric syndrome has been discussed. Amongst other pathomechanisms, the degeneration of the neuromuscular junction (NMJ) may be of major relevance. The intact balance between the pro-synaptic agent agrin and the anti-synaptic agent neurotrypsin ensures a structurally and functionally intact NMJ. Excessive cleavage of the native motoneuron-derived agrin by neurotrypsin into a C-terminal Agrin Fragment (CAF) leads to functional disintegration at the NMJ and may consecutively cause sarcopenia. The present study evaluates the hypothesis that CAF serum concentration is a potential marker for the loss of appendicular lean mass in older adults. It also explores how CAF concentration is influenced by vitamin D supplementation and physical exercise. METHOD Serum was taken from 69 (47 female) prefrail community-dwelling older adults participating in a training intervention study to measure the CAF concentration using the Western blot technique. All participants were supplemented orally with vitamin D3 before the training intervention period commenced. Appendicular lean mass (aLM) was evaluated by dual energy X-ray absorptiometry. Multiple linear regression models were used to identify factors significantly associated with CAF concentration. RESULTS Appendicular lean mass, age and sex were identified as significant explanatory factors for CAF concentration. Gait speed and hand grip strength were not associated with CAF concentration. Male participants showed a strong correlation (r=-0.524) between CAF serum concentration and aLM, whereas this was not the case (r=-0.219) in females. Vitamin D supplementation and physical exercise were significantly associated with a reduction in CAF concentration, especially in participants with initially high CAF concentrations. CONCLUSIONS C-terminal Agrin Fragment could be a potential marker for identifying sarcopenia in a subgroup of affected individuals in the future. The decline of muscle mass seems to be a CAF-associated process in males, whereas the situation in females may be more complex and multifactorial. CAF concentration is reduced by vitamin D supplementation and physical exercise and therefore suggests a potentially positive effect on NMJs. Further prospective studies of sarcopenic patients in addition to muscle biopsy and electromyographical investigations are planned to verify the external validity of the CAF concept.

Bioelectric impedance phase angle is associated with hospital mortality of geriatric patients

Malnutrition is regularly associated with weight loss and changes in body composition, which lead to an increase in disability, complications and mortality. Bioelectric impedance analysis (BIA) is a simple and non-invasive bedside body composition analysis technique. In particular, bioelectric impedance phase angle (PA) has been shown to predict prognosis and mortality in several clinical conditions. The purpose of this study was to determine the relationship of BIA measurements and hospital mortality in multimorbid geriatric patients. The data obtained from the routine clinical admissions of 1071 consecutive patients (783 women and 288 men, age 81.4±8.5 years) to a geriatric hospital unit was analyzed retrospectively. A significant difference of PA (50 kHz) between survivors (4.2±1.1°) and non-survivors (3.6±1.2°; p<0.001) of the hospital stay could be detected. Subjects with a PA below 3.5° showed a significant fourfold increased hospital mortality of 20% (95% CI=15-24%) compared to all other subjects (5%; 95% CI=4-7%). No calculated parameters of BIA reflecting body composition were associated with hospital mortality. Although the extent to which the PA may be regarded as a marker of nutritional state is still controversial, it was associated with hospital mortality in geriatric patients.