Objectives: Osteoporosis is associated with greater risk of fracture, which can lead to increased morbidity and mortality. DEXA scans are often inaccessible for patients, leaving many cases of osteoporosis undetected. A portable 3D topographical scan offers an easily accessible and inexpensive potential adjunct screening tool. We hypothesized that 3D scanning of arm and calf circumference and volume would correlate with DEXA T-scores. Methods: 96 female patients were enrolled. Patients were consented and completed a topographical scan of bilateral arms and lower legs with a mobile 3D scanner for arm and calf circumference and volume in clinic. Patient charts were then retrospectively reviewed for DEXA T-scores. Results: Forearm DEXA T-score was positively correlated with arm circumference (r = 0.49, p<0.01), arm volume (r=0.62, p<0.01), and calf volume (r=0.47, p<0.01). Femoral neck DEXA T-score was positively correlated with calf circumference (r=0.36, p<0.01) and calf volume (r=0.36, p<0.01). Conclusions: Our results showed significant correlations between DEXA T-scores and topographical measurements from mobile device acquired 3D scans, although these were in the “moderate” range. Mobile device-based 3D scanning may hold promise as an adjunct screening tool for osteoporosis when DEXA scanning is not available or feasible for patients, although further studies are needed to elucidate the full potential of its clinical utility. At a minimum, identifying a patient as high risk may promote earlier diagnostic DEXA scanning.

Objective: This study aimed to assess the association between measures of frailty phenotype (FP) and malnutrition, and sarcopenia measured by bioelectrical impedance analysis (BIA), in individuals aged 50 and above attending an outpatient falls clinic. Methods: The Survey of Health, Ageing and Retirement in Europe Frailty Instrument (SHARE-FI) gauged FP status, while nutritional assessment relied on the Mini Nutritional Assessment-Short Form (MNA^®-SF). Body composition, specifically appendicular skeletal muscle mass (ASMM), was determined through TANITA^® DC-430MA BIA. Multivariable binary logistic regression models were used to predict pre-frailty or frailty based on SHARE-FI and at-risk of malnutrition or malnutrition based on MNA^®-SF. Results: Out of the 123 participants (68 women, 55 men), 56.1% were classified as robust, 27.6% as living with pre-frailty, and 16.3% as living with frailty according to SHARE-FI. MNA^®-SF results were available for 116 patients, with 54.3% categorised as normal, 39.7% at risk of malnutrition, and 6.0% as malnourished. Among the 118 patients who underwent BIA, ASMM was independently associated with pre-frail/frail status, but there was no significant association between abnormal MNA^®-SF and sarcopenia. Conclusion: SHARE-FI, a modified FP tool, demonstrated an independent association with sarcopenia as measured by BIA.

Objectives: The most efficient way to adjust skeletal muscle area (SMA) derived from chest CT to body size remains unclear. We hypothesized that vertebral body area (VBA) measurement would allow such efficient adjustment. Methods: We conducted a retrospective observational study of chest CT imaging in a cohort of critically ill COVID-19 patients. We measured paravertebral SMA at T5 level and T5 vertebral body anteroposterior length, width, and area. We used linear regression and multivariable modelling to assess the association of VBA with SMA. Results: In 48 COVID-19 patients in ICU, T5 VBA could be easily derived from simple width and anteroposterior length linear measurements. T5 VBA (measured manually or estimated from width and length) performed similarly to height (R² of 0.22) as an adjustment variable for SMA, with R² of 0.23 and 0.22, respectively. Gender had the strongest correlation with SMA (R² = 0.28). Adding height or age to a model using gender and VBA did not improve correlation. Conclusions: Gender and estimated VBA from simple linear measurements at T5 level on CT images can be utilized for adjustment of SMA without the need for height. Validation of these findings in larger cohorts of critically ill patients is now needed.

