Cognitive frailty in older adults: examining the impact of frailty criteria on neuropsychological profile, functional outcomes, activity levels, and quality of life.

PURPOSE: Cognitive frailty (CF) is the co-existence of cognitive impairment and physical frailty without dementia, conferring greater risks of adverse clinical outcomes compared to either condition alone. However, the impact of physical frailty components on cognitive performance remains unclear. This study aims to evaluate CF by determining the neuropsychological profiles, functional outcomes, activity levels, and quality of life across the Fried Frailty Phenotype (FFP) and its components. METHODS: Cross-sectional study involving 120 community-dwelling older adults without dementia, but with subjective cognitive complaints (SCC, defined as AD8 ≥ 1). Participants were stratified into three groups to assess CF: SCC-Robust, SCC-Prefrail, and SCC-Frail, and further categorized by individual FFP components. Cognitive performance was assessed by comparing neuropsychological test battery (NTB) Z-scores between CF and non-CF groups with Cohen's d for effect sizes. We performed linear regression to examine the relationships between both groups with NTB scores, Instrumental Activities of Daily Living (IADL), Frenchay Activities Index (FAI), and quality of life scores. RESULTS: NTB scores showed no differences between individuals with CF when classified according to FFP criteria. Individuals with SCC-slow gait speed exhibited reduced processing speed (d = 0.62) and memory (d = 0.61); SCC-fatigue was associated with decreased working memory (d = 0.55). Regression analyses, adjusted for demographic and clinical variables, identified significant associations: slow gait speed with logical memory (- 0.42; 95% CI - 0.79 to - 0.038]) and symbol search (- 0.28; 95% CI - 0.56 to - 0.006]); fatigue with digit span backwards (- 0.66; 95% CI - 1.19 to - 0.14) and color trails 2 (- 0.67; 95% CI, - 1.15 to - 0.20). SCC-slow gait speed and SCC-fatigue were associated with reduced quality of life scores, but not with IADL and FAI scores. CONCLUSION: Specific frailty components, notably slow gait speed and fatigue, influence cognitive function and quality of life. Our findings provide greater insights into characterizing CF. Further longitudinal studies are required to determine the cognitive and functional trajectories of CF.

Yubi-Wakka Test for Sarcopenia Screening in the Community: Comparative Agreement, Diagnostic Performance and Validity with Calf Circumference Measurements.

BACKGROUND: Screening tools such as calf circumference (CC) and Yubi-wakka (finger-ring) test have been recognized as effective tools by Asian Working Group for Sarcopenia 2019 (AWGS'19) for sarcopenia screening but their comparative agreement, diagnostic performance and validity are unclear. OBJECTIVES: This study aims to determine: (i)agreement between calf and finger-ring circumference, (ii)diagnostic performance for low muscle mass and AWGS'19 sarcopenia diagnosis, (iii)correlation with muscle mass, strength, and physical performance, and (iv)association with frailty, life space mobility and physical activity. METHODS: We studied 187 healthy community-dwelling older adults (mean age=66.8+7.0years) from the GERILABS-2 study. CC was measured via (i) both calves in sitting and standing positions, and (ii) Yubi-wakka test by encircling the thickest part of the non-dominant calf with index fingers and thumbs of both hands. We performed Cohen's kappa to check for agreement, area under receiver operating characteristic curve (AUC) to compare diagnostic performance, partial correlations adjusted for age and gender to compare convergent validity, and logistic regression to determine predictive validity for outcome measures. RESULTS: Sarcopenia prevalence was 24.0% (AWGS'19). Yubi-wakka identified 16.6% of participants as screen-positive ("smaller"), showing moderate agreement only with non-dominant sitting CC measurements (k=0.421,p<0.001) and having lower diagnostic performance in determining low muscle mass (AUC=0.591 vs 0.855-0.870,p<0.001; sensitivity=57.1% vs 75.5-90.8%; specificity=58.4% vs 70.8-80.9%) and sarcopenia diagnosis (AUC=0.581 vs 0.788-0.818,p<0.001; sensitivity=55.6% vs 57.5-71.8%; specificity=74.4% vs 75.6-88.9%) compared to CC measurements. Yubi-wakka correlated significantly with muscle mass, grip strength and knee extension but not physical performance. When adjusted for age, gender and hypertension, Yubi-wakka was significantly associated with frailty (OR=3.96,95%CI:1.09-14.38), life space mobility (OR=2.38,95%CI:1.08-5.24) and physical activity (OR=2.50,95%CI:1.07-5.86). DISCUSSION AND CONCLUSIONS: Yubi-wakka provides a self-administered, low-cost and practicable community screening tool for sarcopenia. Our study affirmed the convergent and predictive validity of Yubi-wakka, albeit with lower sensitivity and specificity in diagnostic performance compared to CC measurements.

