Stany Perkisas

Where frailty meets diabetes

Diabetes is a chronic illness that has an effect on multiple organ systems. Frailty is a state of increased vulnerability to stressors and a limited capacity to maintain homeostasis. It is a multidimensional concept and a dynamic condition that can improve or worsen over time. Frailty is either physical or psychological or a combination of these two components. Sarcopenia, which is the age‐related loss of skeletal muscle mass and strength, is the main attributor to the physical form of frailty. Although the pathophysiology of diabetes is commonly focused on impaired insulin secretion, overload of gluconeogenesis and insulin resistance, newer insights broaden this etiologic horizon. Immunologic factors that create a chronic state of low‐grade inflammation – ‘inflammaging’ – have an influence on both the ageing process and diabetes. Persons with diabetes mellitus already tend to have an accelerated ageing process that places them at greater risk for developing frailty at an earlier age. The development of frailty – and sarcopenia – is multifactorial and includes nutritional, physical and hormonal elements; these elements are interlinked with those of diabetes. A lower muscle mass will lead to poorer glycaemic control through lower muscle glucose uptake. This leads to higher insulin secretion and insulin resistance, which is the stepping stone for diabetes itself. Copyright

Intramuscular Adipose Tissue and the Functional Components of Sarcopenia in Hospitalized Geriatric Patients

Intramuscular adipose tissue (IMAT) could be an important missing value in the assessment of sarcopenia. This study tries to determine the relation between IMAT, muscle strength, functionality and mortality. In addition, the relation with nutritional status is screened. For six months, all patients admitted to the University Geriatric Center of Antwerp were evaluated for strength (hand grip), functionality (short physical performance battery—SPPB) and nutritional status. After one year, patients/relatives were contacted to obtain a current health status (mortality). A total of 303 patients were included at a mean age of 83.0 ± 6.4 years. The mean percentage of IMAT was 29.2% ± 13.0% (range 3.2%–86.2%). There was a negative correlation between IMAT and both grip strength and SPPB. SPPB was positively correlated with both grip strength and muscle mass. There was a positive correlation between IMAT and mortality. There was a negative correlation between grip strength, SPPB and mortality. IMAT did not have a clear relation with nutritional status. IMAT should be addressed in the work-up of sarcopenia, as it is correlated with muscle strength, functionality and mortality. In this cohort of hospitalized geriatric patients, there is a mean of about one-third of measured muscle volume that appears to be adipose tissue.

Ramelteon for Prevention of Delirium in Hospitalized Older Patients

Delirium is a transient global disorder of cognition and is very common in hospitalized patients. Nearly 30% of older patients (age >65 years) experience delirium at some time during hospitalization, and 40% of older patients admitted to intensive care units will have delirium.1 Risk factors for delirium include dementia, stroke, Parkinson disease, and sensory impairment. Polypharmacy (particularly the use of psychoactive drugs), infection, dehydration, the use of restraints, and catheters have been associated with the development of delirium. The underlying mechanism of delirium is not fully understood. The leading hypothesis is that reversible impairment of cerebral oxidative metabolism occurs along with neurotransmitter abnormalities. In the brain, for example, a relationship exists between cholinergic and dopaminergic pathways. Impaired cholinergic transmission occurs when anticholinergic drugs are used or Alzheimer disease is present, resulting in heightened susceptibility for delirium. This is also seen when dopaminergic transmission is increased. In addition to eliminating or minimizing potentially contributing factors, the mainstay of current treatment for delirium treatment is symptom control with antipsychotic or sedative medications. Although these medications may provide short-term symptom relief, the drugs may prolong the duration of delirium and worsen clinical outcomes; they have a variety of adverse effects and do not improve a patient’s overall prognosis.1 Antipsychotic agents are often used off-label in older patients.2 Package inserts for antidopaminergic medications commonly used for treating delirium, such as haloperidol, risperidone, olanzapine, and quetiapine, state that their use for delirium in older patients is not recommended. These medications are not recommended for this use because of an increased risk of mortality in older patients associated with the use of antipsychotics.3 Because symptom control for delirium is not optimal, new preventive and supportive strategies are needed. Improving and ensuring better sleep quality may be a helpful approach. Diurnal dysregulation involves disruption of the circadian cycle and sleep stages from an imbalance in the melatonergic pathway and may lead to delirium.4 This pathway may be affected by ramelteon, a medication approved for use in patients with insomnia. In the JAMA Psychiatry, Hatta et al5 report results from a randomized trial assessing the effect of ramelteon for preventing deJAMA PSYCHIATRY

Gait characteristics under different walking conditions: Association with the presence of cognitive impairment in community-dwelling older people

