Assessing Frailty in the General Medical Clinic of a Tertiary Hospital in Northern Malaysia: The FRAIL Scale or the Clinical Frailty Scale

Background. Frailty potentially influences clinicians’ decision making on treatment provided they can select the appropriate assessment tools. This study aims to investigate the difference between the FRAIL scale and the Clinical Frailty Scale (CFS) in assessing frailty among community-dwelling older adults attending the General Medical Clinic (GMC) in Seberang Jaya Hospital, Penang, Malaysia. Methods. The medical records of 95 older patients (age ≥ 65) who attended the GMC from 16 December 2019 to 10 January 2020 were reviewed. Frailty was identified using the FRAIL scale and the CFS. Patient characteristics were investigated for their association with frailty and their difference in the prevalence of frailty by the FRAIL scale and CFS. Results. The CFS identified nonsignificant higher prevalence of frailty compared to the FRAIL scale (21/95; 22.1% vs. 17/95; 17.9%, ratio of prevalence = 1.235, p = 0.481 ). Minimal agreement was found between the FRAIL scale and the CFS (Kappa = 0.272, p < 0.001 ). Three out of 5 components of the FRAIL scale (resistance, ambulation, and loss of weight) were associated with frailty by the CFS. Higher prevalence of frailty was identified by the CFS in those above 70 years of age. The FRAIL scale identified more patients with frailty in ischaemic heart disease patients. Conclusion. Patient characteristics influenced the choice of the frailty assessment tool. The FRAIL scale and the CFS may complement each other in providing optimized care to older patients who attended the GMC.

Determination of Cutoff Values for the Screening of Osteosarcopenia in Obese Postmenopausal Women

Osteosarcopenic obesity (OSO) describes the concurrent presence of obesity, low bone mass, and low muscle mass in an individual. Currently, no established criteria exist to diagnose OSO. We hypothesized that obese individuals require different cut-points from standard cut-points to define low bone mass and low muscle mass due to their higher weight load. In this study, we determined cutoff values for the screening of osteosarcopenia (OS) in obese postmenopausal Malaysian women based on the measurements of quantitative ultrasound (QUS), bioelectrical impedance analysis (BIA), and functional performance test. Then, we compared the cutoff values derived by 3 different statistical modeling methods, (1) receiver operating characteristic (ROC) curve, (2) lowest quintile of the study population, and (3) 2 standard deviations (SD) below the mean value of a young reference group, and discussed the most suitable method to screen for the presence of OS in obese population. One hundred and forty-one (n = 141) postmenopausal Malaysian women participated in the study. Bone density was assessed using calcaneal quantitative ultrasound. Body composition was assessed using bioelectrical impedance analyzer. Handgrip strength was assessed using a handgrip dynamometer, and physical performance was assessed using a modified Short Physical Performance Battery test. ROC curve was determined to be the most suitable statistical modeling method to derive the cutoffs for the presence of OS in obese population. From the ROC curve method, the final model to estimate the probability of OS in obese postmenopausal women is comprised of five variables: handgrip strength (HGS, with area under the curve (AUC) = 0.698 and threshold ≤ 16.5 kg), skeletal muscle mass index (SMMI, AUC = 0.966 and threshold ≤ 8.2 kg/m2), fat-free mass index (FFMI, AUC = 0.946 and threshold ≤ 15.2 kg/m2), broadband ultrasonic attenuation (BUA, AUC = 0.987 and threshold ≤ 52.85 dB/MHz), and speed of sound (SOS, AUC = 0.991 and threshold ≤ 1492.15 m/s). Portable equipment may be used to screen for OS in obese women. Early identification of OS can help lower the risk of advanced functional impairment that can lead to physical disability in obese postmenopausal women.

