Sarcopenia: revised European consensus on definition and diagnosis.

Background: in 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) published a sarcopenia definition that aimed to foster advances in identifying and caring for people with sarcopenia. In early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. This paper presents our updated findings. Objectives: to increase consistency of research design, clinical diagnoses and ultimately, care for people with sarcopenia. Recommendations: sarcopenia is a muscle disease (muscle failure) rooted in adverse muscle changes that accrue across a lifetime; sarcopenia is common among adults of older age but can also occur earlier in life. In this updated consensus paper on sarcopenia, EWGSOP2: (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterise sarcopenia. Conclusions: EWGSOP2's updated recommendations aim to increase awareness of sarcopenia and its risk. With these new recommendations, EWGSOP2 calls for healthcare professionals who treat patients at risk for sarcopenia to take actions that will promote early detection and treatment. We also encourage more research in the field of sarcopenia in order to prevent or delay adverse health outcomes that incur a heavy burden for patients and healthcare systems.

Prevalence of sarcopenia and 9-year mortality in nursing home residents.

BACKGROUND: Sarcopenia is a progressive loss of muscle mass, strength, and function. It is linked to functional decline, and secondary to this, to nursing home admission. AIMS: To look into the prevalence of sarcopenia in a nursing home population and to gain insight into the relation of sarcopenia with mortality in this cohort. METHODS: A longitudinal cohort follow-up started in October 2007 in 52 nursing homes in Belgium. Following data were procured: anthropometrics (weight/length), body composition (muscle mass through bio-impedance absorptiometry, BIA), functional status (Katz), nutritional status (mini-nutritional assessment-short form, MNA), and a number of laboratory parameters. RESULTS: In total, 745 residents were included. Mean age was 84.6 ± 7.2 years. Mean follow-up time was 1632 ± 1026 days. In total, 17% had severe sarcopenia, 45% had moderate sarcopenia, and 38% had no sarcopenia. Following items were significant (p < 0.05) on univariate analysis with mortality as outcome: sarcopenia, gender, BMI, skeletal muscle mass, age, MNA, and functional level. In multivariate analysis, only MNA, skeletal muscle mass, and age were still significant. Odds ratio for skeletal muscle mass was 1.171 for the highest percentile group, 2.277 for the middle percentile group, and 4.842 for the lowest percentile group. DISCUSSION: The prevalence of sarcopenia was higher than in comparative literature, for which there are a few hypotheses. Cut-off values for sarcopenia using BIA for specific cohorts need to be re-evaluated. CONCLUSIONS: It seems to remain useful to screen for muscle mass in institutionalized elderly, because there is a clear and significant correlation with long-term mortality.

The prevalence and health burden of malnutrition in Belgian older people in the community or residing in nursing homes: results of the NutriAction II study.

INTRODUCTION: In 2008, the NutriAction study showed that (risk of) malnutrition was highly prevalent (57%) among Belgian older people living in the community or in a nursing home. In 2013, this study was repeated to re-evaluate the occurrence of malnutrition, as well as mobility problems and dependence in activities of daily living (ADL). METHODS: Health care professionals (HCPs) associated with homecare organizations and nursing homes across Belgium were invited to screen their patients and complete an online questionnaire. Nutritional status, presence of pre-specified comorbidities, mobility, and ADL dependency were assessed. RESULTS: In total, 3299 older patients were analysed: 2480 (86.3 ± 6.3 years) nursing home (NH) residents and 819 (82.7 ± 6.1 years) community dwelling (CD). Overall, 12% was malnourished (MNA-SF score < 8) and 44% was at risk of malnutrition (MNA-SF 8-11). The highest prevalence of (risk of) malnutrition was observed in NHs (63%) and in patients with dementia (CD: 68%; NH: 82%) or depression (CD: 68%; NH: 79%). Of all malnourished individuals, 49% was recognized as malnourished by HCPs and 13% of the malnourished recognized themselves as such. Mobility (stair climbing and walking) and ADL dependency (Belgian KATZ score) were impaired in older people with (risk of) malnutrition in comparison with individuals with normal nutritional status (p < 0.001). DISCUSSION: Despite public awareness initiatives, the prevalence of malnutrition remained stable among Belgian older people seen by HCPs in the period 2008-2013. Moreover, malnutrition is not well recognized. CONCLUSION: Under-recognition of malnutrition is problematic, because associated loss of mobility and independence may accelerate the transformation of frailty into disability in older people.

