Individual and combined associations of sarcopenia, osteoporosis and obesity with frailty in a multi-ethnic asian older adult population.

BACKGROUND: We explored the relationships between sarcopenia (SP), osteoporosis (OP), obesity (OB), (alone and in combination) with physical frailty (PF) in a multi-ethnic, population-based study of Asians aged ≥ 60 years. METHODS: Participants were enrolled from the PopulatION HEalth and Eye Disease PRofile in Elderly Singaporeans Study (PIONEER) study. PF was defined using the modified Fried phenotype; SP using the Asian Working Group for Sarcopenia 2019; OP using bone mineral density scores; and OB using the fat mass index. Modified Poisson regression models investigated the associations between exposures and PF, and the relative excess rates of PF due to interactions (RERI) to determine synergistic or antagonistic interactions. RESULTS: Of the 2643 participants, 54.8% was female; and 49.8%, 25.1%, 25.0% were Chinese, Indians, and Malays, respectively. 25%, 19.0% and 6.7% participants had OB only, SP only, and OP only, respectively. A total of 356 (17.5%), 151 (7.4%) and 97 (4.8%) had osteosarcopenia (OSP), sarcopenic obesity (SOB) and osteo-obesity (OOB), respectively; while 70 (3.5%) had all 3 morbid conditions (osteosarcopenic obesity, OSO). Both SP only and OB only were strongly associated with increased rates of PF (RR: 2.53, 95% CI: 1.95, 3.29; RR: 2.05, 95% CI: 1.58, 2.66 respectively); but not OP. Those with OSP, OOB and SOB were also associated with high risks of PF (RR: 2.82, 95% CI: 2.16, 3.68; RR: 2.34, 95% CI: 1.69, 3.23; and RR: 2.58, 95% CI: 1.95, 3.41, respectively) compared to robust individuals. Critically, individuals with OSO had the highest relative risk of having PF (RR: 3.06, CI: 2.28, 4.11). Only the sarcopenia-obesity interaction was significant, demonstrating negative synergism (antagonism). The concurrent presence of SP and OB was associated with a 100% lower rate of PF compared to the sum of the relatively rates of SP only and OB only. CONCLUSION: The prevalence of SP, OB and OP, alone and combined, is substantial in older Asians and their early identification is needed to mitigate the risk of frailty. OB may interact with SP in an antagonistic manner to moderate rates of frailty. Further longitudinal studies are needed to address causality and mechanistic underpinnings our findings.

Delirium superimposed on dementia: phenomenological differences between patients with and without behavioral and psychological symptoms of dementia in a specialized delirium unit.

BACKGROUND: Overlap between neuropsychiatric symptoms of dementia and delirium complicates diagnosis of delirium superimposed on dementia (DSD). This study sought to examine differences in delirium presentation and outcomes between DSD patients with and without pre-existing behavioral and psychological symptoms of dementia (BPSD). METHODS: This was a prospective cohort study of older adults with DSD admitted to a specialized delirium unit (December 2010-August 2012). We collected data on demographics, comorbidities, illness severity, delirium precipitants, and cognitive and functional scores. Delirium severity was assessed using Delirium Rating Scale Revised-98 (DRS-R-98) and Cognitive Assessment Method severity score (CAM-sev). Patients were categorized as DSD-BPSD+ and DSD-BPSD- based on elicited behavioral and psychological disturbances. RESULTS: We recruited 174 patients with DSD (84.4 +/-7.4 years) with 37 (21.3%) having BPSD. At presentation, delirium severity and symptom frequency on DRS-R98 were similar, but DSD-BPSD+ more often required only a single precipitant (40.5% vs. 21.9%, p = 0.07), and had significantly longer delirium duration (median days: 7 vs. 5, p < 0.01). At delirium resolution, DSD-BPSD+ exhibited significant improvement in sleep-wake disturbances (89.2% vs. 54.1%, p < 0.01), affect lability (81.1% vs. 56.8%, p = 0.05), and motor agitation (73% vs. 40.5%, p < 0.01), while all non-cognitive symptoms except motor retardation were improved in DSD-BPSD-. Pharmacological restraint was more prevalent (62.2% vs. 40.1%, p = 0.03), and at higher doses (chlorpromazine equivalents 0.95 +/-1.8 vs. 0.40 +/-1.2, p < 0.01) in DSD-BPSD+. CONCLUSIONS: BPSD may increase vulnerability of dementia patients to delirium, with subsequent slower delirium recovery. Aggravation of sleep disturbance, labile affect, and motor agitation should raise suspicion for delirium among these patients.

A Combined Cognitive Stimulation and Physical Exercise Programme (MINDVital) in Early Dementia: Differential Effects on Single- and Dual-Task Gait Performance.

