Virtual geriatric and frailty assessment for older adults with cancer.

PURPOSE OF REVIEW: Since SARS-CoV2 pandemic, many specialties have introduced virtual assessments within clinical practice. Conducting an online geriatric assessment, or relying on self-reported questionnaires, may be more challenging than a conventional medical appointment. This review aims to discuss the state of research on virtual assessment and self-reported questionnaires in the general geriatric population and specifically in Oncology. RECENT FINDINGS: Virtual assessment of older adults has been the focus of two separate position papers. Aside from videoconferences or phone appointments, self-reported questionnaires have emerged in recent years as reliable tools to screen for frailty and triage patients who would benefit from a comprehensive in-person assessment, with adequate correlation with in-person tests, good acceptance by the respondents and being well received by healthcare providers. Although some have been tried in geriatric oncology, many still lack validation, and their widespread use may be limited by digital literacy, cognitive impairment, and social supports. SUMMARY: The development, validation and adoption of self-reported questionnaires and virtual assessment in the care of older adults with cancer may overcome the staffing limitations and time constrains that frequently hampers the widespread evaluation of this population to improve their care.

New perspectives on frailty in light of the Global Leadership Initiative on Malnutrition, the Global Leadership Initiative on Sarcopenia, and the WHO's concept of intrinsic capacity: A narrative review.

This review gathered the evidence on the epidemiology of frailty, as well as on screening and diagnostic tools, and new perspectives, in light of the latest global frameworks in malnutrition, sarcopenia, and the World Health Organization's concept of intrinsic capacity. Frailty is a worldwide health challenge and highly prevalent in older adults and the population with chronic diseases independent of age. Regardless of the particular concept of frailty, many screening and diagnostic tools are able to identify frailty in older people, but none of them has shown superiority in every population and healthcare setting. Physical, cognitive, and social components are part of the larger context of frailty. The latest evidence-based initiatives on frailty recommend the use of validated tools to identify frailty's different components, tailored to the needs of specific populations and healthcare systems. Unintentional weight loss is a shared criterion between physical frailty and malnutrition according to the Global Leadership Initiative on Malnutrition criteria. A new definition of sarcopenia by the Global Leadership Initiative on Sarcopenia is awaited, but at present physical frailty shares with sarcopenia the criteria of low muscle function and physical performance (severity grading) according to the revised consensus of the European Working Group on Sarcopenia in Older People (EWGSOP2). The EWGSOP2 includes both muscle mass and function, with most scientific groups agreeing that function is a key hallmark of sarcopenia. The concept of intrinsic capacity features the reserves and positive aspects of aging, and responds to ageism by addressing the deficit model approach. Intrinsic capacity is an emerging, person-centered and public health indicator, aimed at preserving health at mid-life and beyond, to move towards a better aging process in the Decade of Healthy Aging 2020-2030.

ASPEN-AND-ESPEN: A postacute-care comparison of the basic definition of malnutrition from the American Society of Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics with the European Society for Clinical Nutrition and Metabolism definition.

BACKGROUND: The aim of this study was to assess the prevalence of malnutrition by applying the ASPEN/AND definition and the ESPEN consensus definition in a postacute-care population, and secondly, to determine the metrological properties of the set of six clinical characteristics that constitute the ASPEN/AND basic diagnosis, compared to the ESPEN consensus, based mostly on objective anthropometric measurements. METHODS: Prospective study of 84 consecutive deconditioned older inpatients (85.4 ± 6.2; 59.5% women) admitted for rehabilitation in postacute care. ASPEN/AND diagnosis of malnutrition was considered in presence of at least two of the following: low energy intake, fluid accumulation, diminished handgrip strength, and loss of weight, muscle mass, or subcutaneous fat. Sensitivity, specificity, positive and negative predictive values, accuracy, likelihood ratios, and kappa statistics were calculated for ASPEN/AND criteria and compared with ESPEN consensus. RESULTS: The prevalence of malnutrition by ASPEN/AND criteria was 63.1% and by ESPEN consensus, 20.2%; both diagnoses were associated with significantly longer length of stay, but the ESPEN definition was significantly associated with poorer functional outcomes after the rehabilitation program. Compared to ESPEN consensus, ASPEN/AND diagnosis showed fair validity (sensitivity = 94.1%; specificity = 44.8%); kappa statistic was 2.217. CONCLUSIONS: Applying the ASPEN/AND definition obtained a higher prevalence of malnutrition in a postacute-care population than was identified by the ESPEN definition. ASPEN/AND criteria had fair validity and agreement compared with the ESPEN definition. A simple, evidence-based, unified malnutrition definition might improve geriatric care.

