We also unpick the relationship between sarcopenia, frailty and skeletal plus the investigation of exercise, nutritional and pharmacological strategies to for care planning, for example, in relation to lung transplant listing. It is without a doubt a common and complex medical condition, with multiple. obesity) plays a key role in the pathogenesis of frailty and sarcopenia. The quality of the diet along the lifespan has a close relation with the incidence of both. Clinicians should integrate nutritional assessment with sarcopenia screening for optimal Moreover, it is a major contributing factor of physical disability, frailty and loss of Definition, mechanisms, causes and prevalence of sarcopenia . The relationship between muscle mass, strength, physical function and nutritional .
Canadian research also demonstrates that most patients remain in the nutritional state in which they were admitted or decline further while in hospital; a similar pattern is observed 30 days after discharge, leading to readmission Allard et al. In the community, nutrition risk may lead to increased number of visits to the General Practitioner BAPEN Malnutrition Advisory Groupmore hospital visits, and increased risk of falling, among other complications Visvanathan et al.
Frailty and malnutrition concept and prevalence overlap Correspondence in the constructs of frailty and malnutrition, particularly the phenotype concept of frailty, is evident. Shrinkage or weight loss, exhaustion, weakness, and slowness are all symptoms consistent with malnutrition and also represent 4 of the 5 Fried criteria Fried et al. Jeejeebhoy highlighted this overlap in his review of the consistencies and differences among malnutrition, sarcopenia, cachexia, and frailty. This review highlighted that the loss of body tissues contribute to a phenotype common to each of these syndromes, although etiology of this loss of tissue varies with the condition Jeejeebhoy Those who have loss of body tissue because of inadequate food intake or increased requirement are malnourished and thus tissue accretion will result with refeeding.
In clinical practice the reality is that for many older adults these conditions overlap in their occurrence and causes, and treatment should be multifactorial. As malnutrition and frailty share risk factors, it is anticipated that many individuals will present with both frailty and malnutrition. In the community, nutritional risk in older adults increases the risk of frailty and associated consequences, including risk of hospitalization and loss of independence Bollwein et al.
Most studies have focused on community-dwelling older adults, and there is a need to understand the overlapping prevalence within populations such as hospitalized patients, younger adults vulnerable to frailty, and those with high risk of chronic disease.
More focus should be placed on understanding and reversing the effects of pre-frailty, as this is the population that may receive the most benefit from intervention.
Frailty and pre-frailty should also be examined across all populations and healthcare settings. Consistent terminology and assessment tools are required to gain a clear picture of the overlap in prevalence of malnutrition and frailty with direction for potential interventions.
The 2 main models for conceptualizing frailty phenotype and cumulative deficit form the basis for many screening and assessment tools created to date Clegg et al. Many of these tools use inconsistent terminology, yet there is overlap in characteristics such as weight loss, weakness, etc.
Sarcopenia and frailty in chronic respiratory disease
For the cumulative deficit model, primary and ambulatory care can use existing electronic medical record data to identify key risk factors while long-term care can use the interRAI Minimum Data Set Muscedere et al.
Key frailty and malnutrition assessment tools and their overlapping characteristics. Contrary to nutrition tools, there is a minimal distinction between frailty screening identification of potential risk and assessment diagnosis of condition tools. The feasibility of the tool within the target setting should always be considered. A recent review offers a broad understanding of frailty tools in various healthcare settings and highlights that the setting often determines the tool that is utilized Muscedere et al.
Screening for pre-frailty should be incorporated into various clinical environments. Nutrition assessment and screening tools Different definitions of malnutrition have led to various diagnostic frameworks. ESPEN has also released very minimal malnutrition diagnostic criteria out of the desire to have simple, objective measures that can be used in a variety of contexts and clinical populations Cederholm et al.
Since this set of diagnostic criteria was released, there has been criticism Bahat et al. Further, these diagnostic criteria are focused on the phenotype and do not include inadequate food intake, which is the root cause of malnutrition. These tools provide a more comprehensive view of malnutrition including food intake; risk factors for food intake; function; and body mass or composition. In addition to these diagnostic methods, a variety of nutrition screening tools exist.
