The role of calcium supplementation in healthy musculoskeletal ageing : An expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF).

The place of calcium supplementation, with or without concomitant vitamin D supplementation, has been much debated in terms of both efficacy and safety. There have been numerous trials and meta-analyses of supplementation for fracture reduction, and associations with risk of myocardial infarction have been suggested in recent years. In this report, the product of an expert consensus meeting of the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) and the International Foundation for Osteoporosis (IOF), we review the evidence for the value of calcium supplementation, with or without vitamin D supplementation, for healthy musculoskeletal ageing. We conclude that (1) calcium and vitamin D supplementation leads to a modest reduction in fracture risk, although population-level intervention has not been shown to be an effective public health strategy; (2) supplementation with calcium alone for fracture reduction is not supported by the literature; (3) side effects of calcium supplementation include renal stones and gastrointestinal symptoms; (4) vitamin D supplementation, rather than calcium supplementation, may reduce falls risk; and (5) assertions of increased cardiovascular risk consequent to calcium supplementation are not convincingly supported by current evidence. In conclusion, we recommend, on the basis of the current evidence, that calcium supplementation, with concomitant vitamin D supplementation, is supported for patients at high risk of calcium and vitamin D insufficiency, and in those who are receiving treatment for osteoporosis.

[Rivastigmine as treatment for patients with mild to moderately severe Alzheimer disease under normal clinical practice conditions. The ENTERPRISE study]. / Manejo terapéutico con rivastigmina en pacientes con enfermedad de Alzheimer de leve a moderadamente grave en condiciones de práctica clínica habitual. Estudio ENTERPRISE.

INTRODUCTION: Alzheimer disease (AD) causes progressive cognitive decline leading to loss of independence for activities of daily living; rivastigmine is one of the drugs used for symptomatic management. OBJECTIVE: To assess the therapeutic use of different pharmaceutical forms of rivastigmine in patients with AD in normal clinical practice. PATIENTS AND METHODS: Cross-sectional, observational, multi-centre study conducted on patients with mild to moderate AD treated with rivastigmine in Spanish outpatient clinics specialising in Geriatrics, Psychiatry, and Neurology. Data regarding use of oral (OR) and transdermal (TDR) rivastigmine, compliance (degree of adherence), and caregiver satisfaction with treatment were evaluated. RESULTS: In total, 2252 patients with a mean age of 77.2 years were included; 60.2% were women. AD was moderate to moderately severe in 58.4%. Rivastigmine treatment was started orally in 54.4% of the patients and transdermally in 45.6%; 35.6% of those who started treatment by the OR route switched to TDR. A single dose adjustment was sufficient for 77.5% of patients on TDR treatment vs 11.8% of patients receiving OR treatment. More patients on TDR treatment (80.8% vs. 57.1% on OR treatment) reached the maximum therapeutic dose of rivastigmine and did so in a shorter period of time (51.6 vs 205.8 days). Compliance rates (60.5% vs 47.2%) and caregivers' satisfaction with treatment (89.4% vs 81.9%) were also higher for TDR. CONCLUSIONS: In normal clinical practice, using the TDR route of administration improves dose titration and drug compliance, allowing more patients to reach the maximum recommended dose of rivastigmine in a shorter time period.

Chronic benzodiazepine usage among older people: prevalence, indications, and treatment modifications in patients admitted to an acute geriatric unit.

AIM: To investigate the prevalence and indications of benzodiazepines (BZD) usage among patients admitted to an acute geriatric unit and assess changes in prescriptions. METHODS: BZD indications were documented reviewing clinical records, with appropriateness assessed based on the STOPP-START criteria. Changes in BZD prescriptions were recorded at discharge and 3 months later. RESULTS: Among the 366 patients included (mean age: 92.8 years, 68% females), 91 (24.9%) were on BZD upon admission, being inappropriate in 93.4%. At discharge, BZD discontinuation was observed in 40.7% and dose reduction initiated in 57.4%. Among patients discharged without prescriptions, 10.8% resumed their use at 3 months. Of those discharged with BZD tapering, 74.1% were still on them 3 months later. CONCLUSIONS: The majority of patients employing BZD lacked a medical indication. Admission to a geriatric ward resulted in successful discontinuation or dose reduction for most patients but was not maintained in the outpatient setting.

Identification of factors associated with sarcopenic obesity development: Literature review and expert panel voting.

