Liang-Kung Chen

Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia

Sarcopenia, a newly recognized geriatric syndrome, is characterized by age-related decline of skeletal muscle plus low muscle strength and/or physical performance. Previous studies have confirmed the association of sarcopenia and adverse health outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people. Despite the clinical significance of sarcopenia, the operational definition of sarcopenia and standardized intervention programs are still lacking. It is generally agreed by the different working groups for sarcopenia in the world that sarcopenia should be defined through a combined approach of muscle mass and muscle quality, however, selecting appropriate diagnostic cutoff values for all the measurements in Asian populations is challenging. Asia is a rapidly aging region with a huge population, so the impact of sarcopenia to this region is estimated to be huge as well. Asian Working Group for Sarcopenia (AWGS) aimed to promote sarcopenia research in Asia, and we collected the best available evidences of sarcopenia researches from Asian countries to establish the consensus for sarcopenia diagnosis. AWGS has agreed with the previous reports that sarcopenia should be described as low muscle mass plus low muscle strength and/or low physical performance, and we also recommend outcome indicators for further researches, as well as the conditions that sarcopenia should be assessed. In addition to sarcopenia screening for community-dwelling older people, AWGS recommends sarcopenia assessment in certain clinical conditions and healthcare settings to facilitate implementing sarcopenia in clinical practice. Moreover, we also recommend cutoff values for muscle mass measurements (7.0 kg/m(2) for men and 5.4 kg/m(2) for women by using dual X-ray absorptiometry, and 7.0 kg/m(2) for men and 5.7 kg/m(2) for women by using bioimpedance analysis), handgrip strength (<26 kg for men and <18 kg for women), and usual gait speed (<0.8 m/s). However, a number of challenges remained to be solved in the future. Asia is made up of a great number of ethnicities. The majority of currently available studies have been published from eastern Asia, therefore, more studies of sarcopenia in south, southeastern, and western Asia should be promoted. On the other hand, most Asian studies have been conducted in a cross-sectional design and few longitudinal studies have not necessarily collected the commonly used outcome indicators as other reports from Western countries. Nevertheless, the AWGS consensus report is believed to promote more Asian sarcopenia research, and most important of all, to focus on sarcopenia intervention studies and the implementation of sarcopenia in clinical practice to improve health care outcomes of older people in the communities and the healthcare settings in Asia.

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.

Comparisons of Sarcopenia Defined by IWGS and EWGSOP Criteria Among Older People: Results From the I-Lan Longitudinal Aging Study

OBJECTIVE To compare clinical characteristics of sarcopenia defined by the International Working Group on Sarcopenia (IWGS) and European Working Group on Sarcopenia in Older People (EWGSOP) criteria among older people in Taiwan. DESIGN A prospective population-based community study. SETTING I-Lan County of Taiwan. PARTICIPANTS A total of 100 young healthy volunteers and 408 elderly people. INTERVENTION None. MEASUREMENTS Anthropometry, skeletal muscle mass measured by dual x-ray absorptiometry, relative appendicular skeletal muscle index (RASM), percentage skeletal muscle index (SMI), 6-meter walking speed, and handgrip strength. RESULTS The prevalence of sarcopenia was 5.8% to 14.9% in men and 4.1% to 16.6% in women according to IWGS and EWGSOP criteria by using RASM or SMI as the muscle mass indices. The agreement of sarcopenia diagnosed by IWGS and EWGSOP criteria was only fair by using either RASM or SMI (kappa = 0.448 by RASM, kappa = 0.471 by SMI). The prevalence of sarcopenia was lower by the IWGS definition than the EWGSOP definition, but it was remarkably lower by using RASM than SMI in both criteria. Overall, sarcopenic individuals defined by SMI were older, had a higher BMI but similar total skeletal muscle mass, and had poorer muscle strength and physical performance than nonsarcopenic individuals. However, by using RASM, sarcopenic individuals had less total skeletal muscle mass but similar BMI than nonsarcopenic individuals. Multivariable logistic regression showed that age was the strongest associative factor for sarcopenia in both IWGS and EWGSOP criteria. Obesity played a neutral role in sarcopenia when it is defined by using RASM, but significantly increased the risk of sarcopenia in both criteria by using SMI. CONCLUSION The agreement of sarcopenia defined by IWGS and EWGSOP was only fair, and the prevalence varied largely by using different skeletal muscle mass indices. Proper selections for cutoff values of handgrip strength, walking speed, and skeletal muscle indices with full considerations of gender and ethnic differences were of critical importance to reach the universal diagnostic criteria for sarcopenia internationally.

Prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients covered by the Taiwanese National Health Insurance program

BACKGROUND The use of potentially inappropriate medications can have profound medical consequences for elderly patients and place a substantial burden on the health care system. OBJECTIVES This study was conducted to determine the prevalence of potentially inappropriate medication prescribing at ambulatory care visits by patients aged > or =65 years covered by the Taiwanese National Health Insurance program, to examine the characteristics of and risk factors for such prescribing, and to investigate its influence on health care resource utilization. METHODS Ambulatory care visits by patients aged > or =65 years in 2001-2004 were identified from the National Health Insurance claims database. The 2003 Beers criteria for drugs to be avoided in the elderly were used to identify potentially inappropriate medications prescribed at these visits. Only drugs with the potential to lead to higher-severity adverse events were included. Multivariate logistic regression was used to determine predictors of the prescribing of potentially inappropriate medications at ambulatory care visits. Independent variables in the regression model included patient characteristics (eg, sex, age), physician characteristics (sex, age, and specialty), and visit characteristics (site and prescribed drug number). The dependent variable was visits that included a prescription for a potentially inappropriate medication. RESULTS Overall, 176,661,994 ambulatory care visits by patients aged > or =65 years were identified in 2001-2004. Of these, 19.1% involved a prescription for a potentially inappropriate medication. Although the frequency of potentially inappropriate medication prescribing declined over the study period, 62.5% of elderly patients were exposed to such medications in 2004. The only patient characteristic associated with an increased likelihood of the prescribing of potentially inappropriate medications was female sex (male sex: odds ratio [OR] = 0.982 [95% CI, 0.980-0.983], P < 0.001). Physician characteristics associated with a greater likelihood of the prescribing of potentially inappropriate medications was male sex (OR = 1.206 [95% CI, 1.202-1.210], P < 0.001); older age (43-50 years: OR = 1.021 [95% CI, 1.018-1.025], P < 0.001; >/=51 years: OR = 1.238 [95% CI, 1.235-1.242], P < 0.001); and family medicine/general practice (OR = 1.267 [95% CI, 1.265-1.269], P < 0.001). For visit characteristics, significant associations were found with visits to a primary care clinic (OR = 1.887 [95% CI, 1.881-1.892], P < 0.001) and the number of drugs prescribed (4-6 drugs: OR = 2.701 [95% CI, 2.696-2.706], P < 0.001; > or =7 drugs: OR = 4.528 [95% CI, 4.517-4.538], P < 0.001). The most commonly prescribed types of potentially inappropriate medications were antihistamines (4.8% of all prescriptions in 48.3% of elderly patients), muscle relaxants/antispasmodics (4.0% and 40.3%, respectively), and long-acting benzodiazepines (2.4% and 21.4%). In 2004, the mean number of ambulatory care visits per patient was significantly higher among those who received potentially inappropriate medications compared with those who did not (30.78 vs 16.57, respectively; P < 0.001). Patients who received potentially inappropriate medications also had significantly more emergency department visits (0.27 vs 0.15; P < 0.001) and hospital admissions (0.46 vs 0.27; P < 0.001). CONCLUSION There was a high prevalence of the prescribing of potentially inappropriate medications at ambulatory care visits by elderly patients in Taiwan in 2001-2004.

Potentially inappropriate prescribing (IP) for elderly medical inpatients in Taiwan: A hospital-based study