Objectives: To assess the link between ultrasonographic measurements of the biceps brachii and total muscle mass measured by bio-impedancemetry in hospitalized older patients. Methods: A prospective observational study was conducted. The study included patients older than 65 years admitted in internal medicine, acute geriatrics, orthogeriatrics and rehabilitation departments. All measurements, ultrasonographic measurements and muscle mass and function by bio-impedancemetry and dynamometry, were taken within the first 48 hours of admission. Results: In total 19 patients were included, the mean age was 85.4 ± 3.9 years and 7 (36.8%) were females. Very strong direct correlations were obtained in the entire cohort in both biceps brachii cross-sectional area and muscle thickness with skeletal muscle mass displayed in kilograms. Conclusion: Biceps brachii looks like a very good muscle measuring tool: easy, comfortable, fast, good correlated with total body muscle mass. This muscle could effectively be used for the assessment of muscle mass in the diagnosis of sarcopenia since it reflects muscle mass precisely, however more studies are needed to provide reference values in all age cohorts.

Objective: To implement and evaluate a Frailty Care Bundle (FCB) targeting mobilisation, nutrition, and cognition in older trauma patients to reduce hospital associated decline. Methods: We used a two group, pretest-posttest design. The FCB intervention was delivered on two orthopaedic wards and two rehabilitation wards, guided by behaviour change theory (COM-B) to implement changes in ward routines (patient mobility goals, nurse assisted mobilisation, mealtimes, communication). Primary outcomes were patient participants' return to pre-trauma functional capability (modified Barthel Index - mBI) at 6-8 weeks post-hospital discharge and average hospital daily step-count. Statistical analysis compared pre versus post FCB group differences using ordinal regression and log-linear models. Results: We recruited 120 patients (pre n=60 and post n=60), and 74 (pre n=43, post n=36) were retained at follow-up. Median age was 78 years and 83% were female. There was a non-significant trend for higher mBI scores (improved function) in the post compared to pre FCB group (OR 2.29, 95% CI 0.98-5.36), associated with an average 11% increase in step-count. Conclusion: It was feasible, during the Covid-19 pandemic, for multidisciplinary teams to implement elements of the FCB. Clinical facilitation supported teams to prioritise fundamental care above competing demands, but sustainability requires ongoing attention. ISRCTN registry: ISRCTN15145850 (https://doi.org/10.1186/ISRCTN15145850)

This systematic review and meta-analysis aimed to explore the differences in the number of prescribed medications and polypharmacy risk between patients with heart failure (HF) and frailty vs. those with HF but without frailty. Eligible studies included observational or experimental studies in patients aged ≥50 years. Thirteen studies met the criteria and were included in the final analysis. Patients with frailty and HF exhibited a higher risk of polypharmacy (OR: 1.87, 95% CI 1.72 - 2.04, I² = 0%, P < 0.01) compared to those without frailty. Results remained significant after adjusting for comorbidity status. Additionally, patients with frailty and HF were prescribed more medications compared to those without (k = 6; MD: 1.43, 95% CI 0.31 - 2.55, I2 = 94%, P = 0.01), with a high degree of heterogeneity. However, results were non-significant after adjustment for comorbidity status. Patients with HF and frailty have a higher need of polypharmacy compared to those without frailty, which may increase the risk of potentially inappropriate medications (PIM). Investigating the real-world prevalence of PIM may support clinicians in their routine assessment as part of a comprehensive management strategy in patients with HF and frailty.

Physical activity and exercise can limit the development of sarcopenia in Parkinson's Disease. This review aims to evaluate the potential effects of behavioural change (BC) interventions on exercise self-efficacy and adherence in people with Parkinson's. We searched nine databases and included randomised and non-randomised studies reporting exercise self-efficacy, quality of life (QoL), physical function and/or exercise adherence. Two reviewers independently screened, data extracted, and assessed risk of bias and certainty of evidence. The interventions were mapped to the Theoretical Domains Framework. Eleven studies (n=901) were included. Four were randomised trials and risk of bias was mixed. Most interventions were multi-component, including education, behavioural techniques, and support groups. The most effective domains appear to be Behavioural regulation, Belief about Capabilities, Social influences, Reinforcement and Goals. Future research should examine multi-component BC interventions encompassing the five most effective TDF domains.