Association of Oral Health with Frailty, Malnutrition Risk and Functional Decline in Hospitalized Older Adults: A Cross-Sectional Study.

BACKGROUND: Poor oral health is known to be associated with adverse outcomes, but the frequency and impact of poor oral health on older adults in the acute inpatient setting has been less well studied. OBJECTIVES: We examined the association between oral health, frailty, nutrition and functional decline in hospitalized older adults. DESIGN: Retrospective cross-sectional study. SETTING AND PARTICIPANTS: We included data from 465 inpatients (mean age 79.2±8.3 years) admitted acutely to a tertiary hospital. METHODS: We evaluated oral health using the Revised Oral Assessment Guide (ROAG), frailty using the Clinical Frailty Scale (CFS), malnutrition risk using the Nutritional Screening Tool (NST) and functional status using a modified Katz Activities of Daily Living (ADL) scale. We examined cross-sectional associations of oral health with frailty, malnutrition risk and functional decline on admission, followed by multivariate logistic regression models evaluating the association between poor oral health and the aforementioned outcomes. RESULTS: 343 (73.8%), 100 (21.5%) and 22 (4.7%) were classified as low, moderate and high risk on the ROAG, respectively. Poorer oral health was associated with greater severity of frailty, functional decline on admission and malnutrition risk. Abnormalities in ROAG domains of voice changes, swallowing difficulty, xerostomia, lips and tongue appearance were more frequently present at greater severity of frailty. Poor oral health was associated with frailty [odds ratio (OR): 1.76, 95% confidence interval (CI) 1.05-2.97; P=0.034]; malnutrition risk [OR: 2.76, 95% CI 1.46-5.19, P=0.002] and functional decline [OR: 1.62, 95% CI 1.01-2.59, P=0.046]. CONCLUSIONS: Poor oral health is significantly associated with frailty, malnutrition risk and functional decline in older inpatients. Oral health evaluation, as part of a comprehensive geriatric assessment may be a target for interventions to improve outcomes. Further research including longitudinal outcomes and effectiveness of specific interventions targeted at oral health are warranted in older adults in the inpatient setting.

Evaluating Quality-of-Life, Length of Stay and Cost-Effectiveness of a Front-Door Geriatrics Program: An Exploratory Proof-of-Concept Study.

BACKGROUND: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults. OBJECTIVES: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY's cost-effectiveness. DESIGN: A quasi-experiment study. SETTING: The ED of a 1700-bed tertiary hospital. PARTICIPANTS: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas. INTERVENTION: EDIFY versus standard-care. MEASUREMENTS: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined. RESULTS: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY's cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY's average programmatic cost approximated SGD$469.30. CONCLUSIONS: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center.

Singapore Clinical Practice Guidelines For Sarcopenia: Screening, Diagnosis, Management and Prevention.

OBJECTIVES: To present the local evidence and final recommendations of the Clinical Practice Guidelines workgroup convened by the Chapter of Geriatricians and the Society for Geriatric Medicine Singapore. The aim is to develop contextualized evidence-based recommendations that facilitate adoption of the Asian Working Group for Sarcopenia (AWGS) 2019 consensus into current practice in Singapore. METHODS: The workgroup drew upon the AWGS'2019 consensus, updated literature review of Singapore studies till 31 Dec 2020, and evidence from recent systematic reviews. From 40 local studies included for data extraction, we constructed evidence tables organized as: definition and epidemiology; diagnosis and evaluation; and treatment and intervention. Twenty recommendations - case-finding, diagnosis, treatment, prevention, research - were developed, and graded for strength and quality using the GRADE approach. Consensus from an expert panel(N=23) was achieved after two rounds of the modified Delphi process. RESULTS: The local prevalence of sarcopenia among community-dwelling older adults ranged from 13.6% to 25%. Most studies adopted the AWGS'2019 and AWGS'2014 criteria. Reported case finding tools include SARC-F, calf circumference (CC) and SARC-CalF. Gender-specific AWGS cut-offs for appendicular skeletal mass were used to define low muscle mass. Different protocols and dynamometers were used to assess handgrip strength, whilst gait speed and 5-times chair stand were commonly used to assess physical performance. RECOMMENDATIONS: We conditionally recommend a case-finding approach in at-risk older adults using validated case-finding tools. Screen-positive individuals should be assessed for 'possible sarcopenia' and underlying causes. For diagnosis, we conditionally recommend using the AWGS'2019 algorithm, and dual-energy X-ray absorptiometry when necessary to determine low lean mass for a confirmatory diagnosis of sarcopenia. For treatment, we strongly recommend resistance-based exercises and conditionally recommend a quality protein-rich diet/protein supplementation, with Vitamin D supplementation for insufficiency (<30 micrograms/L). For prevention, we recommend regular resistance-based physical activity and adequate protein intake (≥1.0g/kg bodyweight). We encourage more research to address local evidence gaps.