Sarcopenic obesity (SO) is defined as the combination of excess fat mass (obesity) and low skeletal muscle mass and function (sarcopenia). The identification and classification of factors related to SO would favor better prevention and diagnosis. The present article aimed to (i) define a list of factors related with SO based on literature analysis, (ii) identify clinical conditions linked with SO development from literature search and (iii) evaluate their relevance and the potential research gaps by consulting an expert panel. From 4746 articles screened, 240 articles were selected for extraction of the factors associated with SO. Factors were classified according to their frequency in the literature. Clinical conditions were also recorded. Then, they were evaluated by a panel of expert for evaluation of their relevance in SO development. Experts also suggested additional factors. Thirty-nine unique factors were extracted from the papers and additional eleven factors suggested by a panel of experts in the SO field. The frequency in the literature showed insulin resistance, dyslipidemia, lack of exercise training, inflammation and hypertension as the most frequent factors associated with SO whereas experts ranked low spontaneous physical activity, protein and energy intakes, low exercise training and aging as the most important. Although literature and expert panel presented some differences, this first list of associated factors could help to identify patients at risk of SO. Further work is needed to confirm the contribution of factors associated with SO among the population overtime or in randomized controlled trials to demonstrate causality.

Towards developing a Core Outcome Set for malnutrition intervention studies in older adults: a scoping review to identify frequently used research outcomes.

PURPOSE: To conduct a scoping review to provide a systematic overview of outcomes used in nutritional intervention studies focused on the treatment of protein-energy malnutrition in older adults. METHODS: A systematic search of four electronic databases (Medline, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to retrieve randomized controlled trials (RCTs), published until March 9, 2020, that evaluated the effect of nutritional interventions to treat protein-energy malnutrition in older adults and those at risk for malnutrition. Two authors screened titles, abstracts and full texts independently. One author extracted data that were cross-checked by another author. RESULTS: Sixty-three articles reporting 60 RCTs were identified. Most frequently used outcomes included body weight/body mass index (75.0% of RCTs), dietary intake (61.7%), functional limitations (48.3%), handgrip strength (46.7%), and body circumference (40.0%). The frequencies differed by setting (community, hospital and long-term care). For some outcomes there was a preferred assessment method (e.g., Barthel index for functional limitations), while for other outcomes (e.g., functional performance) a much greater variation was observed. CONCLUSION: A large variation in outcomes, not only across but also within settings, was identified in nutritional intervention studies in malnourished older adults and those at risk. Furthermore, for many outcomes there was a large variation in the used assessment method. These results highlight the need for developing a Core Outcome Set for malnutrition intervention studies in older adults to facilitate future meta-analyses that may enhance our understanding on the effectiveness of treatment.

MNA-SF as a screening tool for malnutrition diagnosed with the glim criteria in older persons with cancer.

PURPOSE: We aimed to evaluate and compare the Short Form of the Mini Nutritional Assessment (MNA-SF) as a nutritional screening tool with the new Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria for malnutrition (the most current reference standard) among older patients with cancer. METHODS: Patients ≥ 70 years old, with a G8 screening tool ≤ 14, referred to an oncogeriatric clinic. MNA-SF and GLIM criteria were obtained. RESULTS: 40 patients were included (mean age 84.8 ± 5.5, 60% male). According to the GLIM diagnostic criteria, 57.5% were malnourished. The MNA-SF classified 80% as being malnourished or at risk of malnutrition. MNA-SF showed a high sensitivity (100%) and a low specificity (50%) to detect GLIM-defined malnutrition. The AUC of the ROC curve was 0.75. CONCLUSION: The MNA-SF scale is useful as a screening tool to detect malnutrition in older cancer outpatients.

Effects of hospital pharmacist interventions on health outcomes in older polymedicated inpatients: a scoping review.

PURPOSE: To identify the evidence that supports the effect of interventions made by hospital pharmacists, individually or in collaboration with a multidisciplinary team, in terms of healthcare outcomes, a more effective utilization of resources and lower costs in older polymedicated inpatients. METHODS: We searched the following databases: MEDLINE, EMBASE and the Cochrane Library. We also conducted a hand search by checking the references cited in the primary studies and studies included in reviews identified during the process of research. Four review authors working by pairs searched for studies, extracted data, and drew up the results tables. RESULTS: Twenty-six studies were included in the review. In 13 of them pharmacists carried out their intervention exclusively while the patients were in hospital, whereas in 13 interventions were delivered during admission and after hospital discharge. Outcomes identified were mortality, length of stay, visits to the emergency department, readmissions and reported quality of life, among others. Pharmacist interventions were found to be beneficial in fifteen studies, specifically on hospital readmissions, visits to the emergency department and healthcare costs. CONCLUSION: There is no hard evidence demonstrating the effectiveness of hospital pharmacist interventions in older polymedicated patients. Mortality does not show as a relevant outcome. Other health care outcomes, such as hospital readmissions, visits to the emergency department and healthcare costs, seem to be more relevant and amenable to change. Interventions that include pharmacists in multidisciplinary geriatric teams seem to be more promising that isolated pharmacist interventions. Interventions prolonged after hospital discharge seem to be more appropriate that interventions delivered only during hospital admission. Better-designed studies should be conducted in the future to provide further insight into the effect of hospital pharmacist interventions.