Older people tend to have multiple comorbid conditions and subsequent polypharmacy, which place them at higher risk of adverse drug events, drug-drug and drug-disease interactions and IP. IP includes several patterns, such as inappropriate dose or duration, prescribing drugs having significant drug-disease or drug-drug interactions, and the omission of potentially beneficial medications. The main purpose was to evaluate the prevalence of IP among medical inpatients in a medical center, so to evaluate the associative factors of IP in Taiwan. From January to December of 2009, all patients aged 65 years and older who were discharged from the medical wards of Taipei Veterans General Hospital were randomly sampled for study (the sampling rate around 1.0%). The IP was evaluated by the STOPP and START criteria. Each medical record was carefully reviewed by physicians who had been trained. Overall, 520 records of elderly medical ward inpatients (mean age = 79.2 ± 6.7 years, 73.8% males) were included for study. In total, 3455 items of medication were prescribed for these 520 patients (mean = 6.6 ± 3.2 items). According to STOPP criteria, 36.2% of the study subjects had at least one potentially inappropriate medication (PIM). The most common PIMs were: (1) medications that may adversely affect those who are prone to falls, e.g., benzodiazepines, neuroleptics and first generation antihistamines (14.2%). (2) Ca-channel blockers with chronic constipation (12.3%). (3) Use of neuroleptic agents (5.6%). (4) Long-term, long-acting benzodiazepines (2.5%). (5) Prolonged use of first generation antihistamines (2.1%). Besides, 218 patients (41.9%) had at least one potentially prescribing omission (PPO). Common PPOs included: (1) statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present (19.0%). (2) Antiplatelet therapy in diabetes mellitus with co-existing major cardiovascular risk factors (12.5%). (3) Metformin with type 2 diabetes with or without metabolic syndrome (in the absence of renal impairment) (8.7%). (4) Angiotensin converting enzyme inhibitor or angiotensin II receptor blockers with chronic heart failure (7.3%). (5) Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm (7.1%). Logistic regression showed that older age and number of medications were significant risk factors for PIMs. In conclusion, the prevalence of PIMs among elderly medical inpatients in a medical center in Taiwan was 36.2% and PPOs was 41.9%. Further study is needed to clarify the underlying causes of potentially IP to promote better quality of prescribing for older patients.

Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a retrospective cohort study

Background: Polypharmacy, potentially inappropriate medications and anticholinergic burden (as assessed by the anticholinergic risk scale) are commonly used as quality indicators of pharmacotherapy in older adults. However, their role in clinical practice is undefined. We sought to investigate longitudinal changes in these indicators and their effects on clinical outcomes. Methods: We used Taiwan’s Longitudinal Health Insurance Database to retrieve quarterly information about drug use for people aged 65 years and older over a 10-year period. We analyzed the association between indicators and all-cause admission to hospital, fracture-specific admission to hospital and death using generalized estimating equations. Results: The study cohort comprised 59 042 older adults (65–74 yr: 39 358 [66.7%], 75–84 yr: 16 903 [28.6%], and ≥ 85 yr: 2781 [4.7%]). The mean changes in polypharmacy over the course of the study were greatest among patients aged 65–74 years (absolute difference +2.14, 95% confidence interval [CI] 2.10–2.19), then among those aged 75–84 yr (+1.79, 95% CI 1.70–1.88), and finally those aged 85 years and older (+0.71, 95% CI 0.36–1.05). The number of potentially inappropriate medications increased among patients aged 65–74 years (+0.16 [0.15–0.18]) and 75–84 years (+0.09 [0.06–0.08]), but decreased in those aged 85 years and older (−0.15 [−0.26 to −0.04]). Polypharmacy, potentially inappropriate medications and anticholinergic risk scale were each associated with an increased risk of admission to hospital, but not with death. In addition, both polypharmacy (5–9 drugs: odds ratio [OR] 1.18, 95% CI 1.12–1.24; ≥ 10 drugs: OR 1.54, 95% CI 1.42–1.66) and anticholinergic burden (score 1–2: 1.39, 95% CI 1.31–1.48; ≥ 3: 1.53, 95% CI 1.41–1.66) showed dose–response relations with fracture-specific admission to hospital. Interpretation: The total number of drugs taken (polypharmacy), number of potentially inappropriate medications and anticholinergic risk changed during follow-up and varied across age groups in this cohort of older adult patients. These indicators showed dose–response relations with admission to hospital, but not with death.

Association of cognitive impairment, depressive symptoms and sarcopenia among healthy older men in the veterans retirement community in southern Taiwan: A cross-sectional study

To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan

Age-related skeletal muscle mass loss and physical performance in Taiwan: Implications to diagnostic strategy of sarcopenia in Asia

Skeletal muscle loss is a common feature of aging, and is associated with unfavorable outcomes. Although several indexes of skeletal muscle mass measurement have been developed, the most optimal index for sarcopenia diagnosis among Asian populations has remained unclear. The present study aimed to evaluate the relationship between skeletal muscle mass and physical performance among community‐dwelling people in Taiwan.