Objectives: The objective of this pilot study was to investigate the feasibility of a three month 'Motor control Home ergonomics Elderlies' Prevention of falls' (McHeELP) programme on muscle mass, muscle strength, functionality, balance and fear of falling among older adults with sarcopenia. Methods: A feasibility study of the McHeELP programme was performed in patients with sarcopenia. Primary outcome measures included number of participants; number of participants that showed engagement with the programme; adherence rates; data loss in questionnaires and secondary outcome measures; any adverse events, related or not to the intervention programme. All participants received a home-based motor control exercise programme combined with an ergonomic home modification for 12 weeks. Secondary outcome measures included Hand Grip Strength, Bioimpendance Analysis, Muscle Mass, Functionality and Fear of Falling. Results: Twelve participants, (74.9±5 years), completed the pilot study. Significant differences were recorded before and after the programme on participants' functionality (p < 0.001), balance (p < 0.05) and fear of falling (p < 0.001). Conclusions: The present study revealed that the McHeELP programme is fesasible and that it is possible to implement the programme in clinical practice. The McHeELP programme positively affects functionality, balance and fear of falling. Thus, it seems feasible to conduct a full-scale randomised controlled trial.

Objectives: 1) Map FaME delivery across the UK, 2) explore and understand delivery of the FaME programme in practice. Methods: Sequential exploratory mixed methods. 1) survey of n=247 Postural Stability Instructor (PSIs) across the UK, 2) purposively sampled n=23 PSIs to take part in interviews. Quantitative data was described descriptively due to low sample size, and qualitative data coded using thematic analysis. Results: Instructors pre-dominantly delivered classes in a community-setting, were mostly White British females with a range of experience. Most respondents were exercise instructors, physiotherapists, or therapist assistants. Only 136 (55.1%) respondents currently delivered the programme. The essential components of the FaME programme that instructors did not implement routinely were backward chaining, floorwork and Tai Chi. Five main themes emerged from qualitative data: individual, delivery and set-up, evidence-based delivery, motivational strategies, and instructor-based factors. Most instructors reported fidelity to most components of FaME and shared barriers and facilitators to delivering classes. Conclusion: This study gives a UK overview of the implementation of FaME. PSIs present a complex picture of the ways set-up and delivery of evidence-based programmes in practice can influence older adults' attendance, adherence and experience of the programme, and barriers and facilitators to delivery of the programme with fidelity.

Objectives: The objective of the study was to investigate factors associated with subjective aging among older patients visiting a geriatric medicine outpatient department in Northern-India. Methods: The study is a crosssectional study. Patients were categorized into three groups: whether they felt younger, equal, or older than their peers of same age. Factors such as fall, incontinence, anorexia, hand grip strength, cognition, depression, vision, hearing, cardiopulmonary function and immunization were assessed. Multinominal logistic regression was used to investigate the associated factors of subjective aging. Results: We assessed 184 older patients with a median age of 66.5 years (IQR 63.0 -78.8). Chronological age and hand grip strength were the significant factors associated with subjective aging. With one year increase in age, odds of feeling older than peers of same age decreased by 8.9% (OR, 0.911; 95% CI, 0.831-0.999, p = 0.047). With one kilogram increase in hand grip strength, odds of feeling younger than peers of same age increased by 7.3% (OR, 1.073; 95% CI, 1.01-1.14, p = 0.032). Conclusion: Chronological age and hand grip strength are the factors associated with subjective aging in Northern-Indian older adults. Further longitudinal multi-center studies are needed to confirm our findings.

Objectives: We surveyed healthcare staff working with older people to understand current practice in nutrition screening, initial management and referral for older people with sarcopenia and frailty. Methods: We conducted a UK-wide web-based survey of staff working with older people in both hospital and community settings. Surveys were distributed through professional organisation e-mail lists and social media channels. Descriptive data were generated from categorical responses and inductive thematic analysis was applied to free-text responses. Results: Data were analysed from 169 respondents (110 hospital, 59 community), representing 99 healthcare organisations. 91 (83%) hospital respondents and 24 (41%) community respondents reported that nutrition screening was performed on all patients with sarcopenia or frailty. The Malnutrition Universal Screening Tool was most commonly used to trigger referral to dietetics teams, but there was considerable variation in management before referral, referral thresholds and referral pathways. Themes derived from free-text responses included the need for training, issues of responsibility and ownership, inadequate resources (time, staff and equipment) and ineffective or inefficient processes for referral and management. Conclusions: Current UK nutritional care for older people with sarcopenia and frailty is heterogeneous. There are opportunities for better tools, processes, training and resources to improve current practice and pathways.