Osteoporosis in Frail Older Adults: Recommendations for Research from the ICFSR Task Force 2020.

Interactions among physiological pathways associated with osteoporosis and sarcopenia are thought to contribute to the onset of frailty. The International Conference on Frailty and Sarcopenia Research Task Force thus met in March 2020 to explore how emerging interventions to manage fracture and osteoporosis in older adults may reduce frailty, disability, morbidity, and mortality in the older population. Both pharmacological and non-pharmacological interventions (including nutritional intervention, exercise, and other lifestyle changes) were discussed, including nutritional intervention, exercise, and other lifestyle changes. Pharmacological treatments for osteoporosis include bone-forming and antiresorptive agents, which may optimally be used in sequential or combination regimens. Since similar mechanisms related to resorption underlie physiological changes in muscle and bone, these interventions may provide benefits beyond treating osteoporosis. Clinical trials to test these interventions, however, often exclude frail older persons because of comorbidities (such as mobility disability and cognitive impairment) or polypharmacy. The Task Force recommended that future clinical trials use harmonized protocols, including harmonized inclusion criteria and similar outcome measures; and that they test a range of multidomain therapies. They further advocated more high-quality research to develop interventions specifically for people who are frail and old. The ICOPE program recommended by WHO appears to be highly recommended to frail older adults with osteoporosis.

Joint action malnutrition in the elderly (MaNuEL) knowledge hub: summary of project findings.

PURPOSE: The Joint Action Malnutrition in the Elderly (MaNuEL) Knowledge Hub was established to extend scientific knowledge, strengthen evidence-based practice, build a sustainable, transnational network of experts and harmonize research and clinical practice in the field of protein-energy malnutrition in older persons. This paper aims to summarize the main scientific results achieved during the 2-year project and to outline the recommendations derived. METHODS: 22 research groups from seven countries (Austria, France, Germany, Ireland, Spain, The Netherlands and New Zealand) worked together on 6 relevant domains of malnutrition-i.e. prevalence, screening, determinants, treatment, policy measures and education for health care professionals-making use of existing datasets, evidence and expert knowledge. RESULTS: Four systematic reviews, six secondary data analyses of existing cohort and intervention studies, two web-based surveys and one Delphi study were performed. In addition, a scoring system to rate malnutrition screening tools and a theoretical framework on the aetiology of malnutrition in older persons were developed. Based on these activities and taking existing evidence into consideration, 13 clinical practice, 9 research and 4 policy recommendations were developed. The MaNuEL Toolbox was created and made available to effectively distribute and disseminate the MaNuEL results and recommendations. CONCLUSIONS: The MaNuEL Knowledge Hub successfully achieved its aims. Results and recommendations will support researchers, healthcare professionals, policy-makers as well as educational institutes to advance their efforts in tackling the increasing problem of protein-energy malnutrition in the older population.

[Sarcopenia: a new geriatric hot topic]. / Sarcopénie: nouveau thème d'actualité en gériatrie.

Highly prevalent in the population older than 65 years, and leading to poor outcomes (functional decline and its related consequences), sarcopenia does not benefit yet either of a clear understanding of its patho-physiology. Its origin, its risk factors, its clinical presentation will be detailed. The diagnosis of sarcopenia imposes a clear identification of the risk factors, a specific muscular assessment, a pragmatic clinical approach. The treatment is based on nutritional supplements and/or drugs which to be active need to be associated to physical exercises of moderate intensity. Geriatricians are expecting new therapy to delay the consequences of sarcopenia, e.g. frailty and inability in daily living.

Muscle loss: The new malnutrition challenge in clinical practice.