Correction to: The prevalence and health burden of malnutrition in Belgian older people in the community or residing in nursing homes: results of the NutriAction II study.

In the original publication, table row alignment was incorrectly formatted for all the tables. The corrected tables are given below.

[Validation of the Dutch EAT-10 for screening of oropharyngeal dysphagia in the elderly population]. / Validatie van de EAT-10 in het Nederlands ter screening van orofaryngeale dysfagie in een oudere populatie.

The prevalence of oropharyngeal dysphagia (OD) in the elderly population >76y is estimated at 26%. OD can lead to malnutrition, depression, diminished quality of life and increased mortality in the elderly. Despite these important complications, OD is still underdiagnosed due to a lack of a reliable and easily applicable screening tool. The Eating Assessment Tool-10 (EAT-10) questionnaire consists of ten statements about symptoms and signs of OD. In the current literature, a cut-off value of ≥3 points is preferred to be considered as in risk for OD. The EAT-10 questionnaire shows good internal consistency and reliability and is validated in different languages with comparable results. The purpose of this study is to validate the EAT-10 questionnaire in Dutch. The results show a strong test-retest reliability (Spearman's rho 0.841) and an internal consistency of 0.917 via Cronbach's alpha. The Dutch EAT-10 questionnaire is well applicable in a clinical environment with a mean duration of 2 minutes and 28 seconds (± 1 minute and 32 seconds) to complete the test. Validation of the Dutch EAT-10 questionnaire makes screening of OD in the Dutch (elderly) population possible.

The impact of cognitive impairment on the physical ageing process.

BACKGROUND: Physical decline and cognitive degeneration characterise the ageing process. AIM: Physical parameters, performance and the functional indexes were studied in relation to age in healthy and cognitively impaired older persons to understand the interactions and changes during normal ageing, cognitive decline and progression to frailty. METHODS: Cross-sectional analysis was performed on a data registry of an ambulatory Memory Diagnosis Centre. The quantitative gait characteristics at usual pace, body composition parameters, disability scales (activity of daily living and instrumental activity of daily living) and Rockwood frailty index were compared in cognitively healthy (CHI), mild cognitively impaired, mildly and moderately demented < 80-years old and > 80-years old adults. RESULTS: Quality of gait deteriorated with age in CHI and cognitively impaired. Skeletal muscle mass index decreased when cognitive status worsened. Disability and frailty correlated with increasing cognitive impairment. Age, gender, cognitive impairment, body composition and Rockwood's Frailty scale had a combined forecasting effect, as well as the individual effect on the gait characteristics. Disability score, Frailty index, skeletal muscle mass and skeletal muscle mass index, gait speed, normalised mean step length and swing time variability in mildly demented < 80-years old adults mirrored the parameters in the CHI > 80-years old. CONCLUSION: Quantitative gait characteristics, muscle mass and disabilities change along with cognitive impairment, frailty and age. A more rapid physical ageing process accompanies cognitive decline. Therefore, gait characteristics should be age-referenced and studies on gait in older persons should include muscle mass, frailty and cognitive parameters.

Where frailty meets diabetes.

Diabetes is a chronic illness that has an effect on multiple organ systems. Frailty is a state of increased vulnerability to stressors and a limited capacity to maintain homeostasis. It is a multidimensional concept and a dynamic condition that can improve or worsen over time. Frailty is either physical or psychological or a combination of these two components. Sarcopenia, which is the age-related loss of skeletal muscle mass and strength, is the main attributor to the physical form of frailty. Although the pathophysiology of diabetes is commonly focused on impaired insulin secretion, overload of gluconeogenesis and insulin resistance, newer insights broaden this etiologic horizon. Immunologic factors that create a chronic state of low-grade inflammation--'inflammaging'--have an influence on both the ageing process and diabetes. Persons with diabetes mellitus already tend to have an accelerated ageing process that places them at greater risk for developing frailty at an earlier age. The development of frailty--and sarcopenia--is multifactorial and includes nutritional, physical and hormonal elements; these elements are interlinked with those of diabetes. A lower muscle mass will lead to poorer glycaemic control through lower muscle glucose uptake. This leads to higher insulin secretion and insulin resistance, which is the stepping stone for diabetes itself.

Comprehensive geriatric assessment as an essential tool to register or update DNR codes in a tertiary care hospital.