Objectives: To develop strategies against sarcopenia, physiological and biochemical data in older women were analyzed using propensity score matching. Methods: Fifty-six women aged ≥75 years with the AWGS calf circumference <33 cm were included in the sarcopenia risk group. Low muscle strength (handgrip strength <18kg) or low physical performance (five-times-sit-to-stand test ≥12s) were used the possible-sarcopenia group. Propensity score matching adjusted for age and BMI was performed between the possible-sarcopenia group with low muscle strength (or physical performance) and the sarcopenia risk group without low muscle strength (or physical performance). The comparison included nutritional index, metabolic syndrome parameters, BMD, and skeletal muscle mass index score between both groups. Results: The possible-sarcopenia group with low muscle strength exhibited significantly lower BMD (p=0.014) and skeletal muscle mass index score (p=0.002) compared to the sarcopenia risk group without low muscle strength. The possible-sarcopenia group with low physical performance exhibited significantly lower AST (p=0.034) compared to the sarcopenia risk group without low physical performance. Conclusion: These results suggest that older women with possible sarcopenia and low muscle strength may have reduced BMD and skeletal muscle mass index.

Age-related changes in body composition have been associated with reduced physical performance. However, the relationship of fat and lean mass indexes with physical performance in the setting of frailty is yet to be clearly established. We investigated the association between fat and lean mass indexes and physical performance in prefrail and frail older women. Fifty-one community-dwelling women 65 years and older (mean age 76 years) were classified as prefrail or frail according to a modified frailty phenotype. Body composition was estimated by dualenergy X-ray absorptiometry, while physical performance was assessed via the following tests: Berg balance scale, timed-stands, timed up-and-go test, 6-minute walk test, and the short performance physical battery. Correlation coefficients were determined to assess the association between body composition and physical performance parameters. Associations between continuous variables with a p-value <0.05 were included in a linear regression analysis. All fat mass indexes predicted a reduced performance in at least one functional test. Among the lean mass indexes, only leg lean mass adjusted by body fat mass was directly associated with better physical performance. Our findings indicate that fat mass indexes may have a greater impact on physical performance than lean mass in frail and prefrail older women.

Malnutrition, inflammation, comorbid diseases, and inactivity are known causes of sarcopenia. It results in clinical consequences like fractures, falls, low quality of life, cognitive dysfunction, and mortality. Especially in the treatment of patients with prolonged immobilization syndrome, management should not only focus on functional limitations but patients should also be evaluated and followed up for sarcopenia. In this case report, we present the management of probable secondary sarcopenia in the intensive care unit as a result of urosepsis and discuss it in the light of the literature.

This is a commentary on the published article:
Canever JB, de Souza Moreira B, Danielewicz AL, de Avelar NCP.
Are multimorbidity patterns associated with fear of falling in community-dwelling older adults?
BMC Geriatr 2022;22(1):192.1

Objectives: The Benchmarking Exercise Programme for Older People (BEPOP) service improvement project seeks to determine and promote the exercise training characteristics associated with positive outcomes for resistance exercise for older people living with, or at risk of, sarcopenia or physical frailty. Methods: Mixed-methods service improvement project. Ten UK National Health Service physiotherapist-led therapy services delivering exercise interventions for older people submitted anonymized data for up to 20 consecutive patients. A multidisciplinary expert panel generated a report and recommendations with site-specific benchmarking data and feedback. In parallel, participating physiotherapy team members were interviewed to elicit feedback on BEPOP rationale, processes and perceived value. Results: Data from 188 patients were included, mean age 80 years (range 60-101). 115 (61%) received objective assessment of strength-based physical performance. Bodyweight exercises (173 [92%]) and resistance bands (49 [26%]) were the commonest exercise modalities. Exercises progressed predominantly through increased repetitions (163 [87%]) rather than increased load. 50 (30%) had no reassessment of outcomes; only 68 (41%) were signposted to follow-on exercise services. Staff interviews identified themes around knowledge, diagnosis, data collection and practice reflection. Conclusion: BEPOP was feasible to deliver and generated actionable insights for service improvement via improved diagnosis, measurement and progression of resistance exercise.