These tools are designed so non-nutrition professionals, such as admission nurses, can quickly and sufficiently identify if a patient is at mal nutrition risk. All screening tools result in false positives and negatives, and diagnostic methods are required to confirm malnutrition. A recent review suggests that no single tool is best van Bokhost-de van der Schueren et al. Screening tools commonly include patient recall of weight change, food intake, and if there are objective measures, height and weight to determine BMI Elia ; Ferguson et al.
Height and weight can be difficult to obtain in a busy clinical environment Laporte et al. CNST contains only 2 questions, and has been demonstrated to be valid and reliable for this setting when compared with the SGA Laporte et al.
Other screening tools specific to older adults that provide a more upstream view of nutrition risk are available; these are designed for and are potentially more appropriate for a community-based or primary-care population Akhtar et al.
An example of this correspondence was demonstrated by Bollwein et al. A significant association between 12 of the 18 MNA items and frailty status appeared to exist, some of which included anorexia, weight loss, impaired mobility, and psychological problems Bollwein et al.
However, a recent article suggests that there are important differences between frailty and malnutrition tools. These results suggest that use of malnutrition and frailty tools in combination may be valuable in a hospital setting, and the apparent overlap further suggests that a minimum set of indicators should be further defined and researched to determine their utility.
This minimum set of measures would need to be i responsive to change with intervention, ii predict adverse outcomes in the medical setting, and iii be feasible in the fast-paced clinical environment.
Which objective indicator of frailty could be added to nutrition tools? Long, subjective frailty measures are challenging to complete in a clinical setting Cesari et al. Two objective frailty measures are worthy of consideration in a minimum set of indicators that could be added to current nutrition screening tools to identify malnutrition and frailty in the clinical setting.
Slow gait speed has been reported to successfully characterize older adults who have experienced adverse outcomes Clegg et al. However, the feasibility of conducting this assessment may be of concern for particular settings and patient populations with mobility issues, and needs to be explored further. Recent studies have also suggested that decreased muscle strength specifically HGS is an appropriate indicator of frailty Bohannon ; Jeejeebhoy ; Morley et al.
One of the challenges with HGS is that it is not specific to frailty. A systematic review highlighting decreased muscle function in relation to nutritional deprivation found that HGS is often being used as a proxy for nutritional status Norman et al.
However, as discussed previously, other studies suggest that HGS measures more than nutrition Jeejeebhoy et al. HGS reference values for healthy Canadians were published in Wongalthough a variety of cut-points have been used to predict various outcomes such as mortality Rijk et al. Despite the evidence for using HGS as a clinical measure, it is important to consider some of its limitations. HGS is not strictly objective, as it is heavily dependent on mood, motivation, and encouragement from the clinician administering the test White et al.
As with gait speed, some patients will not be able to complete HGS e. Improving research on treatment by considering both malnutrition and frailty It is not surprising that after discussing the overlap in definitions and ways of assessing frailty and malnutrition, there would also be an overlap in research on treatment efforts for these often comorbid conditions.
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Yet, confusion surrounding definitions and assessment methods has led to challenges in researching appropriate treatments. Studies using ONS as a treatment strategy have been selected to highlight these gaps in the literature because of the sizable body of research conducted using these products in a variety of contexts. Abstract Sarcopenia and frailty are geriatric syndromes characterized by multisystem decline, which are related to and reflected by markers of skeletal muscle dysfunction. In older people, sarcopenia and frailty have been used for risk stratification, to predict adverse outcomes and to prompt intervention aimed at preventing decline in those at greatest risk.
In this review, we examine sarcopenia and frailty in the context of chronic respiratory disease, providing an overview of the common assessments tools and studies to date in the field. We contrast assessments of sarcopenia, which consider muscle mass and function, with assessments of frailty, which often additionally consider social, cognitive and psychological domains.
