10. Sarcopenia and frailty + JC Flashcards
explain how muscle pathology (5) leads to _________ (3 ish), which leads to __________ (2) which leads to __________ (1)
*schéma ish
- MUSCLE PATHOLOGY
- loss of motor units
- change in fiber type
- muscle fiber atrophy
- reduced neuromuscular activation
- slowed rate of activation
*overall reduced muscle quality - IMPAIRMENT
- reduced velocity of movement
- reduced force production
- reduced power output - FUNCTIONAL LIMITATION
- prolonged chair rise
- stair climb time - if no intervention –> DISABILITY
- change in societal/environmental role
- what is the prevalence of sarcopenia? explain
- highest prevalence in (3 populations)
- depends on definition, setting and age group!
- affects 5-13% of community dwelling older adults + up to 50% of ppl >80 yo
- over 80 yo
- those living in nursing homes/assisted living
- individuals that meet criteria for fraily
what are the primary/age-related mechanisms for sarcopenia (3)?
- what are 5 other mechanisms for developing sarcopenia?
- change in sex hormones
- apoptosis (change in muscle size and number)
- mitochondrial dysfunction (from anabolic resistance)
a) disuse: immobility, physical inactivity, zero gravity (space flight)
b) inadequate nutrition/malabsorption
c) cachexia
d) neuro-degenerative diseases (motor neuron loss)
e) endocrine (corticosteroids, GH, IGF1, abnormal thyroid function, insulin resistance
CLINICAL DEFINITION OF SARCOPENIA:
1) originally, defined as what?
2) European Working Group of Sarcopenia in Older people defines sarcopenia as what? –> 3 categories ish
3) new global conceptual definition?
1) defines as appendicular (in arms and legs) lean mass / heigh^2 (in kg/m^2) less than 2SD below mean value for young adults
2) syndrome characterized by progressive loss of skeletal muscle mass (and strength) and function
a) Pre-sarcopenia: low muscle mass WITHOUT impact of muscle strength or physical performance
b) sarcopenia: low muscle mass + (low muscle strength OR low physical performance)
c) severe sarcopenia: all 3 criteria are met (low muscle mass, muscle strength and physical performance)
3) muscle mass, muscle strength and muscle-specific strength (ie muscle strength divided by muscle size)
- physical performance, mobility limitations, falls, fractures, poor quality of life are now outcomes of sarcopenia!
Growing interest in understanding clinical relevance of sarcopenia has led to large-scale guidelines outlining critical thresholds for which 3 key components + what are the thresholds ish (probs not important tho)
1) low muscle mass –> appendicular lean mass
- EWGSOP: < 5.67 - 7.23 kg/m^2
- FNIH: < 15.09-19.75 kg
2) low grip strength:
- EWGSOP: < 20-30 kg
- FNIH: 16-26 kg
3) slow gait speed:
- <0.8 m/s for both men and women
general aspects of sarcopenia:
a) disease of ________ ________
b) increase with __________
c) reversible?
d) definition does NOT depend on (3)
e) same for research and clinical practice?
a) skeletal muscle
b) age
c) potentially reversible
d) does NOT depend on age, setting of care or clinical condition
e) same for clinical practice and research
what are 2 types of assessments of muscle mass?
- each estimates what?
DUAL-ENERGY XRAY ABSORPTIOMETRY (DXA)
- reference method for measuring body comp in clinical research bc assesses bone mass + fat mass + fat-free mass (surrogate for muscle mass)
BIOELECTRICAL IMPEDANCE ANALYSIS (BIA)
- estimates volume of fat AND lean body mass
- measures resistance of electric current passed btw electrodes (increase fat-free mass + faster signal)
- using Janssen equation
*but need to consider previous hydration, food intake and exercise
what are 2 assessments of muscle strength?
- handgrip strength testing –> can compare with normative grip strength data
- biodex dynamometer testing (sitting on chair and have a mechanical thing that your leg has to push against)
what are 2 assessments of physical performance?
- explain!
- threshold for functional decline ish?
- reliable predictor?
GAIT SPEED
- measured as time to walk over 3 to 10m with 2m for acceleration and 2m for deceleration
- at usual speed OR comfortable speed OR as fast as they can
- slow = < 0.8m/s
- reliable predictor of risk for hospitalization and functional decline!