Objectives: Sarcopenia is a skeletal muscle mass (SMM) disease characterized by loss of strength with generalized loss of SMM. The aim of this study is to evaluate the effects of a 12-week intervention on SMM, strength, and functionally in older adults. Methods: This is a retrospective analysis of an intervention protocol with older adults at risk of sarcopenia who performed a daily intake of oral nutritional supplements (ONS) and resistance training exercise (RET), 3 times a week. Calf circumference (CC), bioelectrical impedance analysis (BIA), handgrip strength (HGS) and Timed Up and Go (TUG) were performed at baseline and at 12 weeks. Results: Fifty-one older adults were included. The mean age was 76.3 ± 8.3 years and 68.6% were women. After 12 weeks, the study showed an increase of CC in cm (1.9 ± 2.5, p < 0.001), increase of strength in kg (5.4 ± 2.1, p < 0.001), reduction of TUG in seconds (-2.4 ± 4.8, p = 0.001), increase of free-fat mass in kg (1.0 ± 1.3, p < 0.001) and SMM in kg (0.9 ± 0.5, p < 0.001). Conclusions: Nutritional intervention with ONS associated with RET, can increase muscle strength, SMM and functionality among older adults at risk for sarcopenia.

Objectives: To compare the European Working Group on Sarcopenia in Older People (EWGSOP2) and the Sarcopenia Definition and Outcomes Consortium (SDOC) in identifying muscle quality indexes (MQI) and lower limb muscle performance in older women aged ≥ 65. Methods: Participants meeting EWGSOP2 and SDOC criteria were classified into the sarcopenia group (GS); others were placed in the non-sarcopenia group (GNS). Using an isokinetic dynamometer, we assessed peak torque (PT), maximal work (MW), and power (POW) of lower limbs. MQI was calculated as the ratio of muscle performance to appendicular lean mass, adjusted for body mass index (BMI) and lean tissue mass of the right lower limb (LTM). Results: We included 96 older women. In both SDOC (n=37) and EWGSOP2 (n=48) sarcopenia groups, muscle performance and BMI-adjusted MQI were significantly lower. Sarcopenia (SDOC) was significantly associated with all lower limb muscle performance and MQI variables [adjusted model by age and race: MQI_POW/LTM OR = 0.67 (95% CI 0.52; 0.85); MQI_PT/LTM OR = 0.76 (95% CI 0.64; 0.89)]. Conclusions: Older women diagnosed with sarcopenia by EWGSOP2 and SDOC criteria showed significant declines in muscle function and quality. The SDOC definition discriminated muscle contraction quality components in older individuals with and without sarcopenia.

Objectives: We aimed to evaluate the association between scores on each item of the SARC-F questionnaire and life expectancy in patients undergoing major surgery for urologic cancer. Methods: This retrospective study included 1018 patients undergoing elective major urologic cancer surgery. All patients completed the SARC-F questionnaire preoperatively. Demographic and clinical data were collected. The primary endpoint was an association between SARC-F scores and overall survival (OS). Results: Of the 1018 patients, the median age was 72 years and 920 (90%) were male. Multivariate analysis revealed four factors significantly and independently associated with shorter OS: assistance with walking score ≥1 (Hazard ratio: HR=2.18, P=0.044), cancer stages ≥ III (HR=7.98, P<0.001), high blood loss ≥78 ml or blood transfusion during surgery (HR=4.53, P=0.007 and HR=2.41, P=0.037, respectively). Conclusions: This study found that among the items of the SARC-F questionnaire, assistance with walking was a strong predictor of life expectancy. Incorporating such a simple screening tool into the preoperative assessment would help to ensure more appropriate perioperative care for urologic cancer patients.