Prognostic Value of the ESPEN Consensus and Guidelines for Malnutrition: Prediction of Post-Discharge Clinical Outcomes in Older Inpatients.

INTRODUCTION: Our study aimed to determine whether malnutrition and nutrition-related conditions using the European Society for Clinical Nutrition and Metabolism (ESPEN) consensus were associated with functional status, institutionalization, readmissions, and mortality in older patients at 3-month follow-up. METHODS: A cohort of 102 consecutive deconditioned patients was assessed at 3 months postdischarge from postacute geriatric care. Inclusion criteria were age ≥70 years, scores of Mini-Mental Status Examination ≥21/30, and being admitted for rehabilitation after an acute non-disabling disease. Malnutrition as defined by ESPEN consensus and nutrition-related conditions (such as frailty, sarcopenia, overweight/obesity, nutrient deficiency, and cachexia) was assessed, and related to postdischarge clinical outcomes at 3-month follow-up. RESULTS: Of 95 included patients (84.5 ± 6.5 years; 63.2% women), 31 had unintentional weight loss and 19 fulfilled malnutrition criteria defined by the ESPEN consensus. Nutrition-related conditions were frequent: 94 patients had frailty, 44 sarcopenia, 58 overweight/obesity, and 59 nutrient deficiency. Sarcopenia reduced functional status at 3-month follow-up (median difference: -25.5; 95% confidence interval (CI) -46.4 - -4.3, P = 0.008). Institutionalization was related to unintentional weight loss in univariate analysis (odds ratio (OR) = 3.9; 95%CI 1.3 - 12.4, P = 0.018). Meeting the basic ESPEN definition of malnutrition was related to institutionalization in univariate (OR = 3.4; 95%CI 1.0 to 11.3, P = 0.042) but not multivariate analysis, and was not significantly associated with readmissions or mortality at 3-month follow-up. CONCLUSIONS: Further research is needed on the potential value of the ESPEN consensus and guidelines for malnutrition to identify older patients at risk of worse functional status, institutionalization, readmissions, and mortality at 3-month follow-up postdischarge.

Malnutrition according to ESPEN definition predicts long-term mortality in general older population: Findings from the EPIDOS study-Toulouse cohort.

BACKGROUND: The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population. METHODS: This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders. RESULTS: Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9]). CONCLUSIONS: Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up.

Clinical application of the basic definition of malnutrition proposed by the European Society for Clinical Nutrition and Metabolism (ESPEN): Comparison with classical tools in geriatric care.

BACKGROUND: Malnutrition is a prevalent condition related to adverse outcomes in older people. Our aim was to compare the diagnostic capacity of the malnutrition criteria of the European Society of Parenteral and Enteral Nutrition (ESPEN) with other classical diagnostic tools. METHODS: Cohort study of 102 consecutive in-patients ≥70 years admitted for postacute rehabilitation. Patients were considered malnourished if their Mini-Nutritional Assessment-Short Form (MNA-SF) score was ≤11 and serum albumin <3 mg/dL or MNA-SF ≤ 11, serum albumin <3 mg/dL, and usual clinical signs and symptoms of malnutrition. Sensitivity, specificity, positive and negative predictive values, accuracy likelihood ratios, and kappa values were calculated for both methods: and compared with ESPEN consensus. RESULTS: Of 102 eligible in-patients, 88 fulfilled inclusion criteria and were identified as "at risk" by MNA-SF. Malnutrition diagnosis was confirmed in 11.6% and 10.5% of the patients using classical methods,whereas 19.3% were malnourished according to the ESPEN criteria. Combined with low albumin levels, the diagnosis showed 57.9% sensitivity, 64.5% specificity, 85.9% negative predictive value,0.63 accuracy (fair validity, low range), and kappa index of 0.163 (poor ESPEN agreement). The combination of MNA-SF, low albumin, and clinical malnutrition showed 52.6% sensitivity, 88.3% specificity, 88.3%negative predictive value, and 0.82 accuracy (fair validity, low range), and kappa index of 0.43 (fair ESPEN agreement). CONCLUSIONS: Malnutrition was almost twice as prevalent when diagnosed by the ESPEN consensus, compared to classical assessment methods: Classical methods: showed fair validity and poor agreement with the ESPEN consensus in assessing malnutrition in geriatric postacute care.