BACKGROUND: Gait disorders are common in early dementia, with particularly pronounced dual-task deficits, contributing to the increased fall risk and mobility decline associated with cognitive impairment. OBJECTIVE: This study examines the effects of a combined cognitive stimulation and physical exercise programme (MINDVital) on gait performance under single- and dual-task conditions in older adults with mild dementia. METHODS: Thirty-nine patients with early dementia participated in a multi-disciplinary rehabilitation programme comprising both physical exercise and cognitive stimulation. The programme was conducted in 8-week cycles with participants attending once weekly, and all participants completed 2 successive cycles. Cognitive, functional performance and behavioural symptoms were assessed at baseline and at the end of each 8-week cycle. Gait speed was examined under both single- (Timed Up and Go and 6-metre walk tests) and dual-task (animal category and serial counting) conditions. A random effects model was performed for the independent effect of MINDVital on the primary outcome variable of gait speed under dual-task conditions. RESULTS: The mean age of patients enroled in the rehabilitation programme was 79 ± 6.2 years; 25 (64.1%) had a diagnosis of Alzheimer's dementia, and 26 (66.7%) were receiving a cognitive enhancer therapy. There was a significant improvement in cognitive performance [random effects coefficient (standard error) = 0.90 (0.31), p = 0.003] and gait speed under both dual-task situations [animal category: random effects coefficient = 0.04 (0.02), p = 0.039; serial counting: random effects coefficient = 0.05 (0.02), p = 0.013], with reduced dual-task cost for gait speed [serial counting: random effects coefficient = -4.05 (2.35), p = 0.086] following successive MINDVital cycles. No significant improvement in single-task gait speed was observed. Improved cognitive performance over time was a significant determinant of changes in dual-task gait speed [random effects coefficients = 0.01 (0.005), p = 0.048, and 0.02 (0.005), p = 0.003 for category fluency and counting backwards, respectively]. CONCLUSION: A combined physical and cognitive rehabilitation programme leads to significant improvements in dual-task walking in early dementia, which may be contributed by improvement in cognitive performance, as single-task gait performance remained stable.

Automated assessment of thigh composition using machine learning for Dixon magnetic resonance images.

OBJECTIVES: To develop and validate a machine learning based automated segmentation method that jointly analyzes the four contrasts provided by Dixon MRI technique for improved thigh composition segmentation accuracy. MATERIALS AND METHODS: The automatic detection of body composition is formulized as a three-class classification issue. Each image voxel in the training dataset is assigned with a correct label. A voxel classifier is trained and subsequently used to predict unseen data. Morphological operations are finally applied to generate volumetric segmented images for different structures. We applied this algorithm on datasets of (1) four contrast images, (2) water and fat images, and (3) unsuppressed images acquired from 190 subjects. RESULTS: The proposed method using four contrasts achieved most accurate and robust segmentation compared to the use of combined fat and water images and the use of unsuppressed image, average Dice coefficients of 0.94 ± 0.03, 0.96 ± 0.03, 0.80 ± 0.03, and 0.97 ± 0.01 has been achieved to bone region, subcutaneous adipose tissue (SAT), inter-muscular adipose tissue (IMAT), and muscle respectively. CONCLUSION: Our proposed method based on machine learning produces accurate tissue quantification and showed an effective use of large information provided by the four contrast images from Dixon MRI.

New DSM-V neurocognitive disorders criteria and their impact on diagnostic classifications of mild cognitive impairment and dementia in a memory clinic setting.

OBJECTIVE: To examine diagnostic agreement between Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) Neurocognitive Disorders (NCDs) criteria and DSM, Fourth Edition (DSM-IV) criteria for dementia and International Working Group (IWG) criteria for mild cognitive impairment (MCI) and DSM-V's impact on diagnostic classifications of NCDs. The authors further examined clinical factors for discrepancy in diagnostic classifications between the different operational definitions. METHODS: Using a cross-sectional study in tertiary memory clinic, the authors studied consecutive new patients aged 55 years or older who presented with cognitive symptoms. Dementia severity was scored based on the Clinical Dementia Rating scale (CDR). All patients completed neuropsychological evaluation. Agreement in diagnostic classifications between DSM-IV/IWG and DSM-V was examined using the kappa test and AC1 statistic, with multinomial logistic regression for factors contributing to MCI reclassification as major NCDs as opposed to diagnostically concordant MCI and dementia groups. RESULTS: Of 234 patients studied, 166 patients achieved concordant diagnostic classifications, with overall kappa of 0.41. Eighty-six patients (36.7%) were diagnosed with MCI and 131 (56.0%) with DSM-IV-defined dementia. With DSM-V, 40 patients (17.1%) were classified as mild NCDs and 183 (78.2%) as major NCDs, representing a 39.7% increase in frequency of dementia diagnoses. CDR sum-of-boxes score contributed independently to differentiation of MCI patients reclassified as mild versus major NCDs (OR: 0.01; 95% CI: 0-0.09). CDR sum-of-boxes score (OR: 5.18; 95% CI: 2.04-13.15), performance in amnestic (OR: 0.14; 95% CI: 0.06-0.34) and language (Boston naming: OR: 0.52; 95% CI: 0.29-0.94) tests, were independent determinants of diagnostically concordant dementia diagnosis. CONCLUSION: The authors observed moderate agreement between the different operational definitions and a 40% increase in dementia diagnoses with operationalization of the DSM-V criteria.