Objectives: Hip fractures (HFx) resulting from falls are a significant health concern, and drugs with anticholinergic properties (DAP) increase the risk of falls. This study aimed to assess the association between use of DAP at hospital admission and HFx risk in older patients. Methods: This nationwide population-based study included all patients ≥65 years admitted to Danish geriatric wards during 2005-2014. Outcome of interest was first HFx within 2-years follow-up. The Anticholinergic Cognitive Burden (ACB) scale quantified DAP use. Cox regression analysis of data from four national registries was adjusted for activities of daily living, age, marital status, admission year, BMI, fracture history, previous admissions, dementia, anti-osteoporotic drugs, and Charlson comorbidity index. Results: 74,589 patients (62.8% female) were included, 45,463 (60.9%) received DAP at index, and 7,861 HFx occurred during follow-up. Cumulative 2-year HFx hazard was highest for ACB=0 (15.3%). Higher ACB-score was not associated with increased HFx risk in univariable nor multivariable analyses. In sensitivity analysis, use of DAP with high anticholinergic burden (≥2) did not alter results. Conclusions: In this high-incidence national cohort, higher ACB-score was not associated with increased HFx risk. Our results call for further research on association between specific DAP and risk of HFx.

Objective: To conduct an economic cost analysis and budget impact assessment (BIA) of implementing the Frailty Care Bundle (FCB) intervention nationally over five-years for hip fracture patients. The FCB was designed to reduce hospital associated decline in older hospitalised patients. Methods: The FCB was delivered in two Irish hospitals on two wards per hospital. A micro level cost analysis, from the Irish health service perspective was undertaken. Direct costs of the FCB were considered (personnel, training, resources), expressed in Euros (2020). For the BIA national population estimates for hip fracture and costs avoided were based on 18% difference in patients returning to their baseline capability in the post compared to pre-intervention group, valued using cost estimates of functional decline. Results: We estimated total intervention costs at €53,619 (89% for personnel) and the average cost per patient was €156.03. The expected costs of implementing the FCB nationally over 12-months was €57,274 per hospital (€72.92 per patient). The BIA for an expected targeted population (16,000 over 5 years), estimated that the cost of implementing the FCB (€1.2m) was less than the expected value of functional decline avoided owing to the intervention (€3.6m), suggesting a positive net effect (€2.4m). Conclusion: Investment in the FCB can be offset with more rapid patient return to baseline functional capability, reducing health care costs. Trial and Protocol Registration (retrospective): BMC ISRCTN 15145850, (https://doi.org/10.1186/ISRCTN15145850).

In 1998, Fried and Walston introduced the Cycle of Frailty (CF) as a foundational concept for defining the physical frailty phenotype (FP). While the FP has been extensively validated, the CF hypothesis lacks equivalent support. This study aimed to internally validate the CF using structural equation modeling (SEM) in a clinical dataset of adults aged 50 or older attending an outpatient falls clinic. Measures included: age, morbidity, nutrition, sarcopenia by bioelectrical impedance, VO₂max, handgrip strength, basal metabolic rate (BMR), 5-times chair stand test (5CST), physical activity, and total energy expenditure (TEE). The SEM, incorporating CF hypothesized causal pathways, was tested using IBM^® SPSS^® Amos 27.0.0 (maximum likelihood method) with a sample of 102 adults (mean age 69.8 years, 58.8% women). Overall, the SEM was supported by the data (χ² = 44.4, df = 37, p = 0.189), with significant (p < 0.05) regression weights for morbidity→sarcopenia, age→sarcopenia, sarcopenia→VO₂max, sarcopenia→handgrip strength, handgrip strength→5CST, physical activity→TEE, TEE→nutrition, and BMR→TEE. However, nutrition→sarcopenia, sarcopenia→BMR, VO₂max→5CST, and 5CST→physical activity were not significant. Although the SEM was limited by inclusion of surrogate CF measures (e.g., 5CST instead of gait speed, VO₂max based on age-predicted maximal/resting heart rate), it provided some internal support for the CF hypothesis.