Recent definitions of malnutrition include low muscle mass within its diagnostic criteria. In fact, malnutrition is one of the main risk factors of skeletal muscle loss contributing to the onset of sarcopenia. However, differences in the screening and diagnosis of skeletal muscle loss, especially as a result of malnutrition in clinical and community settings, still occur mainly as techniques and thresholds used vary in clinical practice. The objectives of this position paper are firstly to emphasize the link between skeletal muscle loss and malnutrition-related conditions and secondly to raise awareness for the timely identification of loss of skeletal muscle mass and function in high risk populations. Thirdly to recognize the need to implement appropriate nutritional strategies for prevention and treatment of skeletal muscle loss and malnutrition across the healthcare continuum. Malnutrition needs to be addressed clinically as a muscle-related disorder and clinicians should integrate nutritional assessment with muscle mass measurements for optimal evaluation of these two interrelated entities to tailor interventions appropriately. The design of monitoring/evaluation and discharge plans need to include multimodal interventions with nutrition and physical exercise that are key to preserve patient's muscle mass and function in clinical and community settings.

Clinical characteristics and prognosis for delirium in Spanish internal medicine departments: An analysis from a large clinical-administrative database. / Características clínicas del delirio y sus implicaciones pronósticas en los servicios de medicina interna españoles: análisis de una gran base de datos clínico-administrativa.

OBJECTIVES: To investigate the prevalence of reported delirium and its associated factors and costs. DESIGN: Retrospective and descriptive analysis of a national clinical-administrative database that includes all patients hospitalised in Spain in internal medicine departments from January 2007 to December 2014. MATERIAL AND METHOD: The study included the patients' sociodemographic and clinical data (sex, age, diagnosis and procedures). RESULTS: The prevalence of reported delirium was 2.5% (114,343 of 4,628,397 discharge reports). Delirium was most common in the 81-90-year age group (48%) and in institutionalised patients (4.5% vs. 2.9%; P<.001). The diagnoses most associated with delirium were dementia (14% vs. 7% for patients without delirium), cerebrovascular disease (17% vs. 11%), malnutrition (4% vs. 2%), pressure ulcers (4% vs. 2%), dysphagia (2% vs. 0.2%) and hyponatraemia (5% vs. 2%) (P<.001 in all cases). Patients with delirium also had longer mean stays (11.85±13.15days vs. 9.49±11.17) and higher hospital mortality (OR: 1.41; 95%CI: 1.39-1.43; P=.0001). The costs attributable to delirium in 8years exceeded €100 million (almost €1,000 per hospitalisation/patient). We developed a predictive model for the risk of developing delirium, which has insufficient sensitivity but is useful for identifying low-risk patients. CONCLUSIONS: Patients who develop delirium during their hospitalisation in internal medicine have a longer stay, greater mortality and an increased risk of being institutionalised at discharge. Delirium is probably poorly reported in the discharge reports prepared by internists.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management.

OBJECTIVE: The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. METHODS: These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Compliance with an oral hyperproteic supplement with fibre in nursing home residents.

BACKGROUND: Undernutrition is a common problem in older individuals that may be related to a low protein dietary intake. Oral supplements may improve the health status in this population, but their use may be limited by compliance and side effects. OBJECTIVES: To evaluate effects of an oral supplement of protein and fibre on compliance, on nutritional status, and on intestinal habits in nursing home residents. METHOD: A prospective observational study was carried out in 66 Spanish nursing homes. 358 subjects undernourished or at risk of undernutrition requiring nutritional supplements. After informed consent was given, subjects received 2 daily cartons (400 ml) of a liquid oral supplement rich in protein and fibre along 3 months. Supplement intake compliance was measured at baseline and after 6 and 12 weeks. Nutritional status was assessed using the Mini- Nutritional Assessment (MNA), weight, and Body Mass Index (BMI). Changes in intestinal habits and digestive symptoms were also recorded, as well as subject's supplement acceptance. RESULTS: Compliance with the supplement intake was 97.46% at 6 weeks and 96% at 12 weeks of follow-up. Significant changes (p<0.0001) were found in nutritional status: mean value of MNA improved from baseline (MNA=14.0+/-3.9) after 12 weeks (MNA=17.0+/-4.0), as well as weight (+2.1 kg, a 4.1% increase). The BMI did not change significantly (BMI=21.43 at baseline; BMI=21.78 at 12 weeks). Undernutrition prevalence (MNA<17) decreased from 76.4 to 46.6% (p<0.0001). Intestinal habits showed a significant improvement in defecation frequency (from 4.7 to 6.1 stools per week, p<0.0001) and faeces consistency (from 53.2% to 74.5% reporting formed soft stools, p<0.0001). 48.9% of the subjects considered to have better intestinal habits after 6 weeks and 50.5% after 3 months of supplementary food intake, the rest reporting no change. Vomits and flatulence were also significantly reduced (p<0.0001). CONCLUSION: The administration of an oral hyperproteic supplement with fibre in aged subjects who are undernourished or at risk of malnutrition can be done in nursing homes with a high level of compliance. Supplements improve their nutritional status and their intestinal habits.