Identifying phenomenological differences and recovery of cognitive and non-cognitive symptomatology among delirium superimposed upon dementia patients (DsD) versus those without dementia (DaD) in an acute geriatric care setting.

BACKGROUND: Phenomenological differences between delirium superimposed on dementia (DsD) versus delirium in the absence of dementia (DaD) remain poorly understood. We aimed to identify phenomenological differences in delirium symptoms (cognitive and non-cognitive) and compare delirium recovery trajectories between DsD and DaD. METHODS: We conducted a prospective observational study on individuals admitted to the Geriatric Monitoring Unit (GMU), a five-bed unit specializing in managing older adults with delirium, between December 2010 and August 2012 (n = 234; mean age 84.1 ± 7.4). We collected data on demographics, comorbidities, severity of illness, cognitive and functional scores, and number of precipitants. Cognitive status was assessed using locally validated Chinese Mini-Mental State Examination (CMMSE) and delirium severity assessed using Delirium Rating Scale-Revised-98 (DRS-R98). Delirium disease trajectory was plotted over five days. RESULTS: DsD patients had a longer duration of delirium with slower recovery in terms of cognition and delirium severity scores compared with DaD patients (0.33 (0.0-1.00) vs. 1.0 (0.36-2.00) increase in CMMSE per day, p < 0.001, and 1.49 ± 1.62 vs. 2.63 ± 2.28 decrease in DRS-R98 severity per day, p < 0.001). When cognitive and non-cognitive sub-scores of DRS-R98 were examined separately, we observed steeper recovery in both sub-scores in DaD patients. These findings remained significant after adjusting for significant baseline differences. CONCLUSIONS: Our findings of slower cognitive symptom recovery in DsD patients suggest cognitive reserve play a role in delirium syndrome development and recovery. This merits further studies to potentially aid in appropriate discharge planning and to identify potential pharmacological and non-pharmacological cognitive interventions for hospitalized older persons with delirium.

Prospective longitudinal study of frailty transitions in a community-dwelling cohort of older adults with cognitive impairment.

BACKGROUND: Frailty and cognitive impairment are seemingly distinct syndromes, but have a shared vulnerability to stress in older adults, resulting in poorer outcomes. Although there has been recent interest in cognitive frailty, frailty transitions in relation to cognitive deterioration in older adults with cognitive impairment have not yet been well studied. We thus aim to study frailty transitions and change in cognitive status over 1-year follow-up among subjects with cognitive impairment attending a tertiary Memory Clinic. METHODS: This is a prospective cohort study of mild cognitive impairment (MCI) and mild-moderate Alzheimer's disease (AD) community-dwelling subjects. We obtained data on clinical measures, muscle mass and physical performance measures. Cognitive status was measured using Chinese Mini-Mental State Examination (CMMSE) and Clinical Dementia Rating-Sum of Boxes (CDR-SB) scores. We measured gait speed, hand grip strength, exhaustion and weight loss at baseline, 6 and 12 months to classify subjects according to the modified Fried criteria (involving strength, gait speed, body composition and fatigue) into non-frail (<2 frail categories) and frail categories (≥2 frail categories). Frailty transitions between baseline and 12-months were assessed. We performed random effects statistical modelling to ascertain baseline predictors of longitudinal frailty scores for all subjects and within MCI subgroup. RESULTS: Among 122 subjects comprising 41 MCI, 67 mild and 14 moderate AD, 43.9, 35.8 and 57.1% were frail at baseline respectively. Frailty status regressed in 32.0%, remained unchanged in 36.0%, and progressed in 32.0 % at 12 months. Random effects modelling on whole group showed longitudinal CDR-SB scores (coeff 0.09, 95% confidence interval (CI) 0.03-0.15) and age (coeff 0.04, 95 % CI 0.02-0.07) to be significantly associated with longitudinal frailty score. Among MCI subjects, only female gender (coeff 1.28, 95 % CI 0.21-2.36) was associated with longitudinal frailty score, while mild-moderate AD subjects showed similar results as those of the whole group. CONCLUSIONS: This is the first study to show longitudinal frailty state transitions in cognitively-impaired older adults. Frailty transitions appear to be independent of progression in cognitive status in earliest stages of cognitive impairment, while mild-moderate AD subjects showed associations with age and cognitive deterioration. The potential for cognitive frailty as a separate therapeutic entity for future physical frailty prevention requires further research with a suitably powered study over a longer follow-up period.

Differential perceptions of quality of life (QoL) in community-dwelling persons with mild-to-moderate dementia.

BACKGROUND: Discordance between patient- and caregiver-reported quality of life (QoL) is well recognized. This study sought to (i) identify predictors of discrepancy between patient- and caregiver-rated QoL amongst community-dwelling persons with mild-to-moderate dementia, and (ii) differentiate between patients who systematically rate their QoL lower versus those who rate their QoL higher relative to their caregiver ratings. METHODS: We recruited 165 patient-caregiver dyads with mild-to-moderate dementia. Quality of life in Alzheimer's disease (QoL-AD) scale was administered separately to patients and caregivers. Data on socio-demographics, interpersonal relationship, and disease-related characteristics (cognitive performance, mood, neuropsychiatric symptoms, functional ability, and caregiver burden) were collected. Patient-caregiver dyads were categorized based on whether patient-rated QoL was lower or higher than their respective caregiver ratings. Univariate analyses and multiple regression models were performed to identify predictors of dyadic rating discrepancy. RESULTS: Mean patient-rated QoL was significantly higher than caregiver rating (mean difference: 3.8 ± 7.1, p < 0.001). Majority (111 (67.2%)) of patients had more positive self-perceived QoL (QoL-ADp (QoL-AD self rated by the patient) > QoL-ADc (QoL-AD proxy-rated by a caregiver)), compared with those (44 (26.7%)) with poorer self-perceived QoL (QoL-ADp < QoL-ADc). Patient's education level, depressive symptoms, and severity of neuropsychiatric symptoms predicted magnitude of discrepancy. Depression (OR = 1.17, 95% CI = 1.02-1.35) and being cared for by other relative (non-spouse/adult child; OR = 7.54, 95% CI = 1.07-53.03) predicted poorer self-perceived QoL. CONCLUSIONS: Dyadic rating discrepancy in QoL should draw the clinician's attention to patient depression and neuropsychiatric symptoms. Consideration should also be given to nature of patient-caregiver relationship when discordance between patient and caregiver assessments of QoL is observed.

Intrinsic capacity assessment using World Health Organization Integrated Care for Older People Step 1, and the association with frailty in community dwelling older adults.

AIM: This study aimed to investigate the association between intrinsic capacity (IC) and frailty in community-dwelling older adults. Specifically, we examined the utility of the World Health Organization's Integrated Care for Older People Step 1 screen for identifying frail older persons in the community. METHODS: This is a cross-sectional analysis of a community frailty screening initiative. IC loss was ascertained using the World Health Organization's Integrated Care for Older People Step 1 questions. The Clinical Frailty Scale was used to categorize participants as robust (Clinical Frailty Scale S1-3) or frail (Clinical Frailty Scale ≥4). Logistic regression was used to analyze the association of individual and cumulative IC losses with frailty, adjusting for confounders. Additionally, the diagnostic performance of using cumulative IC losses to identify frailty was assessed. RESULTS: This study included 1164 participants (28.2% frail). Loss in locomotion (adjusted odds ratio [AOR] 1.47, 95% CI 1.07-2.02), vitality (AOR 1.58, 95% CI 1.04-2.39), sensory (AOR 1.99, 95% CI 1.51-2.64) and psychological capacities (AOR 1.92, 95% CI 1.45-2.56) were significantly associated with frailty. Loss in more than three IC domains was associated with frailty. Using loss in at least three ICs identifies frailty, with sensitivity of 38.6%, specificity of 83.5% and positive predictive value of 47.4%. Using loss in at least four ICs improved specificity to 96.9%, and is associated with the highest positive predictive value of 57.6% and highest positive likelihood ratio of 3.55 for frailty among all cut-off values. The area under the receiver operating characteristic curve was 0.64 (95% CI 0.61-0.68). CONCLUSIONS: IC loss as identified through World Health Organization's Integrated Care for Older People Step 1 is associated with frailty community-dwelling older adults. Geriatr Gerontol Int 2024; 24: 457-463.

Improving nutrition care and diet intake for hospitalised older people at risk of malnutrition through a nurse-driven mealtime assistance bundle.

BACKGROUND: Poor dietary intake is common in hospitalised older people. A targeted mealtime intervention is needed to improve nutrition care and dietary intake, especially for those at risk of malnutrition. OBJECTIVES: This quality improvement project designed, implemented and evaluated a mealtime assistance bundle consisting of care measures driven by the hospital nursing team. The aims were to improve the mealtime care process to promote dietary intake of the hospitalised older people and to improve nursing staff's knowledge, attitude and practice in malnutrition. METHODS: This project adopted a pre-post design, targeting older people aged 65 years and above, who were admitted to a general medical unit in a regional hospital in Singapore. A mealtime assistance bundle consisting of seven care measures, using the acronym CANFEED, was implemented for older adults at risk of malnutrition. Outcome measures on the amount of dietary intake during meals through chart reviews and surveys of nursing staff using Malnutrition Knowledge, Attitudes and perceived Practices (M-KAP) questionnaire were performed before and after implementation. RESULTS: There were fewer older adults with poor intake in the post-implementation group than the pre-implementation group. Among those at risk of malnutrition, older adults in the post-implementation group had higher average intake of all provided meals as well as the protein-dense main dish. Significant improvements were noted in the total scores rated by the nursing staff in both the Knowledge-Attitude subscale and Practice subscale of the M-KAP questionnaire. CONCLUSIONS: Integrating a nurse-driven mealtime assistance bundle into usual care may have positive outcomes on nutritional intake of hospitalised older people at risk of malnutrition, and on knowledge, attitude and practice of hospital nurses in nutrition care. IMPLICATIONS FOR PRACTICE: Nurses play a critical role in nutrition care for hospitalised older people. Continuing efforts to improve nutritional intake of hospitalised older people should focus on staff education, building a multidisciplinary food-promoting culture and patient, family and community empowerment. More efficient clinical processes incorporating information technology with the EMR to support better nutrition care of the hospitalised older people are needed.

Using item response theory to estimate interpretation threshold values for the Frailty Index in community dwelling older adults.

BACKGROUND: Although the frailty index (FI) is designed as a continuous measure of frailty, thresholds are often needed to guide its interpretation. This study aimed to introduce and demonstrate the utility of an item response theory (IRT) method in estimating FI interpretation thresholds in community-dwelling adults and to compare them with cutoffs estimated using the receiver operating characteristics (ROC) method. METHODS: A sample of 1,149 community-dwelling adults (mean[SD], 68[7] years) participated in this cross-sectional study. Participants completed a multi-domain geriatric screen from which the 40-item FI and 3 clinical anchors were computed - namely, (i)self-reported mobility limitations (SRML), (ii)"fair" or "poor" self-rated health (SRH), and (iii) restricted life-space mobility (RLSM). Participants were classified as having SRML-1 if they responded "Yes" to either of the 2 questions regarding walking and stair climbing difficulty and SRML-2 if they reported having walking and stair climbing difficulty. Participants with a Life Space Assessment score <60 points were classified as having RLSM. Threshold values for all anchor questions were estimated using the IRT method and ROC analysis with Youden criterion. RESULTS: The proportions of participants with SRML-1, SRML-2, Fair/Poor SRH, and RLSM were 21 %, 8 %, 22 %, and 9 %, respectively. The IRT-based thresholds for SRML-2 (0.26), fair/poor SRH (0.29), and RLSM (0.32) were significantly higher than those for SRML-1 (0.18). ROC-based FI cutoffs were significantly lower than IRT-based values for SRML-2, SRH, and RLSM (0.12 to 0.17), and they varied minimally and non-systematically across the anchors. CONCLUSIONS: The IRT method identifies biologically plausible FI thresholds that could meaningfully complement and contextualize existing thresholds for defining frailty.

The prevalence patterns and risk factor profiles of poor muscle health and its associated components in multiethnic older Asians: The PIONEER study.

BACKGROUND: We aim to determine the multiethnic patterns of the prevalence and associated factors of poor muscle health and its associated components in older Chinese, Malays, and Indian Asian adults. METHODS: We included 2199 participants (mean age ± SD: 72.9 ± 8.3 years; 54.3% female) from the baseline assessment of the Population Health and Eye Disease Profile in Elderly Singaporeans (PIONEER; 2017-2022) cohort study. Poor muscle health was defined as the presence of either low muscle mass (DEXA), or low muscle strength (handgrip strength), or low physical performance (gait speed). Its components include poor muscle function (low muscle strength and/or low physical performance without low muscle mass), pre-sarcopenia (low muscle mass only), and any sarcopenia (low muscle mass with low muscle strength and/or low physical performance). Sociodemographic, clinical, and lifestyle factors were assessed using biochemistry, clinical tests, and validated questionnaires. Regression models were utilized to evaluate the independent risk factors of poor muscle health and its components. RESULTS: The national census-adjusted prevalence of poor muscle health (88%) was similar across the three ethnic groups. However, Chinese individuals had higher prevalence of pre-sarcopenia and any sarcopenia, and a lower prevalence of poor muscle function compared with Indians or Malays. We observed ethnic differences in modifiable risk factors (low physical activity, diabetes, osteoporosis, and obesity) of poor muscle health and its components. Although obesity was protective of pre-sarcopenia (RRR = 0.19, 95% CI: 0.11, 0.36) and any sarcopenia (RRR = 0.29, 95% CI: 0.18, 0.47) in the overall population and across ethnic groups, it was associated with 1.7 times (95% CI: 1.07, 2.67) the likelihood of poor muscle function in the entire population. CONCLUSIONS: Almost 90% of community dwelling Singaporean aged ≥60 years have poor muscle health across the three ethnic groups with ethnic disparities in modifiable risk factors, highlighting an urgent need for community-wide targeted interventions to promote muscle health.

Development and validation of a physical frailty phenotype index-based model to estimate the frailty index.

BACKGROUND: The conventional count-based physical frailty phenotype (PFP) dichotomizes its criterion predictors-an approach that creates information loss and depends on the availability of population-derived cut-points. This study proposes an alternative approach to computing the PFP by developing and validating a model that uses PFP components to predict the frailty index (FI) in community-dwelling older adults, without the need for predictor dichotomization. METHODS: A sample of 998 community-dwelling older adults (mean [SD], 68 [7] years) participated in this prospective cohort study. Participants completed a multi-domain geriatric screen and a physical fitness assessment from which the count-based PFP and the 36-item FI were computed. One-year prospective falls and hospitalization rates were also measured. Bayesian beta regression analysis, allowing for nonlinear effects of the non-dichotomized PFP criterion predictors, was used to develop a model for FI ("model-based PFP"). Approximate leave-one-out (LOO) cross-validation was used to examine model overfitting. RESULTS: The model-based PFP showed good calibration with the FI, and it had better out-of-sample predictive performance than the count-based PFP (LOO-R2, 0.35 vs 0.22). In clinical terms, the improvement in prediction (i) translated to improved classification agreement with the FI (Cohen's kw, 0.47 vs 0.36) and (ii) resulted primarily in a 23% (95%CI, 18-28%) net increase in FI-defined "prefrail/frail" participants correctly classified. The model-based PFP showed stronger prognostic performance for predicting falls and hospitalization than did the count-based PFP. CONCLUSION: The developed model-based PFP predicted FI and clinical outcomes more strongly than did the count-based PFP in community-dwelling older adults. By not requiring predictor cut-points, the model-based PFP potentially facilitates usage and feasibility. Future validation studies should aim to obtain clear evidence on the benefits of this approach.

Associations of height, weight, and body mass index with handgrip strength: A Bayesian comparison in older adults.

BACKGROUND & AIMS: Handgrip strength is commonly normalized or stratified by body size to define subgroup-specific cut-points and reference limits values. However, it remains unclear which anthropometric variable is most strongly associated with handgrip strength. We aimed to, in older adults with no self-reported mobility limitations, determine whether height, weight, and body mass index (BMI) were meaningfully associated with handgrip strength. METHODS: This cross-sectional study included community-dwelling ambulant participants, and we identified 775 older adults who reported no difficulty walking 100 m, climbing stairs, and rising from the chair. Handgrip strength was measured with a digital dynamometer. Bayesian linear regression was used to estimate the probabilities that the positive associations of height, weight, and BMI with handgrip strength exceeded 0 kg (the null value) and 2.5 kg (the clinically meaningful threshold value). RESULTS: Mean handgrip strength was 22.1 kg (SD, 4) for women and 32.9 kg (SD, 6) for men. Body height, weight, and BMI had >99.9% probabilities of a positive association with handgrip strength; however, the associations of per interquartile increase in body weight and BMI with handgrip strength had low probabilities (<5%) of exceeding the clinically meaningful threshold of 2.5 kg. In contrast, body height had the highest probability (99.6%) of a clinically meaningful association with handgrip strength: adjusting for age and gender, handgrip strength was 3.2 kg (95% CrI, 2.7 to 3.8) greater in older adults 1.61 m tall than in older adults 1.51 m tall. CONCLUSIONS: In a large sample of mobile-intact older adults, handgrip strength differed meaningfully by body height. Although requiring validation, our findings suggest that future efforts should be directed at normalizing handgrip strength by body height to better define subgroup-specific handgrip weakness. A web-based application (https://sghpt.shinyapps.io/ippts/) was created to allow interactive exploration of predicted values and reference limits of age-, gender-, and height-subgroups.

Estimating cutpoints of gait speed and sit-to-stand test values for self-reported mobility limitations in a cohort of community-dwelling older adults from Singapore: comparing receiver operating characteristic (ROC) analysis with adjusted predictive modelling.

OBJECTIVES: Clinical interpretability of the gait speed and 5-times sit-to-stand (5-STS) tests is commonly established by comparing older adults with and without self-reported mobility limitations (SRML) on gait speed and 5-STS performance, and estimating clinical cutpoints for SRML using the receiver operating characteristics (ROC) method. Accumulating evidence, however, suggests that the adjusted predictive modeling (APM) method may be more appropriate to estimate these interpretational cutpoints. Thus, we aimed to compare, in community-dwelling older adults, gait speed and 5-STS cutpoints estimated using the ROC and APM methods. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: This study analyzed data from 955 community-dwelling independently walking older adults (73%women) aged ≥60 years (mean, 68; range, 60-88). METHODS: Participants completed the 10-metre gait speed and 5-STS tests. Participants were classified as having SRML if they responded "Yes" to either of the 2 questions regarding walking and stair climbing difficulty. Cutpoints for SRML and its component questions were estimated using ROC analysis with Youden criterion and the APM method. RESULTS: The proportions of participants with self-reported walking difficulty, self-reported stair climbing difficulty, and SRML were 10%, 19%, and 22%, respectively. Gait speed and 5-STS time were moderately correlated with each other (r=-0.56) and with the self-reported measures (absolute r-values, 0.39-0.44). ROC-based gait speed cutpoints were 0.14 to 0.16 m/s greater than APM-based cutpoints (P < 0.05) whilst ROC-based 5-STS time cutpoints were 0.8 to 3.3 s lower than APM-based cutpoints (P < 0.05 for walking difficulty). Compared with ROC-based cutpoints, APM-based cutptoints were more precise and they varied monotonically with self-reported walking difficulty, self-reported stair climbing difficulty, and SRML. CONCLUSIONS AND IMPLICATIONS: In a sample of 955 older adults, our findings of precise and biologically plausible gait speed and 5-STS cutpoints for SRML estimated using the APM method indicate that this promising method could potentially complement or even replace traditional ROC methods.

Clinical practice for sarcopenia in Asia: Online survey by the Asian Working Group for Sarcopenia.

OBJECTIVE: This study aimed to (1) investigate the clinical practice for the management of sarcopenia among healthcare professionals in Asia, (2) determine the characteristics of clinical care provided by geriatricians versus by other healthcare professionals, and (3) clarify the awareness of sarcopenia. METHODS: From December 1 to 31, 2022, an online survey was completed by 1990 healthcare professionals in Asia. The survey comprises demographics and institutional characteristics, basic sarcopenia-related details, and sarcopenia-related assessment and treatment details. RESULTS: The mean respondent age was 44.2 ± 10.7 years, 36.4% of the respondents were women, and the mean years of experience in clinical practice were 19.0 ± 10.6 years. The percentages of respondents who were aware of the term "sarcopenia", its definition and the importance of its management were high, at 99.3%, 91.9%, and 97.2%, respectively. The percentages of respondents who had screened patients for, diagnosed patients with, and treated patients for sarcopenia were 42.4%, 42.9%, and 58.8%, respectively. Medical doctors had higher performance rates compared to allied health professionals (45.5% vs. 40.5% for screening, 56.8% vs. 34.5% for diagnosis, and 65.0% vs. 55.0% for treatment) (P < 0.001). Especially, among medical doctors, geriatricians had significantly higher rates compared to non-geriatricians (64.3% vs. 34.1% for screening; 76.7% vs. 44.8% for diagnosis; 82.7% vs. 54.4% for treatment, respectively) (P < 0.001). CONCLUSION: Although the importance of the concept and management of sarcopenia is well recognized, there is a gap in its detection and management in clinical practice between medical doctors and allied health professionals, and also between geriatricians and non-geriatricians. Many geriatricians collaborate with other healthcare professionals to appropriately manage sarcopenia. In the future, educating all medical staff on the proper management of sarcopenia is necessary.

Intrinsic capacity rather than intervention exposure influences reversal to robustness among prefrail community-dwelling older adults: A non-randomized controlled study of a multidomain exercise and nutrition intervention.

Background: The differential risk profiles associated with prefrailty may be attributable to underlying intrinsic capacity (IC). Objectives: We examine (i) effect of a multi-domain physical exercise and nutrition intervention on pre-frailty reversal in community-dwelling older adults at 1-year, and (ii) whether IC contributes to pre-frailty reversal. Methods: Prefrail participants in this non-randomized study were invited to attend a 4-month exercise and nutritional intervention following a frailty screen in the community. Prefrailty was operationalized as (i) FRAIL score 1-2 or (ii) 0 positive response on FRAIL but with weak grip strength or slow gait speed based on the Asian Working Group for Sarcopenia cut-offs. Participants who fulfilled operational criteria for prefrailty but declined enrolment in the intervention programme served as the control group. All participants completed baseline IC assessment: locomotion (Short Physical Performance Battery, 6-minute walk test), vitality (nutritional status, muscle mass), sensory (self-reported hearing and vision), cognition (self-reported memory, age- and education adjusted cognitive performance), psychological (Geriatric Depression Scale-15, self-reported anxiety/ depression). Reversal of prefrailty was defined as achieving a FRAIL score of 0, with unimpaired grip strength and gait speed at 1-year follow-up. Results: Of 81 participants (70.0 ± 6.6 years, 79.0% female), 52 participants (64.2%) were enrolled in the multi-domain intervention, and 29 participants (35.8%) who declined intervention constituted the control group. There was no difference in age, gender and baseline composite IC between groups. Reversal to robustness at 1-year was similar between intervention and control groups (30.8% vs. 44.8% respectively, p = 0.206). Reduced prevalence of depression was observed among participants in the intervention group at 1-year relative to baseline (7.8% vs. 23.1%, p = 0.022). In multiple logistic regression, intervention had no effect on prefrailty reversal, while higher composite IC exhibited reduced likelihood of remaining prefrail at 1-year (OR = 0.67, 95% CI 0.45-1.00, p = 0.049). Conclusion: Focusing only on the locomotion and vitality domains through a combined exercise and nutritional intervention may not adequately address component domain losses to optimize prefrailty reversal. Future studies should examine whether an IC-guided approach to target identified domain declines may be more effective in preventing frailty progression.

Screening accuracy of percentage predicted gait speed for prefrailty/frailty in community-dwelling older adults.

AIM: In order to account for the variability in gait speed due to demographic factors, an observed gait speed value can be compared with its predicted value based on age, sex, and body height (observed gait speed divided by predicted gait speed, termed "GS%predicted" henceforth). This study aimed to examine the screening accuracy of an optimal GS%predicted threshold for prefrailty/frailty. METHODS: This cross-sectional study included 998 community-dwelling ambulant participants aged >50 years (mean age = 68 years). Participants completed a multi-domain geriatric screen and a physical fitness assessment, from which the 10-m habitual gait speed, GS%predicted, Physical Frailty Phenotype (PFP) index, and 36-item Frailty Index (FI) were computed. RESULTS: Based on the FI, ~49% of participants had pre-frailty or frailty. The optimal threshold of GS%predicted (0.93) had greater screening accuracy than the 1.0 m/s fixed threshold for gait speed (AUC, 0.65 vs. 0.60; DeLong's P < 0.001). Replacing gait speed with GS%predicted in the PFP improved its overall discrimination (AUC, 0.70 vs. 0.67 of original PFP; DeLong's P < 0.001). CONCLUSIONS: Defining a "slow" gait speed by a GS%predicted value of <0.93 provided greater screening accuracy than the traditional 1.0 m/s threshold for gait speed. Our results also support the use of GS%predicted-derived PFP to identify older adults at risk of prefrailty/frailty. Geriatr Gerontol Int 2022; 22: 575-580.

Reference Ranges for Gait Speed and Sit-to-Stand Performance in a Cohort of Mobility-Intact Community-Dwelling Older Adults From Singapore.

OBJECTIVES: Slow gait speed and sit-to-stand performance are associated with adverse clinical outcomes in older adults. Identifying older adults with functional performance "below norms" is the first step toward prevention. We aimed to (1) examine the associations of age, body height, and gender with gait speed and sit-to-stand performance and (2) develop subgroup-specific reference ranges in older adults with no self-reported mobility limitations. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: This study analyzed data from 775 community-dwelling older adults who reported no difficulty walking 100 m, climbing stairs, and rising from the chair. METHODS: Gait speed and sit-to-stand performance were measured by the 10-m gait speed test and 5-times sit-to-stand test, respectively. Bayesian linear regression was used to derive 95% reference ranges for gait speed and sit-to-stand performance, defined by different levels of age, body height, and gender. RESULTS: Overall, 95% reference range was 0.89-1.79 m/s for habitual gait speed and 7.4-27.9 stands/30 s for sit-to-stand pace. Age had the highest posterior probability (>99%) of a meaningful association with both functional outcomes. Additionally, height was strongly associated with gait speed: a 10-cm increase in height was associated with 0.07 m/s (95% credible interval, 0.05-0.10) faster gait speed. For sit-to-stand test, the lower 95% reference range limits tended to be similar across gender and gender-specific height subgroups, owing to the associations of faster sit-to-stand pace with shorter height and male gender. Because extensive tables of reference ranges are impractical, a web-based application (https://sghpt.shinyapps.io/ippts/) is created to provide subgroup-specific reference ranges. CONCLUSIONS AND IMPLICATIONS: In a large sample of mobile-intact older adults, reference ranges for gait speed and sit-to-stand performance differed meaningfully by age. Furthermore, gait speed was stature dependent. Although requiring validation, our findings may be used to define subgroup-specific "below-range" values and to complement existing universal clinical cut points for gait speed and sit-to-stand performance.

Association of Monocyte Chemotactic Protein-1 and Dickkopf-1 with Body Composition and Physical Performance in Community-Dwelling Older Adults in Singapore.

OBJECTIVE: We aim to determine the association of monocyte chemotactic protein-1 (MCP-1) and dickkopft-1 (DKK-1) as potential biomarkers that may predict changes in body composition and physical performance in healthy older adults from Singapore. METHODS: Two-hundred community-dwelling older adults (mean age: 67.9 years; 68.5% females) were classified into elevated versus non-elevated groups based on quintile cut-offs of MCP-1 and DKK-1 levels (156.02 pg/mL and 606.31 pg/mL, respectively). Multiple linear regression was performed to examine the relationship between MCP-1 and DKK-1 with body composition and physical performance, adjusted for age, gender and ethnicity. RESULTS: MCP-1 was significantly associated with higher fat mass, fat mass index, percentage body fat, waist circumference and trunk-limb ratio for fat mass (all p<0.01), and repeated chair stand (p=0.004). DKK-1 was not associated with body composition and physical performance measures. Utilising the Asian Working Group for Sarcopenia (AWGS) 2019 criteria, there were 39 (19.5%) sarcopenia and 161 (80.5%) non-sarcopenia participants respectively, with MCP-1 levels significantly higher in sarcopenia compared with non-sarcopenia (p=0.046), but not for DKK-1 (p=0.525). CONCLUSIONS: Elevated MCP-1 are associated with changes in fat composition, physical performance and sarcopenia, suggesting its usefulness in identifying at-risk group with sarcopenic obesity.