PURPOSE: To investigate the prevalence of Do not Resuscitate (DNR) code registration in patients with a geriatric profile admitted to Antwerp University Hospital, a tertiary care hospital in Flanders, Belgium, and the impact of comprehensive geriatric assessment (CGA) on DNR code registration. PATIENTS AND METHODS: Retrospective analysis of a population of 543 geriatric patients (mean age 82.4 ± 5.19 years, 46.4% males) admitted to Antwerp University Hospital from 2018 to 2020 who underwent a CGA during admission. An association between DNR code registration status before and at hospital admission and age, gender, ethnicity, type of residence, clinical frailty score (CFS), cognitive and oncological status, hospital ward and stay on intensive care was studied. Admissions before and during the first wave of the pandemic were compared. RESULTS: At the time of hospital admission, a DNR code had been registered for 66.3% (360/543) of patients. Patients with a DNR code at hospital admission were older (82.7 ± 5.5 vs. 81.7 ± 4.6 years, p = 0.031), more frail (CFS 5.11 ± 1.63 vs. 4.70 ± 1.61, p = 0.006) and less likely to be admitted to intensive care. During the hospital stay, the proportion of patients with a DNR code increased to 77% before and to 85.3% after CGA (p < 0.0001). Patients were consulted about and agreed with the registered DNR code in 55.8% and 52.1% of cases, respectively. The proportion of patients with DNR codes at the time of admission or registered after CGA did not differ significantly before and after the start of the COVID-19 pandemic. CONCLUSION: After CGA, a significant increase in DNR registration was observed in hospitalized patients with a geriatric profile.

COGNOS: care for people with cognitive dysfunction: a national observational study.

Care plans are intended to improve the independence and functioning of patients with cognitive dysfunction and support the caregivers involved. They are an integral part of the Belgian reimbursement procedure for cholinesterase inhibitors. This nationwide, multicenter, observational study examined the content and implementation of the care plan along with patient satisfaction in community-dwelling patients newly diagnosed with Alzheimer disease in Belgium. The patients' opinion of their quality of life was measured using Anamnestic Comparative Self-Assessment (ACSA) scale. A total of 720 participants (453 female) were enrolled with 86.0% (619/719) living at home alone or with their spouse/partner. Cognitive problems (627/717, 87.4%) were the main reason for initiation of the consultation. Most patients had a caregiver (646/719, 89.8%): generally the spouse/partner (351/646, 54.3%) or a child (232/646, 35.9%). A total of 511 patients (71.0%) were prescribed a cholinesterase inhibitor after the initial consultation. A total of 236 care plans were advised with 169 (71.6%) realized and 157 of these (92.9%) considered adequate. Most patients were satisfied with the help received in the care plan (service satisfaction range, 80.0% to 98.6% of patients). Quality of life as rated by the patient significantly increased between baseline (average ACSA score: 5.2±2.4) and follow-up (5.8±2.1). The use of care plans appears to improve management of care for Alzheimer disease patients.

Validation of SARC-F-Proxy for the Screening of Sarcopenia in Older Patients with Cognitive Impairment.

Objectives: The SARC-F is a validated questionnaire for the screening of sarcopenia in an older population. However, the clinical relevance of this self-reported questionnaire in patients with cognitive problems is questionable. This study aims to validate the SARC-F-Proxy as an alternative screening tool for sarcopenia in patients with cognitive impairment. Methods: This cross-sectional study included hospitalised community-dwelling older adults aged 60 years or older with confirmed cognitive impairment. Three SARC-F questionnaires were completed: one by patients, one by informal caregivers and one by formal caregivers. Muscle strength, mass and physical performance were measured by handgrip strength, anthropometric measurements, and gait speed respectively. The recently updated EWGSOP2 diagnostic criteria were used as the "gold standard" for diagnosis of sarcopenia. Results: The prevalence of sarcopenia using SARC-F-Proxy was 75.4% for SARC-F-Proxy-Formal caregiver and 66% for SARC-F-Proxy-Informal caregiver. SARC-F-Proxy had high sensitivity (85.9% for SARC-F-Proxy-Formal caregiver and 77% for SARC-F-proxy-informal caregiver) and low specificity (46.5% for SARC-F-Proxy-Formal caregiver and 54.7% for SARC-F-Proxy-Informal caregiver). Conclusions: the proxy-reported SARC-F questionnaire can be applied as a surrogate for the SARC-F in the screening of sarcopenia in hospitalised community-dwelling older people with known or suspected cognitive impairment. Second, the results in this study suggest a higher reliability when the proxy-reported questionnaire is performed by the formal caregiver.

Health-care and home-care utilization among frail elderly persons in Belgium.