[Prognostic value of assessment tools on elderly patients with chronic advanced disease and end of life, admitted to an intermediate care centre]. / Valor pronóstico de los instrumentos de evaluación de enfermedad avanzada y de final de vida en ancianos ingresados en un centro sociosanitario.

OBJECTIVE: To apply 3advanced chronic disease evaluation tools in elderly patients admitted to an intermediate and long-term care centre, and evaluate its relationship with mortality. METHODS: The NECPAL tool, PROFUND prognostic index, and Charlson comorbidity index were applied to 87 patients. RESULTS: The NECPAL tool identified 31 patients (35.6%) in need of palliative care, and according to the PROFUND index, 45 (54.7%) had high/very high risk of mortality (≥7 points), and according to Charlson index, 31 (35.6%) had high comorbidity (≥4 points). Of the NECPAL positive patients, 80.5% had a PROFUND index score ≥7, and 48.3% a Charlson index ≥ 4. These percentages were 34.4% and 28.5% in negative NECPAL patients (P<.001 and P≤.06, respectively). Correlations between the 3tools: quantitative (Spearman) number of responses in NECPAL with PROFUND (r=.57; P<.001); with Charlson (r=.214; P<.047) and between PROFUND and Charlson (r=.157; P=.148). Qualitative (kappa) NECPAL (positive/negative) with PROFUND (cut-off 6/7) (0.40; P<.001), and Charlson (cut-off 3/4) (0.19; P=.080) and between PROFUND and Charlson (0.08; P=.399). Mortality prediction (area under the curve): NECPAL 3 months 0.81 (95% CI: 0.62-1.00); 6 months 0.71 (95% CI: 0.53-0.89) and 12 months 0.67 (95% CI: 0.52-0.82). PROFUND 3 months 0.71 (95% CI: 0.50-0.91); 6 months 0.73 (95% CI: 0.58-0.87), and 12 months 0.69 (95% CI: 0.57-0.81). Charlson 3 months 0.72 (95% CI: 0.52-0.91); 6 months 0.62 (95% CI: 0.45-0.80), and 12 months 0.64 (95% CI: 0.50-0.78). CONCLUSIONS: The 3tools were significantly associated with high mortality. A low concordance was found between the results of the different tools.

Malnutrition in postacute geriatric care: Basic ESPEN diagnosis and etiology based diagnoses analyzed by length of stay, in-hospital mortality, and functional rehabilitation indexes.

OBJECTIVE: To determine the relationships between malnutrition and nutrition-related conditions according to the European Society of Clinical Nutrition and Metabolism (ESPEN) consensus and guidelines and clinical outcomes in postacute rehabilitation. METHODS: Of 102 eligible inpatients, 95 (84.5 years old, 63.2% women) fulfilled inclusion criteria: aged ≥70 years, body mass index <30kg/m2, admission for rehabilitation. Mini-Nutritional Assessment-Short Form (MNA-SF≤11) identified patients "at risk" and ESPEN basic and etiology based definitions were applied. Nutrition-related conditions (sarcopenia, frailty, overweight/obesity, micronutrient abnormalities) were determined. We assessed the relationship between these conditions and the clinical and rehabilitation outcomes (relative functional gain, rehabilitation efficiency) during hospitalization. RESULTS: All patients were "at risk" by MNA-SF criteria and 31 reported unintentional weight loss >5% in the last year or 2-3kg in the last 6 months. Nineteen fulfilled the ESPEN basic definition, of which 10 had disease-related malnutrition with inflammation and 9 without inflammation, and 20 had cachexia. Sarcopenia (n=44), frailty (n=94), overweight/obesity (n=59), and micronutrient abnormalities (n=70) were frequent. Unintentional weight loss impaired all functional outcomes and increased length of stay [OR=6.04 (2.87-9.22); p<0.001]. In multivariate analysis, relationships between rehabilitation impact indices and the ESPEN basic and etiology-based definitions observed in univariate analysis persisted only (and marginally) for relative functional gain [OR=13.24 (0.96-181.95); p=0.005]. Infrequent in-hospital mortality prevented meaningful analysis of this outcome. CONCLUSIONS: ESPEN basic and etiology-based definitions and nutrition related disorders were determined in postacute care. Malnutrition was associated with poor rehabilitation outcomes, mainly due to unintentional weight loss.