Frailty is emerging as an important syndrome in respiratory disease, being strongly associated with poor outcome. We also unpick the relationship between sarcopenia, frailty and skeletal muscle dysfunction in chronic respiratory disease and reveal these as interlinked but distinct clinical phenotypes. Suggested areas for future work include the application of sarcopenia and frailty models to restrictive diseases and population-based samples, prospective prognostic assessments of sarcopenia and frailty in relation to common multidimensional indices, plus the investigation of exercise, nutritional and pharmacological strategies to prevent or treat sarcopenia and frailty in chronic respiratory disease.
COPD, exercise, frail, respiratory disease, rehabilitation, sarcopenia Introduction Skeletal muscle dysfunction is a well-recognized manifestation of chronic respiratory disease. In older people, sarcopenia and frailty have proved to be useful tools for risk stratification, prognostication and to direct interventions aimed at preventing functional decline towards those carrying the greatest risk. They are probably the most effective intervention to improve physical functioning, prevent falls and disabilities and, consequently, improve the quality of life in the older population.
This is especially important given that world is ageing and older adults will utilise healthcare services at an increased rate in the next years [ 4 ]. Unlike earlier definitions of sarcopenia, focusing on measurements of low muscle mass only, the current definition of sarcopenia according to the European consensus of the EWGSOP European Working Group on Sarcopenia in Older People [ 5 ] requires the presence of both low muscle mass and low muscle function muscle strength or physical performancealthough they have not achieved consensus on the cut-off points of muscle mass indicating sarcopenia.
The International Working Group on Sarcopenia IWGS also proposed an operational definition of sarcopenia, which was targeted to individuals with functional decline, mobility-related difficulties, history of recurrent falls, recent unintentional weight loss, post-hospitalisation and chronic conditions [ 67 ].
Nutrition and Sarcopenia: A Review of the Evidence and Implications for Preventive Strategies
In many older people, sarcopenia is a multifactorial process where several mechanisms can be involved. When the only evident cause of sarcopenia is the ageing, sarcopenia can be considered as primary or age-related.
In fact, malnutrition status is one of the main causes of sarcopenia protein-poor diet determines a compensatory response characterised by a reduction in lean mass [ 8 ]. Epidemiological data suggest that the prevalence of sarcopenia varies widely, depending on the different populations studied, gender, age, settings, diagnostic criteria used and the cut-off points chosen to define a low muscle mass.
The highest prevalence was found in people staying in convalescence and rehabilitation units, while community-dwelling older people had the lowest prevalence.
Definition and aetiology of malnutrition Malnutrition has been defined as a condition of an imbalance of energy, protein and other nutrients that can cause measurable negative effects on body composition, physical function and clinical outcomes [ 10 ]. Older adults are known to be at high risk of malnutrition. Advanced age is an independent risk factor for malnutrition and is associated with a lower body weight, body mass index BMI and serum albumin.
Malnutrition is not an inevitable side effect of ageing, but many changes associated with the process of ageing can promote a poor nutritional status. The decline in taste acuity and smell, poor dentition and a decreased appetite are some factors that can affect nutrient intake and can lead to malnutrition and its potentially serious consequences. Other factors, such as an increased frequency and severity of acute and chronic medical conditions, multiple medications, social or economic challenges and cognitive decline, all play a role in the aetiology of malnutrition among older adults [ 11 ].
Nutritional assessment in the elderly The best validated and most widely used test to measure nutritional status of older people is the Mini Nutritional Assessment MNA. This includes 18 questions regarding weight change, dietary change, gastrointestinal symptoms, mobility, physical assessment and disease and its relationship with nutritional requirements, with a maximum score of 30 points.
This instrument was designed as a form that contains items that reflect functional, social, nutritional and health-related aspects of nutritional intake [ 13 ]. Prevalence of malnutrition Depending on the method or parameters used for the nutritional assessment, prevalence rates of malnutrition among elderly subjects range between 6.
Early identification of older adults at nutritional risk, followed by adequate nutritional intervention, is expected to contribute to conservation of muscle function and muscle strength, and herewith to maintenance the functional independence, the quality of life and possibly to prolong the survival [ 15 ]. The prevalence of malnutrition depends on multiple factors, including the definition and the diagnostic criteria used.