BACKGROUND: The patterns of health- and home-care utilization among Belgian frail elderly persons living at home with varying socio-economic status are currently unknown. METHODS: In this cross-sectional study based on a representative sample of 4777 elderly participants (≥65 years) in the Belgian Health Interview Survey the prevalence of frailty, as determined by items referring to the Fried phenotype, was estimated according to age, gender, comorbidity, place of residence, survey year, living situation and socio-economic status. Differing health-care utilization [contacts with a general practitioner (GP), specialist and emergency department; and hospital admission) and home-care utilization (home nursing, home help and meals-on-wheels] patterns among the frail, prefrail and robust subpopulations were examined. RESULTS: Overall, 9.3% respondents (426) were classified as frail, 30.7% (1636) as prefrail and 60.0% (2715) as robust. Frailty was associated with age, gender, comorbidity, region, survey year and socio-economic status. The frail and prefrail groups were more likely than the robust to contact a GP, a specialist or an emergency department and were more likely to be admitted to hospital, independent of age, gender, comorbidity, survey year, living situation, region and socio-economic status. They were also more likely to appeal to home nursing, home help and meals-on-wheels than the robust participants. CONCLUSION: Even after adjustment for potential confounders, including age, gender and comorbidity, frailty among Belgian elderly persons is associated with their socio-economic status and is strongly associated with their health- and home-care utilization.

Muscle measurements in daily clinical practice: correlations between ultrasound, bioelectrical impedance analysis and hand grip strength.

Objectives: Muscle ultrasound is gaining importance as a measurement tool to evaluate sarcopenia in daily clinical practice. This study sought to collect reference values of the biceps brachii (BB) in healthy subjects, and to correlate them to bioelectrical impedance analysis (BIA) and hand grip strength (HGS). Methods: Ultrasound was used to measure muscle thickness (MT), cross-sectional area (CSA) and muscle stiffness (EG). Lean mass (LM), fat mass (FM) and phase angle (PhA) were measured by BIA. HGS was measured using a Jamar dynamometer. Intra-rater reliability was calculated using intraclass correlation (ICC). Correlations were investigated using Pearson correlation (PCC). Results: One-hundred-twenty-three Caucasian individuals (51 male and 72 female subjects) between 18 and 69 years old were included. ICC for ultrasound was 0.99 (CI 0.98-0.99). LM, PhA and HGS showed significant correlations with MT and CSA in the entire population (PCC>0.684). These correlations were more significant and stronger in male than in female subjects (PCC>0.419 and >0.279 resp.). Significant correlations with respect to FM and EG were seen exclusively in female subjects. Conclusion: Significant correlations were observed between parameters of muscle quantity measured by ultrasound, BIA and HGS. Intra-rater reliability was excellent. Future studies in larger populations are needed to clarify the observed gender differences.

Bedside medication review with cognitive and depression screening by a clinical pharmacist as part of a comprehensive geriatric assessment in hospitalized older patients with polypharmacy: A pilot study.

BACKGROUND: Polypharmacy is highly prevalent in older patients with multimorbidity and is associated with increased risk of adverse drug events. This pilot study investigated the added value of a bedside medication review with cognitive and depression screening by a clinical pharmacist to identify potentially inappropriate medications (PIMs) and medication use issues in older patients with polypharmacy. METHODS AND RESULTS: In the period from September 2018 to March 2019, a clinical pharmacist took part in the comprehensive geriatric assessment of 37 older patients hospitalized at Antwerp University Hospital and conducted a medication review consisting of a record review, a bedside interview questionnaire covering medication use, evaluation of cognitive function (abbreviated MMSE), depression (GDS-4), and systematic check for possible PIMs (STOPP/START criteria). Patients were 83±4 years old and on a median of 12 home medications (range 5-20). The clinical pharmacist formulated an average of 7.7 recommendations to optimize medication use per patient, of which 89.9% were considered clinically relevant by the geriatrician. Only 2 out of 286 PIMs were discovered during routine electronic validation of medication prescriptions. Supervision of medication intake was absent in 75% of cognitively impaired patients, but advice to do so was implemented in 86.4% of cases. The multidisciplinary geriatric advice was communicated to the treating physician, who fully implemented 33.8% of the recommendations. CONCLUSIONS: Bedside medication review with cognitive and depression screening by a clinical pharmacist is useful to discover polypharmacy related problems and medication intake issues in a population of geriatric patients. Systematic screening for cognitive impairment and depression are needed to detect patients in need of support for correct medication use and therapy compliance.