Prevalence of malnutrition and sarcopenia in a post-acute care geriatric unit: Applying the new ESPEN definition and EWGSOP criteria.

BACKGROUNDS & AIMS: The European Society of Clinical Nutrition and Metabolism (ESPEN) consensus definition of malnutrition has been applied in hospitalized older diabetics and middle-aged patients, geriatric outpatients, and healthy elderly and young individuals. In a post-acute care setting, our aim was to assess malnutrition (ESPEN definition) and determine its relationship with sarcopenia in older in-patients deconditioned due to an acute process. METHODS: Eighty-eight in-patients aged ≥70 years with body mass index (BMI) <30 kg/m2 were included (84.1 years old; 62% women) and screened for malnutrition risk using biochemical markers and Mini-Nutritional Assessment-Short Form (MNA-SF). The ESPEN definition was applied: 1) BMI <18.5 kg/m2 or 2) unintentional weight loss plus a) low BMI or b) low fat-free mass index (FFMI). European Working Group on Sarcopenia in Older People (EWGSOP) criteria were also applied. RESULTS: Unintentional weight loss occurred in 27 (30.7%) of 88 in-patients considered "at risk" by MNA-SF. Malnutrition prevalence was 4.5%, 7.9%, and 17% using ESPEN definitions 1, 2a, and 2b, respectively; 19.3% were malnourished. Prevalence of sarcopenia was 37.5%, of which 90.9% fulfilled ESPEN malnutrition criteria, a significant association (p = 0.02). No differences in biochemical markers were observed between patients with or without malnutrition or sarcopenia. CONCLUSIONS: ESPEN criteria constitute an appropriate tool to establish a malnutrition diagnosis in post-acute care. Sarcopenia, as defined by EWGSOP, was present in 37.5% of patients, of which 90.9% fulfilled ESPEN criteria; therefore, malnutrition was significantly related to sarcopenia. Additional work is needed to determine further implications of the ESPEN consensus definition.

Three measures of physical rehabilitation effectiveness in elderly patients: a prospective, longitudinal, comparative analysis.

BACKGROUND: Rehabilitation success is measured by instruments that assess performance of activities of daily living. Guidelines on the use and choice of these instruments are lacking. The present study aimed to analyse prognostic indicators of physical rehabilitation effectiveness in elderly patients according to three rehabilitation impact indices. METHODS: Prospective, longitudinal study in a post-acute care unit. The study included rehabilitation-eligible deconditioned elderly in-patients prospectively admitted to post-acute care (n = 685, aged 83.2 ± 8.3 years, mean length of stay 15 ± 9.2 days). DATA COLLECTION: Premorbid health status variables (PHSV): age, sex, comorbidity (Charlson index), medical history (heart failure, pulmonary disease, cerebrovascular disease, dementia), previous living situation and pre-admission functional status (premorbid Lawton and Barthel indices). Admission health status variables (AHSV): main diagnoses, referral source, physical (Barthel-adm) and cognitive function (Pfeiffer test), undernutrition and dysphagia. OUTCOME MEASURES: Absolute functional gain (AFG, admission-to-discharge Barthel change), relative functional gain (RFG, achieved percentage of potential gain) and rehabilitation efficiency index (REI, AFG over length of stay). Univariate analysis considered these parameters, along with PHSV and AHSV. Multivariate logistic regression analysis was performed for AFG ≥20, RFG ≥35 % and REI ≥ 0.50. RESULTS: Greater AFG was associated with 14 variables, 8 PHSV (57.1 %) and 6 AHSV (42.8 %); greater RFG with 9 variables, 3 PHSV (33.3 %) and 6 AHSV (66.6 %); and REI with 9 variables, 4 PHSV (44.4 %) and 5 AHSV (55.5 %). Mean AFG value was 34.5 ± 15.8 in patients who achieved complete recovery (RFG 100 %, n = 189, 27.5 %) and 35.3 ± 15.0 (p = 0.593) in the remaining patients (n = 311, 45.4 %). In multivariate analysis, only Barthel-adm was related to all three rehabilitation impact indices. CONCLUSIONS: Both premorbid and acute-process variables have a greater impact on AFG and REI, compared to RFG. Although AFG gives information about the degree of reduction in dependence, it does not provide clinical information about post-rehabilitation functional status (mean AFG values did not differ between patients with and without complete recovery). A future implication for evaluating rehabilitation effectiveness in elderly patients is to recommend RFG corrected by premorbid Barthel score, which is less affected by previous health conditions, as the optimum method to assess the degree to which maximum potential improvement was achieved.