Sarcopenia in Distal Radius Fractures: A Scoping Review.

BACKGROUND: Sarcopenia is an emerging disease that adversely impacts outcomes of older adults across the spectrum of fragility fractures. Few studies have examined sarcopenia in upstream fragility fractures such as the distal radius. Understanding the state of current evidence is essential in defining a research agenda in this critical area of sentinel distal radius fractures and sarcopenia. OBJECTIVES: The aim of this scoping review was to summarize existing literature on sarcopenia in distal radius fracture in older adults, and to identify research areas and gaps to guide future studies. METHODS: We utilized the 5-stage framework of Arksey and O'Malley. We searched studies from 2010 to 2020 relating to «Sarcopenia¼ and «Distal radius fractures¼ in major databases. Two reviewers independently screened articles for inclusion and conducted full text reviews of shortlisted articles. We extracted data on research areas, key findings, and study limitations. RESULTS: Thirteen studies met the inclusion and exclusion criteria. They covered the areas of epidemiology (N=9), risk factors (N=4), basic science (N=2), outcomes (N=1), and diagnostic modalities (N=1). There were no studies on screening/case finding, prognostic scoring, intervention, or health economics. Identified limitations included the lack of clear definition and diagnostic criteria for sarcopenia, and lack of, or inappropriate, control group. Majority of studies were retrospective or cross-sectional in study design. CONCLUSIONS: This scoping review on sarcopenia in distal radius fractures highlighted gaps in research areas and in the rigor of studies conducted, and the need for more prospective cohort and interventional studies. Building upon current consensus criteria, we propose setting a research agenda along the timeline of sarcopenia management, from screening through to intervention and follow-up, which will inform future research in this early disease cohort of fragility fractures.

Social Frailty and Executive Function: Association with Geriatric Syndromes, Life Space and Quality of Life in Healthy Community-Dwelling Older Adults.

BACKGROUND: Despite emerging evidence about the association between social frailty and cognitive impairment, little is known about the role of executive function in this interplay, and whether the co-existence of social frailty and cognitive impairment predisposes to adverse health outcomes in healthy community-dwelling older adults. OBJECTIVES: We aim to examine independent associations between social frailty with the MMSE and FAB, and to determine if having both social frailty and cognitive impairment is associated with worse health outcomes than either or neither condition. METHODS: We studied 229 cognitively intact and functionally independent community-dwelling older adults (mean age= 67.2±7.43). Outcome measures comprise physical activity; physical performance and frailty; geriatric syndromes; life space and quality of life. We compared Chinese Mini Mental State Examination (CMMSE) and Chinese Frontal Assessment Battery (FAB) scores across the socially non-frail, socially pre-frail and socially frail. Participants were further recategorized into three subgroups (neither, either or both) based on presence of social frailty and cognitive impairment. Cognitive impairment was defined as a score below the educational adjusted cut-offs in either CMMSE or FAB. We performed logistic regression adjusted for significant covariates and mood to examine association with outcomes across the three subgroups. RESULTS: Compared with CMMSE, Chinese FAB scores significantly decreased across the social frailty spectrum (p<0.001), suggesting strong association between executive function with social frailty. We derived three subgroups relative to relationship with socially frailty and executive dysfunction: (i) Neither, N=140(61.1%), (ii) Either, N=79(34.5%), and (iii) Both, N=10(4.4%). Compared with neither or either subgroups, having both social frailty and executive dysfunction was associated with anorexia (OR=4.79, 95% CI= 1.04-22.02), near falls and falls (OR= 5.23, 95% CI= 1.10-24.90), lower life-space mobility (odds ratio, OR=9.80, 95% CI=2.07-46.31) and poorer quality of life (OR= 13.2, 95% CI= 2.38-73.4). CONCLUSION: Our results explicated the association of executive dysfunction with social frailty, and their synergistic relationship independent of mood with geriatric syndromes, decreased life space and poorer quality of life. In light of the current COVID-19 pandemic, the association between social frailty and executive dysfunction merits further study as a possible target for early intervention in relatively healthy older adults.