Care of elderly patients with diabetes mellitus: A focus on frailty

The prevalence and incidence of type 2 diabetes mellitus (DM) increase with age, and its diagnosis and treatment in older people present a challenge. Applying evidence to elderly patients can be problematic, because older persons with frailty, multiple comorbidities, and functional disabilities are generally excluded from diabetes clinical trials. Frailty is characterized by multisystem decline and vulnerability to adverse health outcomes. Insulin resistance predicts frailty, and DM accelerates muscle strength loss. Geriatric diabetes care guidelines have refocused from risk factor control to geriatric syndromes. The European Diabetes Working Party guidelines for elderly type 2 DM patients consider frailty, recommending a conservative target (hemoglobin A1c <8%). Diabetic care-home residents with physical disabilities, cognitive impairment, tube feeding, and the inability to communicate pose particular challenges. Tight glycemic control for such patients increases the risk of hypoglycemia and significant functional decline; a mean hemoglobin A1c <7% did not protect them from care-home-acquired pneumonia. In conclusion, caring for elderly diabetic patients poses unique challenges. Little is known about diabetes care of elderly people with frailty, disabilities, or multiple comorbidities. The interrelationship between frailty and DM deserves further investigation. Practice guidelines for care-home residents with DM are needed to ensure quality of care.

Association of Insulin Resistance and Hematologic Parameters: Study of a Middle-aged and Elderly Chinese Population in Taiwan

Background: Chronic inflammation is a common feature related to changes in hematologic parameters in insulin resistance. The aims of this study were to explore the relationship between hematologic parameters and insulin resistance, and to establish a gerontologic profile for following studies. Methods: Residents aged over 40 years in 3 major townships in I‐Lan County participating in the Adult Health Examination were invited for the study. Diagnosis of diabetes mellitus (DM) was done according to American Diabetes Association criteria. Insulin resistance was measured by homeostasis model assessment (HOMA‐IR), and subjects with the highest tertile of HOMA‐IR were defined as being insulin resistant. Hematologic parameters including white blood cell (WBC) count, red blood cell (RBC) count, hemoglobin, and platelet count were measured for comparisons. Results: A total of 857 subjects (mean age, 64.6 ± 11.2 years; male/female, 373/484) participated in this study. Their mean body mass index (BMI) was 24.5 ± 3.7 kg/m2, and 42.4% of them were obese and 21.8% were overweight. The overall prevalence of DM was 15.4% (7.7% were previously diagnosed and 7.7% were newly diagnosed), and impaired fasting glucose was 7.2%. Trend analyses confirmed that age, BMI, HOMA‐IR, WBC and platelet counts were significantly increased as glycemic metabolism exacerbated (p = 0.007, < 0.001, < 0.001, < 0.001 and 0.025, respectively). Compared with insulin‐sensitive subjects, insulin‐resistant subjects were more likely to be females (70.2% vs. 49.7%, p < 0.001), and had significantly higher BMI (26.2 ± 3.9 kg/m2 vs. 23.7 ± 3.3 kg/m2, p < 0.001), HOMA‐IR (3.6 ± 3.5 vs. 0.7 ± 0.3, p 0.001), WBC count (6686.9 ± 1889.2/mm3 vs. 5942.9 ± 1740.4/mm3, p < 0.001), and platelet count (243.5 ± 70.9 × 103/mm3 vs. 231.0 ± 62.2 × 103/mm3, p = 0.011), but not age (64.5 ± 11.0 years vs. 64.6 ± 11.4 years, p = 0.93) or RBC count (4.6 ± 0.6 M/mm3 vs. 4.6 ± 0.6 M/mm3, p = 0.76). When age and sex were controlled, HOMA‐IR significantly correlated with WBC count (γ = 0.23, p < 0.001) and platelet count (γ = 0.09, p = 0.007). However, by multiple logistic regression, female gender, overweight and obesity, and elevated WBC count were all found to be independent risk factors of insulin resistance, but age, RBC and platelet counts were not. Conclusion: Elevated WBC count but not RBC count was significantly associated with insulin resistance and glycemic metabolism. The relationship between platelet count and insulin resistance deserves further investigations.