[V debate forum of the SENPE. Current issues on home-based and ambulatory artificial nutrition]. / V Foro de Debate SENPE: Problemática actual de la nutrición artificial domiciliaria y ambulatoria.

A multidisciplinary and multiprofessional debate is established trying to detect and find plausible solutions regarding Home-based and Ambulatory Enteral Nutrition (HBAEN) in Spain, due to the little attention paid by the Administration to the global problem of hyponutrition, the little interest showed by the collectivity of health care professionals, and the lack of a regulation differentiating the patient at his/her home and the patient at a nursing home. It was concluded that the current legislation on Home Based Enteral Nutrition (HBEN) has been variedly applied and does not contemplate the real clinical health care, with some pathologies subsidiary of this kind of therapy being excluded. Proposals to improve both financing and pathologies irrespective of the kind of nutritional therapy are made.

Nutritional screening in a case management program for community-living older individuals at high risk of hospital admission.

BACKGROUND: The prevalence of malnutrition in older persons depends on the healthcare setting. In recent years, hospital-based case management programs (CM Programs) targeting individuals in the community with chronic multimorbidity and high use of hospital resources (admissions or emergency visits) have been developed in many countries to reduce the need for complex health care. The objective of this study was to assess the prevalence of risk of malnutrition, using the Short Form of the Mini-Nutritional assessment, of community dwelling patients included in a chronic CM Program. Factors associated with malnutrition risk were also explored. METHODS: Patients included in a hospital-based integrated CM Program for older persons at high risk for hospital readmission after an index admission were studied. MNA-SF was used at program inclusion to assess the risk of malnutrition. An array of factors potentially associated with malnutrition were explored (including feeding route, use of dental prosthesis, dysphagia, consistency of foods, specific therapeutic diets, use of oral nutritional supplements, polypharmacy, falls, and other diseases and geriatric syndromes). RESULTS: 791 participants were included, mean age 79.8 years, 50.1% females. Risk of malnutrition was present in 44.9%. Participants at risk of malnutrition were more frequently female, had a lower BMI, were less likely to be fed orally and used more nutritional supplements. They also had a higher prevalence of dysphagia, needing changes in food consistency or using specific therapeutic diets, and had dementia or cancer more frequently. They also showed a higher need for palliative care. CONCLUSIONS: Risk of malnutrition in patients included in a CM Program is higher than in non-selected community dwelling older individuals. This information may help inform screening policies in similar populations at risk of hospital readmission.

Role of Oral Nutritional Supplements Enriched with ß-Hydroxy-ß-Methylbutyrate in Maintaining Muscle Function and Improving Clinical Outcomes in Various Clinical Settings.

Aging and disease-related malnutrition are well associated with loss of muscle mass and function. Muscle mass loss may lead to increased health complications and associated increase in health care costs, especially in hospitalized individuals. High protein oral nutritional supplements enriched with ß-hydroxy-ß-methylbutyrate (HP-ONS+HMB) have been suggested to provide benefits such as improving body composition, maintaining muscle mass and function and even decreasing mortality rates. The present review aimed to examine current evidence on the effect of HP-ONS+HMB on muscle-related clinical outcomes both in community and peri-hospitalization patients. Overall, current evidence suggests that therapeutic nutrition such as HP-ONS+HMB seems to be a promising tool to mitigate the decline in muscle mass and preserve muscle function, especially during hospital rehabilitation and recovery.

Implications of ICD-10 for Sarcopenia Clinical Practice and Clinical Trials: Report by the International Conference on Frailty and Sarcopenia Research Task Force.

Establishment of an ICD-10-CM code for sarcopenia in 2016 was an important step towards reaching international consensus on the need for a nosological framework of age-related skeletal muscle decline. The International Conference on Frailty and Sarcopenia Research Task Force met in April 2017 to discuss the meaning, significance, and barriers to the implementation of the new code as well as strategies to accelerate development of new therapies. Analyses by the Sarcopenia Definitions and Outcomes Consortium are underway to develop quantitative definitions of sarcopenia. A consensus conference is planned to evaluate this analysis. The Task Force also discussed lessons learned from sarcopenia trials that could be applied to future trials, as well as lessons from the osteoporosis field, a clinical condition with many constructs similar to sarcopenia and for which ad hoc treatments have been developed and approved by regulatory agencies.