SARC-F at the Emergency Department: Diagnostic Performance for Frailty and Predictive Performance for Reattendances and Acute Hospitalizations.

OBJECTIVES: Sarcopenia is associated with adverse health outcomes including mortality, functional loss, falls, and poorer quality of life. However, the value of screening sarcopenia at the Emergency Department (ED) remains unclear. We aimed to examine the SARC-F questionnaire for its (1) diagnostic ability in identifying frailty, and (2) predictive ability for adverse health outcomes. DESIGN: A secondary analysis of a quasi-experimental study. SETTING: An ED within a 1700-bed tertiary hospital. PARTICIPANTS: ED patients aged ≥85 years (mean age 90.0 years) recruited into the Emergency Department Interventions of Frailty (EDIFY) study. MEASUREMENTS: Data of demographics, premorbid function, frailty status [Frailty Index (FI), Clinical Frailty Scale (CFS), FRAIL], comorbidities, medications, and cognitive status were gathered. We also captured outcomes of mortality, acute hospitalization, and ED reattendance at 1-, 3-, and 6-month. We then compared area under the operating characteristic curves (AUCs) for the abovementioned measures against the FI (reference) for diagnosis of frailty. Lastly, we performed univariate analyses and logistic regression to compare SARC-F and other measures against the adverse outcomes of interest. RESULTS: Amongst the various instruments, the SARC-F (AUC 0.92, 95% Confidence Interval (CI) 0.86-0.98, P<0.001; Sensitivity 79.0%, and Specificity 88.9%) performed best for frailty detection as defined by FI. Optimal cutoff was ≥3 (Sensitivity 91.4%, Specificity 83.3%, and Negative Predictive Value 68.2%). Only SARC-F was predictive of acute hospitalization [Adjusted Odds Ratio (OR) 4.00, 95% CI 1.47-10.94, P=0.007] and ED-reattendance [Adjusted OR 3.29, 95% CI 1.26-8.56, P=0.015] at 3-month. CONCLUSIONS: The SARC-F demonstrated excellent diagnostic ability for frailty detection and predictive validity for ED reattendance and acute hospitalization at 3 months. Lowering cutoff score to ≥3 may improve case-finding at the ED to facilitate early identification and management of sarcopenia. Further studies are required to validate the diagnostic and predictive performance of SARC-F at ED settings.

Disentangling the Relationship between Frailty and Intrinsic Capacity in Healthy Community-Dwelling Older Adults: A Cluster Analysis.

BACKGROUND: Frailty and intrinsic capacity (IC) are distinct but interrelated constructs. Uncertainty remains regarding how they are related and interact to influence health outcomes. We aim to understand the relationship between frailty and IC by identifying subgroups based on frailty criteria and IC domains and studying one-year outcomes. METHODS: We studied 200 independent community-dwelling older adults (mean age 67.9±7.9 years, Modified Barthel Index (MBI) score 99±2.6). Frailty was defined by modified Fried criteria. Scores (range: 0-2) were assigned to individual IC domains (cognition, psychological, locomotion, and vitality) to yield a total IC score of 8. To identify subgroups, two-step cluster analysis was performed with age, frailty and IC domains. Cluster associations with one-year outcomes (frailty, muscle strength (grip strength, repeated chair stand test), physical performance (gait speed, Short Physical Performance Battery), function (MBI) and quality-of-life (EuroQol (EQ)-5D)) were examined using multiple linear regression adjusted for age, gender and education. RESULTS: Three distinct clusters were identified - Cluster 1: High IC/Robust (N=74, 37%); Cluster 2: Intermediate IC/Prefrail (N=73, 36.5%); and Cluster 3: Low IC/Prefrail-Frail (53, 26.5%). Comparing between clusters, IC domains, cognition, depressive symptoms, nutrition, strength and physical performance were least impaired in Cluster 1, intermediate in Cluster 2 and most impaired in Cluster 3. At one year, the proportion transitioning to frailty or remaining frail was highest in Cluster 3 compared to Cluster 2 and Cluster 1 (39% vs 6.9% vs 2.8%, P<0.001). Compared to Cluster 1, Cluster 3 experienced greatest declines in grip strength (ß=-4.1, P<.001), MBI (ß=-1.24, P=0.045) and EQ-5D utility scores (ß=-0.053, P=0.005), with Cluster 2 intermediate between Cluster 1 and Cluster 3. CONCLUSIONS: Amongst independent community-dwelling older adults, IC is complementary to frailty measures through better risk-profiling of one-year outcomes amongst prefrail individuals into intermediate and high-risk groups. The intermediate group merits follow-up to ascertain longer-term prognosis.