SHORT PHYSICAL PERFORMANCE BATTERY
- composite measure of physical performance (balance, gait, strength, endurance)
- includes:
a) 10-m walk test
b) 5-times sit-to-stand test
c) side-by-side, semi-tandem and tandem timed balance tests
- score from 0 (worst) to 12 (best) –> usually < 9 = major mobility impairment
- has shown predictive validity for identifying risk of mortality, nursing home admission and disability
explain the clinical assessment of sarcopenia (flow chart)
for older subject >65yo
1) measure gait speed
a) if > 0.8m/s –> measure grip strength
- if normal = no sarcopenia (no need to measure muscle mass)
- if low –> go to 2)
b) if <= 0.8m/s –> go to 2)
2) measure muscle mass:
- if low = sarcopenia
- if normal: no sarcopenia (so maybe mobility issue or frailty)
what is SARC-F screening?
- good for what?
- bad for what?
- screening tool (5 questions asking about strength (ie difficulty lifting 10lb?), assistance in walking, rise from chair, climb stairs (can climb 5 flights of stairs?), falls) –> score higher than 4 = classified/suspected of sarcopenia
PRO: excellent specificity –> may be suitable as initial tool to rule out those that don’t have sarcopenia before additional assessment
CON: poor sensitivity for sarcopenia classification
how are frailty and sarcopenia related? (venn diagram)
SARCOPENIA:
- skeletal muscle loss
- poor muscle quality
FRAILTY:
- deficits accumulation
- fatigue
- sedentary behaviour
- weight loss
- cognitive impairment
- social isolation
*physical and psychosocial aspects!
PHYSICAL FUNCTION IMPAIRMENT (common for both)
- weak muscle strength
- slow gait speed
- poor balance
- concept of frailty first published when?
- has 1 operational definition?
- may be of what origin?
- prevalence of frailty?
- exists on a ________ and is __________
- can prevent or reverse?
- in 1950s-60s in geriatric medicine literature –> more contributions by 1980s/90s –> increasing exponentially since 2001
- more than 40 operational definitions proposed!
- multiple causes and contributors –> may be of physical or psychosocial origin (or both)
- affects 5-17% of community dwelling older adults (similar to sarcopenia + depends on def) –> prevalence increases to 32% for >90yo
- on a spectrum + progressive
- good news is that frailty it also modifiable and older individuals can slow, prevent or even reverse frailty status!
what are the 3 dimensions of frailty? + sub
PHYSICAL
- physical health
- unintentional weight loss
- balance and walking problems
- poor hearing and vision
- low hand strength
- physical tiredness
PSYCHOLOGICAL
- problems with memory
- feeling down
- feeling nervous/anxious
- problems with coping
SOCIAL
- living alone
- lack of people around
- lack of people’s support
describe difference btw someone managing well vs mild frailty vs severe frailty
MANAGING WELL
- fit older adult who, following a minor stressor, experiences minor deterioration in function + RETURNS to homeostasis
FRAILTY:
- frail older adult who, following a similar stressor, experiences more significant deterioration and does NOT return to baseline homeostasis.
- MILD: small decrease from normal
- SEVER: big decrease (to below dependence threshold) –> may lead to functional dependency or death
what are 4 big risk factors categories + sub for frailty onset and progression?
DEMOGRAPHIC FACTORS
- older age, female sex, ethnicity minority
- low education/socioeconomic position
- living alone
CLINICAL FACTORS
- multimorbidity and chronic disease
- obesity
- malnutrition
- cognitive impairment
- depression/anxiety
- polypharmacy (interactions!)
LIFESTYLE FACTORS
- physical inactivity
- low food intake (especially protein)
- smoking
- increased alcohol intake
- weight loss
BIOLOGICAL FACTORS
- inflammation (elevated cytokines)
- endocrine factors (androgen deficiency)
- micronutrient deficits (low vit D)
- chronic anemia
what are 4 ways to screen people for frailty?