Does gait speed contribute to sarcopenia case-finding in a postacute rehabilitation setting?

OBJECTIVE: The European Working Group of Sarcopenia in Older People (EWGSOP) has developed an algorithm based on gait speed measurement to begin sarcopenia case-finding in clinical practice, in which a cut-off point of <0.8m/s identifies risk for sarcopenia in community-dwelling older people. The objective of this study was to assess the application of the EWGSOP algorithm in hospitalised elderly patients with impaired functional capacity. METHODS: One hundred in-patients (aged 84.1 SD 8.5, 62% women) were prospectively studied in a postacute care geriatric unit focused on rehabilitation. Sarcopenia was assessed by corporal composition (electrical bioimpedance), handgrip strength, and physical performance (gait speed). Other measurements were Charlson index, length of stay, and functional gain at discharge and 3-month follow-up. All patients were screened by the EWGSOP algorithm and sarcopenia was confirmed according to diagnostic criteria. RESULTS: Gait speed was <0.8m/s in all cases and 58 patients had low muscle mass, which, according to the EWGSOP-algorithm, would indicate a diagnosis of sarcopenia. No differences were observed in functional capacity between these patients and those with normal muscle mass. When decreased handgrip strength was considered, 47 of these patients met the EWGSOP criteria for severe sarcopenia. In this group, differences in functional capacity were observed at discharge (Barthel 45.2 vs. 56.3, p=0.042) and 3-month follow-up (48.3 vs. 59.8, p=0.047). CONCLUSION: The application of the EWGSOP algorithm in hospitalised, postacute, elderly patients with low gait speed suggested that muscle strength should be considered before confirming or discarding a sarcopenia diagnosis.

Sarcopenia, physical rehabilitation and functional outcomes of patients in a subacute geriatric care unit.

Sarcopenia is the loss of muscle mass and strength, which in the elderly can result in disability and affect functional outcomes after hospitalization. The aim of this study was to evaluate the functional outcomes and mortality during hospitalization and at three months post-discharge, according to the presence of sarcopenia. Prospective study of 99 patients (38.4% men, aged 84.6) admitted in a subacute geriatric care unit who underwent a rehabilitation intervention. Main outcomes were mortality and functional improvement at discharge and at three-month follow-up. Sarcopenia was assessed by handgrip strength (hydraulic dynamometer) and by body composition bioimpedance. Forty-six (46.5%) patients met diagnostic criteria of sarcopenia. Patients with sarcopenia had a worse prior functional status than those without the condition (Barthel Index: 64.2±22.8 vs 73.3±21.8; p=0.04) but both groups had similar functional decline at admission (Barthel Index: 24±15.1 vs 28.5±15.2; p=0.1) and achieved similar functional improvement at discharge (20.4±18.3 vs 27.4±21; p=0.08). Barthel Index at discharge remained comparatively worse in patients with sarcopenia (44.2±26.6 vs 55.9±26.7; p=0.03). After completing a 3-month at-home rehabilitation program, no changes in functional capacity were observed in patients with sarcopenia; their peers improved their Barthel Index scores (45.5±24.8 vs 61.6±26.6; p=0.007). Mortality rates at 3-month follow-up did not differ between groups. In conclusion, patients with sarcopenia had a worse functional status, similar functional improvement during hospitalization and a lack of recovery after returning home. Further studies are needed to establish long-terms effects on mortality.