A Rapid Review of the Measurement of Intrinsic Capacity in Older Adults.

OBJECTIVES: This study aims to address the knowledge gap and summarise the measurement for intrinsic capacity for the five WHO domains across different populations. It specifically aims to identify measurement tools, methods used for computation of a composite intrinsic capacity index and factors associated with intrinsic capacity among older adults. METHODS: We performed literature review in Medline, including search terms "aged" or "elderly" and "intrinsic capacity" for articles published from 2000 - 2020 in English. Studies which assessed intrinsic capacity in the five WHO domains were included. Information pertaining to study setting, methods used for measuring the domains of intrinsic capacity, computation methods for composite intrinsic capacity index, and details on tool validation were extracted. RESULTS: Seven articles fulfilling the inclusion criteria were included in the review. Of these, the majority were conducted in community settings (n=5) and were retrospective studies (n=6). The most commonly used tools for assessing intrinsic capacity were gait speed test and chair stand test (locomotion); handgrip-strength and mini-nutritional assessment (vitality); Mini-Mental State Examination (cognition); Geriatric Depression Scale (GDS) and Center for Epidemiological Studies Depression Scale (CES-D) (psychological), and self-reported vision and health questionnaires (sensory). Among the tools used to operationalise the domains, we found variations and non-concordance, especially in the vitality and psychological domains, which make inter-study comparison difficult. Validated scales were less commonly used for vitality and sensory domains. Biomarkers were used for locomotion, vitality, and sensory domains. Self-reported measures were mostly used in the psychological and sensory domains. Three studies operationalised a global score for intrinsic capacity, whereby scores from the individual domains were used to create a composite intrinsic capacity index, using two approaches: a) Structural equation modelling, and b) Sub-scores for each domain which were combined either by arithmetic sum or average. CONCLUSION: We identified considerable variations in measurement instruments and processes which are used to assess intrinsic capacity, especially among the vitality and psychological domains. A standardized intrinsic capacity composite score for clinical or community settings has not been operationalised yet. Further validation via prospective studies of the intrinsic capacity concept and computation of composite score using validated scales are needed.

Development, Validation and Field Evaluation of the Singapore Longitudinal Ageing Study (SLAS) Risk Index for Prediction of Mild Cognitive Impairment and Dementia.

BACKGROUND: Mild cognitive impairment (MCI) is a critical pre-dementia target for preventive interventions. There are few brief screening tools based on self-reported personal lifestyle and health-related information for predicting MCI that have been validated for their generalizability and utility in primary care and community settings. OBJECTIVE: To develop and validate a MCI risk prediction index, and evaluate its field application in a pilot community intervention trial project. DESIGN: Two independent population-based cohorts in the Singapore Longitudinal Ageing Study (SLAS). We used SLAS1 as a development cohort to construct the risk assessment instrument, and SLA2 as a validation cohort to verify its generalizability. SETTING: community-based screening and lifestyle intervention Participants: (1) SLAS1 cognitively normal (CN) aged ≥55 years with average 3 years (N=1601); (2) SLAS2 cohort (N=3051) with average 4 years of follow up. (3) 437 participants in a pilot community intervention project. MEASUREMENTS: The risk index indicators included age, female sex, years of schooling, hearing loss, depression, life satisfaction, number of cardio-metabolic risk factors (wide waist circumference, pre-diabetes or diabetes, hypertension, dyslipidemia). Weighted summed scores predicted probabilities of MCI or dementia. A self-administered questionnaire field version of the risk index was deployed in the pilot community project and evaluated using pre-intervention baseline cognitive function of participants. RESULTS: Risk scores were associated with increasing probabilities of progression to MCI-or-dementia in the development cohort (AUC=0.73) and with increased prevalence and incidence of MCI-or-dementia in the validation cohort (AUC=0.74). The field questionnaire risk index identified high risk individuals with strong correlation with RBANS cognitive scores in the community program (p<0.001). CONCLUSIONS: The SLAS risk index is accurate and replicable in predicting MCI, and is applicable in community interventions for dementia prevention.