Background Gait characteristics measured at usual pace may allow profiling in patients with cognitive problems. The influence of age, gender, leg length, modified speed or dual tasking is unclear. Methods Cross-sectional analysis was performed on a data registry containing demographic, physical and spatial-temporal gait parameters recorded in five walking conditions with a GAITRite® electronic carpet in community-dwelling older persons with memory complaints. Four cognitive stages were studied: cognitively healthy individuals, mild cognitive impaired patients, mild dementia patients and advanced dementia patients. Results The association between spatial-temporal gait characteristics and cognitive stages was the most prominent: in the entire study population using gait speed, steps per meter (translation for mean step length), swing time variability, normalised gait speed (corrected for leg length) and normalised steps per meter at all five walking conditions; in the 50-to-70 years old participants applying step width at fast pace and steps per meter at usual pace; in the 70-to-80 years old persons using gait speed and normalised gait speed at usual pace, fast pace, animal walk and counting walk or steps per meter and normalised steps per meter at all five walking conditions; in over-80 years old participants using gait speed, normalised gait speed, steps per meter and normalised steps per meter at fast pace and animal dual-task walking. Multivariable logistic regression analysis adjusted for gender predicted in two compiled models the presence of dementia or cognitive impairment with acceptable accuracy in persons with memory complaints. Conclusion Gait parameters in multiple walking conditions adjusted for age, gender and leg length showed a significant association with cognitive impairment. This study suggested that multifactorial gait analysis could be more informative than using gait analysis with only one test or one variable. Using this type of gait analysis in clinical practice could facilitate screening for cognitive impairment.

Antidepressant use in older inpatients: current situation and application of the revised STOPP criteria

Objectives: Antidepressant use increases as age rises. Moreover, older patients are more sensitive to side effects and drug interactions. This descriptive study aims to map antidepressant use among patients at the geriatrics department of a university hospital and to evaluate whether prescribing happens in an evidence-based manner. Methods: Patients aged 75 years and over, admitted to the geriatrics department of the Middelheim Hospital in Antwerp between February and July 2017 were included. We checked whether they took antidepressants, which types and doses were prescribed, who prescribed the antidepressants, and whether prescribing was in concordance with the revised STOPP (Screening Tool of Older People’s Prescriptions) criteria. Results: Out of the 239 included patients, 61 were found to use antidepressants, with depression being the most important indication. General practitioners appeared to be the most frequent prescribers. Trazodone was the most prescribed antidepressant and was often used for sleeping disorders. Antidepressants were taken longer than recommended in almost one out of five cases. Patients with diabetes and renal insufficiency were prescribed antidepressants less frequently. Only 2.8% of the study participants were prescribed antidepressants for anxiety disorders. Conclusion: We can conclude that prescription of antidepressants in older patients at the geriatrics department is often not evidence based. Clear guidelines may offer a solution; therefore more studies are needed on antidepressant use in older patients.

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.

The impact of cognitive impairment on the physical ageing process

BackgroundPhysical decline and cognitive degeneration characterise the ageing process.AimPhysical parameters, performance and the functional indexes were studied in relation to age in healthy and cognitively impaired older persons to understand the interactions and changes during normal ageing, cognitive decline and progression to frailty.MethodsCross-sectional analysis was performed on a data registry of an ambulatory Memory Diagnosis Centre. The quantitative gait characteristics at usual pace, body composition parameters, disability scales (activity of daily living and instrumental activity of daily living) and Rockwood frailty index were compared in cognitively healthy (CHI), mild cognitively impaired, mildly and moderately demented < 80-years old and > 80-years old adults.ResultsQuality of gait deteriorated with age in CHI and cognitively impaired. Skeletal muscle mass index decreased when cognitive status worsened. Disability and frailty correlated with increasing cognitive impairment. Age, gender, cognitive impairment, body composition and Rockwood’s Frailty scale had a combined forecasting effect, as well as the individual effect on the gait characteristics. Disability score, Frailty index, skeletal muscle mass and skeletal muscle mass index, gait speed, normalised mean step length and swing time variability in mildly demented < 80-years old adults mirrored the parameters in the CHI > 80-years old.ConclusionQuantitative gait characteristics, muscle mass and disabilities change along with cognitive impairment, frailty and age. A more rapid physical ageing process accompanies cognitive decline. Therefore, gait characteristics should be age-referenced and studies on gait in older persons should include muscle mass, frailty and cognitive parameters.

The mortality determinants of sarcopenia and comorbidities in hospitalized geriatric patients

Objectives: Determine the influence of muscle mass, muscle strength, physical performance, nutritional status and certain comorbidities on the four years mortality risk of hospitalized geriatric patients. Design: Retrospective cohort study. Setting: During hospitalization of the included geriatric patients, the determinants of sarcopenia and nutritional status were obtained. Participants: A total of 302 patients hospitalized at the geriatric department of the Saint-Elisabeth hospital in Antwerp (Belgium) from 01/08/2012 until 31/01/2013. Measurements: Muscle mass was measured using a CT scan. The muscle strength was obtained by measuring the handgrip strength using a Jamar dynamometer. The physical performance was measured by performing the SPPB. The nutritional status was surveyed by using the MNA-SF. Comorbidities were obtained through medical records. Results: The variables gender (HR= 0.609; 95% CI 0.442-0.838), nutritional status (HR= 2.953; 95% CI 1.924-4.531), muscle mass (HR= 0.443; 95% CI 0.251-0.780), muscle strength (HR= 0.215; CI 95% 0.079-0.587), physical performance (HR= 0.407; 95% CI 0.237-0.702) and heart failure (HR= 1.440; 95% CI 1.022-2.029) have been shown to be significant. Conclusion: The determinants gender, nutritional status and physical performance have the greatest prognostic value.