- Fried’s frailty phenotype (most widely known def) (5 criteria)
- frailty index (accumulation of deficits)
- FRAIL instrument (5 elements)
- clinical frailty scale (from 1 to 9)
describe Fried’s frailty phenotype + FRAIL instrument
FRIED’S FRAILTY PHENOTYPE
- operationalized using cardiovascular health study data + validated to predict falls, hospitalizations, disability and mortality
1. poor endurance or E (self-reported exhaustion)
2. weakness (ie poor grip strength)
3. slowness (slow gait speed)
4. low weekly PA levels
5. unintentional weight loss (more than 4.5kg or 5% of bw during previous year)
- >=3 = frail, pre-frail (1-2), robust (0)
FRAIL instrument
Fatigue: are you fatigued?
Resistance: cannot walk up 10 flight of stairs
Ambulation: cannot walk 1 block?
Illness: more than 5 illnesses?
Loss of weight: lost more than 5% wt in last 6mo?
- >=3 = frail, 1-2: pre-frailty, 0 = robust
what are examples of deficits from frailty index?
- scoring?
- Activities of daily living
- Cognitive function
- Chronic diseases
- Cardiovascular disease
- Depression/mental health
- Poor eyesight/hearing
- Falls, fractures and joint replacements
- Calculate the PROPORTION of deficits held (0-1 scale)
SCORING - robust: 0-0.12
- pre-frail: 0.13-0.21
- frail: >0.21
describe the clinical frailty scale
- very fit: robust, active, motivated
- well: no active disease, but less fit than 1
- managing well: medical problems are controlled
- vulnerable: not dependent on others but symptoms limit activities
- mildly frail: more evident slowing, need help with high order ADLs –> impairs shopping, meal prep…
- moderately frail: need help with ALL outside activities + keeping house clean + bathing
- severely frail: completely dependent for personal care
- very severely frail: completely dependent, approaching end of life, typically can’t recover from minor illness
- terminally ill: life expectancy <6months
what is the gold standard treatment for frailty?
- explain
- effective?
COMPREHENSIVE GERIATRIC ASSESSMENT (CGA)
- multi-dimensional care process: identifies medical, social, functional needs of older patients in adult care, rehab or long-term care
- functional status, comorbidity, cognition, nutrition, polypharmacy, social support & mental status = all part of CGA
- older adult who receives CGA is more likely to be living in their own home 6months after acute illness?
CASE STUDY:
Max is an 80-year-old man living alone at home. Previously highly functional and independent, in the last year, he fell and fractured his left femur. After he was discharged from the hospital, he was transferred to a nursing home for rehabilitation. He received physical therapy and has now returned home after a 3-week stay. He has lost 12 lbs (8% of his body weight) in the past year and reports that he is more easily fatigued. He walks slowly, at 0.6 m/s and is unsteady without his walker. He has lost a significant amount of muscle mass, and his grip strength is significantly lower than age-, sex-, and BMI-matched values.
1) Do you think Max would meet the EWGSOP definition of sarcopenia? Based on what?
2) According to Fried’s Frailty Phenotype, is Max robust, pre-frail or frail?
1) - “lost significant amount of muscle mass”
- “grip strength is significantly lower than age-sex-BMI matched values”
- don’t know much about physical performance now that is is home
- meets sarcopenia def for EWGSOP (low muscle mass + low muscle strength) –> maybe even severe sarcopenia (if low physical performance also)
2) - unintentional weight loss (>5% bw)
- poor endurance/energy (“more easily fatigued”
- weakness (poor grip strength)
- slowness (gait speed < 0.8m/s)
- no info about PA levels
*at least 4 out of 5 –> >=3 –> frail!
JOURNAL CLUBS!
- Stec et al. –> describe
- result?
- Bernabei et al: multicomponent intervention to prevent mobility disability in frail older adults! (>1000 participants in 11 countries in Europe)
Stec et al.
- randomized 4-arm –> HHH vs HLH vs HH vs HL
- HLH was the best at increasing muscle mass, strength and CV fitness
- good for people with pre-sarcopenia OR low muscle mass
Bernabei et al.
- multicomponent intervention to prevent mobility disability in frail older adults! (>1000 participants in 11 countries in Europe)
- exercise, training, nutrition, mobility
- large sample size, long follow-up
- good fit for people who have low short physical performance battery score!