Nutritional interventions to improve muscle mass, muscle strength, and physical performance in older people: an umbrella review of systematic reviews and meta-analyses.

CONTEXT: Sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased risk of adverse outcomes such as falls, disability, and death. The Belgian Society of Gerontology and Geriatrics has developed evidence-based guidelines for the prevention and treatment of sarcopenia. This umbrella review presents the results of the Working Group on Nutritional Interventions. OBJECTIVE: The aim of this umbrella review was to provide an evidence-based overview of nutritional interventions targeting sarcopenia or at least 1 of the 3 sarcopenia criteria (ie, muscle mass, muscle strength, or physical performance) in persons aged ≥ 65 years. DATA SOURCES: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the PubMed and Web of Science databases were searched for systematic reviews and meta-analyses reporting the effect of nutritional supplementation on sarcopenia or muscle mass, strength, or physical performance. DATA EXTRACTION: Two authors extracted data on the key characteristics of the reviews, including participants, treatment, and outcomes. Methodological quality of the reviews was assessed using the product A Measurement Tool to Assess Systematic Reviews. Three authors synthesized the extracted data and generated recommendations on the basis of an overall synthesis of the effects of each intervention. Quality of evidence was rated with the Grading of Recommendations Assessment, Development and Evaluation approach. DATA ANALYSIS: A total of 15 systematic reviews were included. The following supplements were examined: proteins, essential amino acids, leucine, ß-hydroxy-ß-methylbutyrate, creatine, and multinutrient supplementation (with or without physical exercise). Because of both the low amount and the low to moderate quality of the reviews, the level of evidence supporting most recommendations was low to moderate. CONCLUSIONS: Best evidence is available to recommend leucine, because it has a significant effect on muscle mass in elderly people with sarcopenia. Protein supplementation on top of resistance training is recommended to increase muscle mass and strength, in particular for obese persons and for ≥ 24 weeks. Effects on sarcopenia as a construct were not reported in the included reviews.

The association between muscle mass and the degree of myosteatosis of the psoas muscle and mortality in older patients with cancer.

OBJECTIVE: Comprehensive geriatric assessment (CGA) is used for oncological management in older patients. The evaluation of muscle characteristics is currently not included in the CGA. This study investigates whether muscle mass and the degree of myosteatosis is associated with mortality in older patients with cancer. METHODS: CGA was performed in a cohort of older patients with cancer. Cross sectional area (CSA) and mean pixel density (Hounsfield units, HU), as measure for respectively muscle mass and myosteatosis, were obtained from CT images of the psoas muscle at the level of mid L3. Mortality was recorded. Correlation was determined between CSA and HU. Paired sample t-test was used to follow changes in muscle mass and density. Logistic regression was performed to define relevant prognostic factors for mortality. RESULTS: In total, 183 patients were included (86 male and 97 female), 120 patients (66%) died. Mean age was 80 years (range 70-94 years). Mean days of survival was 606 (range 1-2023). There was a significant correlation between CSA and HU (PCC = 0.196) at time of diagnosis and at follow-up (PCC = 0.257). There was a significant decrease in CSA (p = .008) and HU (p = .004) in men at follow-up. No significant changes were observed in women. In multivariate analysis, a higher gender-corrected CSA was linked to a lower mortality rate with an odds ratio of 0.657 (CI = 0.457-0.944, p = .023). No association was found between HU and mortality. CONCLUSIONS: Muscle mass correlated with the degree of myosteatosis. CSA and HU tended to decrease during follow-up. Having a greater CSA was prognostic for a lower mortality rate.

Physical components of frailty in predicting mortality after transcatheter aortic valve implantation (TAVI).

OBJECTIVE: This study investigates physical, nutritional and psychological components of frailty in predicting postoperative mortality after transcatheter aortic valve implantation (TAVI). METHODS: A single centre retrospective observational study was conducted from July 2015 until January 2019. Psychological, nutritional and physical components of frailty were measured. Sarcopenia was defined as having both gait speed and grip strength under the threshold. The primary endpoint was the cumulative all-cause 1-year mortality. Secondary endpoint was 30 days all-cause mortality. RESULTS: A total of 125 patients were included. The primary endpoint was observed in 18 patients (14.4%). Five patients died within the first 30 days (4.0%). None of the frailty tests were correlated with early mortality. However, at one year, the nutritional components albumin and Mini Nutritional Assessment - short form (MNA-SF) and the physical components gait speed, chair stand test, TUG, SPPB, EFT and sarcopenia were associated with increased mortality after TAVI. A significant difference in mortality was present if stratified for MNA-SF (log-rank p = .008), sarcopenia (log-rank p < .001), SPPB (log-rank p = .003) and EFT score (log-rank p < .001). CONCLUSIONS: Mainly nutritional and physical components of frailty were associated with 1-year mortality after TAVI.

Application of ultrasound for muscle assessment in sarcopenia: 2020 SARCUS update.

PURPOSE: In 2018, the SARCUS working group published a first article on the standardization of the use of ultrasound to assess muscle. Recommendations were made for patient positioning, system settings and components to be measured. Also, shortcomings in knowledge were mentioned. An important issue that still required standardization was the definition of anatomical landmarks for many muscles. METHODS: A systematic search was performed in Medline, SCOPUS and Web of Sciences looking for all articles describing the use of ultrasound in the assessment of muscle not described in the first recommendations, published from 01/01/2018 until 31/01/2020. All relevant terms used for older people, ultrasound and muscles were used. RESULTS: For 39 muscles, different approaches for ultrasound assessment were found that likely impact the values measured. Standardized anatomical landmarks and measuring points were proposed for all muscles/muscle groups. Besides the five already known muscle parameters (muscle thickness, cross-section area, pennation angle, fascicle length and echo-intensity), four new parameters are discussed (muscle volume, stiffness, contraction potential and microcirculation). The former SARCUS article recommendations are updated with this new information that includes new muscle groups. CONCLUSIONS: The emerging field of ultrasound assessment of muscle mass only highlights the need for a standardization of measurement technique. In this article, guidelines are updated and broadened to provide standardization instructions for a large number of muscles.

Nutritional assessment in geriatric cancer patients.

INTRODUCTION: Geriatric patients are not defined by their age but by their general profile. Aging is characterized by loss of organ function together with a reduced capability for adapting to changes in the environment (loss of homeostatic mechanisms) leading to frailty. In the older patient with cancer, there can be problems of dietary intake next to the effects of aging per se. On top of this situation, the deleterious effects of the inflammatory processes induced by the tumor are superimposed. When these changes are translated into nutritional concepts, it is clear that, in the older cancer patient, there is a strong overlap of starvation, sarcopenia, and cachexia. DISCUSSION: Nutritional assessment should be part of the routine preliminary evaluation of the older oncology patient. Difference should be made between assessment of risk and actual nutritional status, which should be assessed with specific malnutrition indices. Body weight assessment with specific attention to unintended weight loss is essential in this evaluation. One should recognize the fact that body mass index (BMI) should be interpreted with caution, but that a low value for BMI still heralds an increased malnutrition risk. This increased alertness for nutritional problems has a lot to offer in the willingness for early intervention. The nutritional assessment, however, must be framed in a larger comprehensive geriatric assessment addressing several functional domains.

Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People.

The European Working Group on Sarcopenia in Older People (EWGSOP) developed a practical clinical definition and consensus diagnostic criteria for age-related sarcopenia. EWGSOP included representatives from four participant organisations, i.e. the European Geriatric Medicine Society, the European Society for Clinical Nutrition and Metabolism, the International Association of Gerontology and Geriatrics-European Region and the International Association of Nutrition and Aging. These organisations endorsed the findings in the final document. The group met and addressed the following questions, using the medical literature to build evidence-based answers: (i) What is sarcopenia? (ii) What parameters define sarcopenia? (iii) What variables reflect these parameters, and what measurement tools and cut-off points can be used? (iv) How does sarcopenia relate to cachexia, frailty and sarcopenic obesity? For the diagnosis of sarcopenia, EWGSOP recommends using the presence of both low muscle mass + low muscle function (strength or performance). EWGSOP variously applies these characteristics to further define conceptual stages as 'presarcopenia', 'sarcopenia' and 'severe sarcopenia'. EWGSOP reviewed a wide range of tools that can be used to measure the specific variables of muscle mass, muscle strength and physical performance. Our paper summarises currently available data defining sarcopenia cut-off points by age and gender; suggests an algorithm for sarcopenia case finding in older individuals based on measurements of gait speed, grip strength and muscle mass; and presents a list of suggested primary and secondary outcome domains for research. Once an operational definition of sarcopenia is adopted and included in the mainstream of comprehensive geriatric assessment, the next steps are to define the natural course of sarcopenia and to develop and define effective treatment.