Nutritional Status and Risks of Cognitive Decline and Incident Neurocognitive Disorders: Singapore Longitudinal Ageing Studies.

BACKGROUND: Studies suggest that nutritional interventions using the whole diet approach such as the Mediterranean diet may delay cognitive decline and dementia onset. However, substantial numbers of older adults are non-adherent to any ideally healthy dietary pattern and are at risk of malnutrition. OBJECTIVE: The present study investigated the relationship between global malnutrition risk and onsets of cognitive decline and neurocognitive disorders (NCD), including mild cognitive impairment (MCI) or dementia in community-dwelling older adults. METHODS: Participants aged ≥ 55 years in the Singapore Longitudinal Ageing Studies (SLAS) were assessed at baseline using the Elderly Nutritional Indicators for Geriatric Malnutrition Assessment (ENIGMA) and followed up 3-5 years subsequently on cognitive decline (MMSE drop ≥ 2) among 3128 dementia-free individuals, and incident neurocognitive disorders (NCD) among 2640 cognitive normal individuals. RESULTS: Individuals at high nutritional risk score (≥ 3) were more likely to develop cognitive decline (OR=1.42, 95%CI=1.01-1.99) and incident MCI-or-dementia (OR=1.64, 95%CI=1.03-2.59), controlling for age, sex, ethnicity, low education, APOE-e4, hearing loss, physical, social, and mental activities, depressive symptoms, smoking, alcohol, central obesity, hypertension, diabetes, low HDL, high triglyceride, cardiac disease, and stroke. Among ENIGMA component indicators, low albumin at baseline was associated with cognitive decline and incident NCD, and 5 or more drugs used, few fruits/vegetables/milk products daily, and low total cholesterol were associated with incident NCD. CONCLUSION: The ENIGMA measure of global malnutrition risk predicts cognitive decline and incident neurocognitive disorders, suggesting the feasibility of identifying vulnerable subpopulations of older adults for correction of malnutrition risk to prevent neurocognitive disorders.

Grip Strength Criterion Matters: Impact of Average Versus Maximum Handgrip Strength on Sarcopenia Prevalence and Predictive Validity for Low Physical Performance.

IMPORTANCE: Muscle strength has been elevated to the forefront of sarcopenia diagnosis, with handgrip strength the preferred measure. Extant handgrip protocols adopt different handgrip strength (HGS) criteria. Paucity of direct comparison studies assessing the impact of HGS criterion on prevalence of sarcopenia and predictive validity on physical performance contributes to the lack of standardisation of HGS criteria in sarcopenia diagnosis. OBJECTIVES: Our study aims to compare the effect of average (HGSave) versus maximum (HGSmax) HGS criterion on: (1) prevalence of low HGS and sarcopenia; and (2) association with physical performance at baseline and at 2 years. METHODS: We recruited 200 community dwelling, cognitively intact, and functionally independent older adults. Muscle strength, physical performance measures, cognitive tests and nutritional assessments were performed. Short Physical Performance Battery (SPPB) was administered at baseline and at 2 years. We compared HGSave and HGSmax to assess the prevalence of low HGS and sarcopenia. Univariate analysis was performed comparing baseline characteristics between low and normal groups for each HGS criterion. Significantly different variables were included in logistic regression analysis to examine association of low HGS and SPPB at baseline. Predictive validity of low HGS for SPPB<10 at 2 years was examined by performing logistic regression analysis for HGSave and HGSmax. RESULTS: The prevalence of low HGS and sarcopenia incorporating HGSave criterion is 40% and 33% respectively, whereas that of HGSmax criterion is 21% and 19.5% respectively. There is moderate agreement between the 2 HGS criteria for sarcopenia diagnosis (kappa=0.604) and poorer agreement for low HGS (kappa=0.570). There was no significant association with baseline SPPB for both HGS criteria. At 2 years, only low HGSmax was significantly associated with low SPPB (adjusted OR 3.91, 95% CI 1.24 - 12.33). CONCLUSION: Our study demonstrates that HGS criteria matters in diagnosis of sarcopenia and we support extant HGS protocols using HGSmax criterion in view of better predictive validity for poor physical performance.

Variation in clinical outcomes and process of care measures in community acquired pneumonia: a systematic review.

BACKGROUND: Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence. METHODS: Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed. RESULTS: Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4-15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1-24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 h of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis. CONCLUSION: There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence.