[Osteosarcopenia]. / Osteosarkopenie.

Osteoporosis is nowadays understood as an increased risk of fractures, with bone density measurement by dual-energy X­ray absorptiometry (DXA) being a useful diagnostic criterion and a potent fracture predictor; however, especially in geriatric patients the result is often falsely negative, so that the diagnosis, indications for treatment and treatment selection should be based on an overall clinical evaluation of the individual situation. Sarcopenia is defined as a geriatric syndrome characterized by a generalized loss of skeletal mass and muscle function. Sarcopenia is associated with an increased likelihood of adverse outcomes including falls, fractures, disability and mortality. Since 2018 it is possible in Germany to encode sarcopenia in the International Statistical Classification of Diseases and Related Health Problems, 10th revision, German modification (ICD-10-GM, M62.50). In the case of a high fracture risk and indications for the presence of sarcopenia, the whole body composition should be assessed by DXA within the framework of the measurement of bone mineral density. In the treatment of osteosarcopenia non-pharmacological measures must be initiated in addition to pharmacological measures. It is particularly important to clarify and if necessary to resolve the cause of falls resulting in fractures as well as to regularly reevaluate the treatment goals.

Assessment of Bone and Muscle Measurements by Peripheral Quantitative Computed Tomography in Geriatric Patients.

The loss of bone and muscle mass increases the risk of osteoporotic fractures. Dual energy X-ray absorptiometry (DXA) loses sensitivity in older age. The purpose of this study was to evaluate bone and muscle measurements of peripheral quantitative computed tomography (pQCT) in a geriatric cohort with osteoporosis. Bone mineral density and muscle area of 168 patients aged 65 years and older (76.3 ± 6.5) were measured with pQCT at distal forearm additionally to an osteoporosis assessment consisting of anamnesis, blood test and DXA of lumbar spine and hip. Prior fractures were categorized in minor and major osteoporotic fractures. Logistic regression was used to show the association of bone mineral density and muscle area with major fractures. 54.8% of the participants had at least one major fracture. Bone mineral density measured with pQCT and muscle area were significantly associated with these fractures (total and trabecular bone mineral density OR 2.243 and 2.195, p < 0.01; muscle area OR 2.378, p < 0.05), whereas DXA bone mineral density showed no significant association. These associations remained after adjustment for age, sex, BMI, physical activity and other factors. In all models for patients >75 years only muscle area was significantly associated (OR 5.354, p < 0.05) with major fractures. Measurement of bone mineral density and muscle area with pQCT seems to have advantage over DXA in fracture association in geriatric patients. Measuring muscle area also adds useful information to estimate the presence of osteosarcopenia.

The Oldest Old in the Emergency Department: Impact of Renal Function.

OBJECTIVES: The ageing population implicates an increasing numbers of older adults attending Emergency Departments (ED). We assessed the effect of estimated glomerular filtration rate as a predictor of clinical outcomes in oldest-old patients ≥ 85 years attending the ED in an university teaching hospital. DESIGN: Within three years, 81831 patient contacts were made in our ED. 7799 (9.5%) were older than 85 years, in whom we analyzed the impact of renal function on various outcome parameters. Furthermore, this patient group was compared to the patients < 85 years. RESULTS: Within the group of patients ≥ 85 years, not older age, but as denominator decreased glomerular filtration rate led to significant longer hospital stays. In addition, impaired kidney function was associated with lower heart rates, lower blood pressure, lower oxygenation, a higher rate of established ambulant care setting, as well as higher mortality. Compared to younger patients, the oldest-old significantly differed with regard to medical attribution (e.g. internal medicine, surgery), sex distribution, length of hospital stay, Manchester triage score, Glasgow Coma Scale, visual analogue pain scale, heart rate, blood pressure, oxygen saturation as well as fall prophylaxis, outpatient care, and presence of relatives. CONCLUSION: In conclusion, in this large collective of oldest-old patients, impaired kidney function seems to be a more important determinant in adverse outcome and thus increased health care costs than age per se. Adapted strategies in EDs to adjust diagnostic and treatment strategies for this population are thus warranted.

[Sarcopenia and frailty in neurology]. / Sarkopenie und Frailty in der Neurologie.

Sarcopenia and frailty are common geriatric syndromes and are associated with adverse health outcome and impaired health-related quality of life. Co-occurrences of these two syndromes with age-related neurological diseases are potentially high but not well investigated. Moreover, it is not well understood how these syndromes interact with neurological diseases, such as Parkinson's disease, Alzheimer's disease and stroke. This article introduces the currently most accepted concepts of sarcopenia and frailty, discusses the potential relevance of the syndromes for geriatric patients and presents examples of studies that investigated potential interactions between these geriatric and neurological syndromes and conditions. First results indicate that (i) the co-occurrence of these geriatric syndromes and age-related neurological diseases is high, (ii) sarcopenia and frailty can influence the clinical state of neurological diseases to a relevant extent and (iii) at least some common causes and pathophysiological processes confer the geriatric and neurological conditions. In conclusion, profound knowledge about the interaction of sarcopenia, frailty and age-associated neurological conditions is currently not available. Such knowledge would have an enormous potential for improved therapy of these neurological conditions.

Impact of age, performance and athletic event on injury rates in master athletics - first results from an ongoing prospective study.

OBJECTIVES: Recent studies have identified rates of injuries in young elite athletes during major athletic events. However, no such data exist on master athletes. The aim of this study was to assess incidence and types of injuries during the 2012 European Veteran Athletics Championships as a function of age, performance and athletic discipline. METHODS: Report forms were used to identify injured athletes and injury types. Analysis included age (grouped in five-year bands beginning at age 35 years), athletic event, and age-graded performance. RESULTS: Of the 3154 athletes (53.2 years (SD 12.3)) that participated in the championships (1004 (31.8%) women, 2150 (68.2%) men), 76 were registered as injured; 2.8% of the female (29), 2.2% of the male (47) athletes. There were no fractures. One injury required operative treatment (Achilles tendon rupture). Injury rates were significantly higher in the sprint/middle distance/jumps than the throws, long distance and decathlon/heptathlon groups (X(2) (3)=16.187, P=0.001). There was no significant interrelationship with age (X(2) (12)=6.495, P=0.889) or age-graded performance (X(2) (3)=3.563, P=0.313). CONCLUSIONS: The results suggest that healthy master athletes have a low risk of injury that does not increase with age or performance.

The Motor Unit Number Index (MUNIX) in sarcopenic patients.

INTRODUCTION: The cause of sarcopenia is still not fully understood. A multifactorial aetiology is discussed. Neurodegenerative aspects in the genesis of sarcopenia, such as loss of motoneurons, have not yet been explored to a sufficient extent. METHOD: The Motor Unit Number Index (MUNIX) is a method for assessing the number and size (Motor Unit Size Index - MUSIX) of Motor Units (MUs) using the Compound Muscle Action Potential (CMAP) and the Surface electromyographic Interference Pattern (SIP). This method was used to study the hypothenar muscle in the right hand of 27 sarcopenic patients. RESULTS: The mean MUNIX (111±51) of all investigated sarcopenic patients lies between the mean MUNIX of healthy persons and the mean MUNIX of ALS patients. 25% of sarcopenic patients exhibit pathologic values for both MUNIX (<80) and MUSIX (>100 µV). A strong correlation (r=0.75, p<0.001) between MUSIX and the reciprocal value of MUNIX was identified. CONCLUSION: It was demonstrated for the first time by applying the MUNIX technique that loss of motoneurons plays a pathogenic role in the onset of sarcopenia. This was shown in 25% of sarcopenic participants who exhibited pathologic values for both MUNIX and MUSIX. Nerve sprouting seems to be an important mechanism of compensation for loss of motoneurons, reflected by the strong correlation between MUNIX and MUSIX. Use of MUNIX leads to the identification of a distinct subgroup of sarcopenic patients, which might have a major impact on future diagnostic and therapeutic concepts.

C-terminal Agrin Fragment as a potential marker for sarcopenia caused by degeneration of the neuromuscular junction.

INTRODUCTION: Sarcopenia is considered to be an enormous burden for both the individuals affected and for society at large. A multifactorial aetiology of this geriatric syndrome has been discussed. Amongst other pathomechanisms, the degeneration of the neuromuscular junction (NMJ) may be of major relevance. The intact balance between the pro-synaptic agent agrin and the anti-synaptic agent neurotrypsin ensures a structurally and functionally intact NMJ. Excessive cleavage of the native motoneuron-derived agrin by neurotrypsin into a C-terminal Agrin Fragment (CAF) leads to functional disintegration at the NMJ and may consecutively cause sarcopenia. The present study evaluates the hypothesis that CAF serum concentration is a potential marker for the loss of appendicular lean mass in older adults. It also explores how CAF concentration is influenced by vitamin D supplementation and physical exercise. METHOD: Serum was taken from 69 (47 female) prefrail community-dwelling older adults participating in a training intervention study to measure the CAF concentration using the Western blot technique. All participants were supplemented orally with vitamin D3 before the training intervention period commenced. Appendicular lean mass (aLM) was evaluated by dual energy X-ray absorptiometry. Multiple linear regression models were used to identify factors significantly associated with CAF concentration. RESULTS: Appendicular lean mass, age and sex were identified as significant explanatory factors for CAF concentration. Gait speed and hand grip strength were not associated with CAF concentration. Male participants showed a strong correlation (r=-0.524) between CAF serum concentration and aLM, whereas this was not the case (r=-0.219) in females. Vitamin D supplementation and physical exercise were significantly associated with a reduction in CAF concentration, especially in participants with initially high CAF concentrations. CONCLUSIONS: C-terminal Agrin Fragment could be a potential marker for identifying sarcopenia in a subgroup of affected individuals in the future. The decline of muscle mass seems to be a CAF-associated process in males, whereas the situation in females may be more complex and multifactorial. CAF concentration is reduced by vitamin D supplementation and physical exercise and therefore suggests a potentially positive effect on NMJs. Further prospective studies of sarcopenic patients in addition to muscle biopsy and electromyographical investigations are planned to verify the external validity of the CAF concept.

[Malnutrition in the elderly]. / Mangelernährung im Alter.

Malnutrition, which occurs in 27.4% of all elderly persons, is a great burden to those affected and for the health services. There are multiple causes for malnutrition, such as loss of appetite, poorly balanced diet, dementia, dysphagia chewing problems, as well as gastrointestinal disorders. Presence of weight loss and/or anorexia point towards malnutrition. A prerequisite for properly targeted nutritional intervention is to distinguish between sarcopenia and kachexia. In addition the "Mini Nutritional Assessment" (MNA (®)) questionnaire can be used quickly and reliably for diagnose malnutrition as recommended by the European Society for Clinical Nutrition and Metabolism. Treatment should be based on an individually designed nutritional regime, which incorporates eating habits and functional impairment of the patient.

The frailty syndrome in general practitioner care: a pilot study.

BACKGROUND: Knowledge about frailty among patients seen by general practitioners (GP) is currently limited. PATIENTS AND METHODS: Frailty assessment by the criteria of Fried and additional documentation was performed at a GP's office. RESULTS: Out of 119 participating patients, 14.3% were classified as frail, 52.1% as prefrail, and 33.6% as not frail. Frailty was associated with comorbidity, the number of drugs prescribed, depressive symptoms, cognitive function, and frequency of falls. CONCLUSION: The prevalence of frailty is high among the cohort of elderly persons seen by a GP. Routine frailty assessment will help to direct preventive and therapeutic interventions.

The Fried frailty criteria as inclusion criteria for a randomized controlled trial: personal experience and literature review.

BACKGROUND: among current operational definitions of frailty, the criteria proposed by Fried and colleagues have attracted great scientific interest. However, these criteria have usually been applied in epidemiological and only rarely in interventional studies. OBJECTIVE: the present paper aims at testing the applicability of the Fried frailty criteria in the context of the recruitment process of a randomized controlled trial in prefrail older persons, and it discusses the respective scientific literature. METHODS: recruitment was promoted by newspaper articles as well as by targeted mail to customers of a local health insurance company and to recently treated patients of a geriatric day clinic. Furthermore, presentations were given in assisted living facilities. Potential candidates were screened for prefrailty, i.e. to see whether they met 1 or 2 of the Fried criteria (weight loss, handgrip strength, gait speed, exhaustion, physical activity). RESULTS: a total of 298 people were screened. Among them 181 were not frail, 116 were prefrail and 1 was diagnosed as frail. The most prevalent criterion was exhaustion (24% of those screened). The second most prevalent criterion was low handgrip strength (20%). Low gait speed (8%), low physical activity (2%) and weight loss (2%) had a lower prevalence. According to the Geriatric Depression Scale, 14% of those who met the criterion 'exhaustion' were depressed. With regard to the Minnesota Leisure Time Physical Activity Questionnaire, used for the evaluation of 'physical activity', only 3 activities among the 18 selected by Fried were applicable to our cohort. CONCLUSIONS: under the study conditions, good applicability of the Fried criteria was observed. Nevertheless, further refinement may be expedient in several criteria, especially exhaustion and physical activity, to enhance clinical usefulness. It may be helpful to adapt the cutoffs when applying the criteria to a European population.

Contrasting effects of acute and chronic ethanol administration on rat liver tyrosine aminotransferase.

We compared the effects of acute and chronic ethanol administration on the activity and synthesis of tyrosine aminotransferase (TAT) in rat liver. In acute experiments, chow-fed rats received a single dose of either ethanol (6 g/kg body wt.) or saline. In chronic studies, rats were pair-fed liquid diets containing either ethanol (36 % of calories) or isocaloric maltose-dextrin for 6-8 weeks. In rats acutely fed ethanol, the relative rate of TAT synthesis was more than twofold higher than in saline-treated controls. In rats subjected to chronic ethanol administration, both the TAT activity and synthesis rate were the same as in pair-fed controls, but both these parameters in the two groups were equal to those in animals given acute ethanol acutely. These findings indicate that whereas acute ethanol administration was associated with a stimulation of TAT synthesis, long-term ethanol administration was not. The data suggest that ethanol itself does not directly induce TAT. Rather, enzyme synthesis is regulated by one or more endogenous secondary effector(s) whose production is influenced differently by acute or chronic ethanol feeding.

Hepatic lysosomal cathepsin activities after acute ethanol administration.

In order to determine whether acute ethanol administration produces alterations in hepatic lysosomal protease activities, male Sprague-Dawley rats were given either ethanol or isocaloric glucose by gastric intubation and the free and total activities of cathepsins B, D, H and L were measured. Twelve hours after administration, the free (nonlatent) activities of cathepsins D and H were higher in ethanol-fed rats than in glucose-fed controls, indicating a slightly higher lysosomal fragility which probably resulted from a nutritional deficiency which was evident in ethanol-fed animals. Measurement of the total (latent plus nonlatent) activities of these cathepsins in detergent-treated homogenates revealed that only cathepsin H activity in ethanol-fed rats was higher than in controls. The results indicate that acute ethanol consumption causes little or no change in the total activities of the cathepsins examined. Thus previously-reported alterations in hepatic protein catabolism following ethanol administration are not related to changes in the activities of these lysosomal proteases.