Postural Changes on Heart Rate Variability among Older Population: A Preliminary Study

Objective. This study aims to investigate an association between body postures and autonomic nervous system (ANS) responses through analysis of short-term heart rate variability (HRV) data obtained through electrocardiography. Methods. Forty older individuals were recruited to form the sample. HRV measurements were taken in three positions—sitting, supine, and standing—and compared. Results. Results demonstrated statistically significant differences in the HRV parameters used to examine the parasympathetic nervous system (PNS) and the sympathetic nervous system (SNS), specifically in the measurements obtained from the sitting position and the supine position ( P < 0.001 for PNS and P = 0.011 for SNS). The differences in these parameters were, however, negligible between the sitting and the standing positions. Moreover, the ANS responses obtained in the sitting position were strongly and positively correlated with those in the standing position (r = 0.854 for PNS and r = 0.794 for SNS). These results suggested that the PNS and SNS parameters obtained while sitting were likely to be affected by orthostatic hypotension in much the same way as those in the standing position, as compared to the supine position. Conclusions. As such, sitting may not be the best position for older individuals in the assessment of their autonomic responses, whereas the supine position is recommended as the baseline posture in the old-age population. These findings are useful for future research in clinical settings that require accuracy in the ANS responses as determined by the HRV measurements.

Nasogastric Tube Feeding in Older Patients: A Review of Current Practice and Challenges Faced

Nasogastric tube feeding is an essential way of delivering enteral nutrition when the oral route is insufficient or unsafe. Malnutrition is recognised as a reversible factor for sarcopenia and frailty. It is therefore crucial that malnutrition is treated in older inpatients who have dysphagia and require enteral nutrition. Despite five National Patient Safety Alerts since 2005, “Never Events” related to nasogastric feeding persist. In addition to placement errors, current practice often leads to delays in feeding, which subsequently result in worse patient outcomes. It is crucial that tube placement is confirmed accurately and in a timely way. Medical advancements in this area have been slow to find a solution which meets this need. In this paper, we provide an updated review on the current use of feeding nasogastric tubes in the older population, the issues associated with confirming correct placement, and innovative solutions for improving safety and outcomes in older patients.

Sarcopenia and Its Relationships with Depression, Cognition, and Physical Activity in Thai Community-Dwelling Older Adults

Background. Age-related sarcopenia is associated with physical decline, including poor functional capacity, lack of physical activity, problems with activities of daily living, and disability. However, little is known about the association between mental health problems and cognitive function in older adults with sarcopenia. Therefore, this study explored community-dwelling older adults’ sarcopenia prevalence and related associations with depression, cognitive performance, and physical activity. Methods. This cross-sectional study included 330 community-dwelling older adults (66.85 ± 5.54 years, 76.06% female). Based on the Asian Working Group for Sarcopenia guidelines, gait speed, muscle mass, and handgrip were assessed. All participants responded to a set of questionnaires (e.g., Global Physical Activity Questionnaire, cognitive assessment, and depression scale). Logistic regression analysis and multivariate logistic regression were used to determine independent predictors for sarcopenia. Results. Overall, 16.1% of the participants were identified as having sarcopenia. Further, advanced age (i.e., mean age ≥ 70 years; odds ratio: 4.67), high depression scores (odds ratio: 2.09), mild cognitive impairment (odds ratio: 0.22), and low physical activity levels (odds ratio: 1.96) were significant associated risk factors for sarcopenia after adjusting for age, sex, and educational level. Conclusions. Sarcopenia can lead to adverse health outcomes (i.e., depressive symptoms, cognitive decline, and low physical activity) in older adults.

Creation and Implementation of a Large-Scale Geriatric Interprofessional Education Experience

The care of the older adult requires an interprofessional approach to solve complex medical and social problems, but this approach is difficult to teach in our educational silos. We developed an interprofessional educational session in response to national requests for innovative practice models that use collaborative interprofessional teams. We chose geriatric fall prevention as our area of focus as our development of the educational session coincided with the development of an interprofessional Fall Risk Reduction Clinic. Our aim of this study was to evaluate the number and type of students who attended a pilot and 10 subsequent educational sessions. We also documented the changes that occurred due to a Plan-Do-Study-Act (PDSA) rapid-cycle improvement model to modify our educational session. The educational session evolved into an online presession self-study didactic and in-person educational session with a poster/skill section, an interprofessional team simulation, and simulated patient experience. The simulated patient experience included an interprofessional fall evaluation, team meeting, and presentation to an expert panel. The pilot session had 83 students from the three sponsoring institutions (hospital system, university, and medical university). Students were from undergraduate nursing, nurse practitioner graduate program, pharmacy, medicine, social work, physical therapy, nutrition, and pastoral care. Since the pilot, 719 students have participated in various manifestations of the online didactic plus in-person training sessions. Ten separate educational sessions have been given at three different institutions. Survey data with demographic information were available on 524 participants. Students came from ten different schools and represented thirteen different health care disciplines. A large-scale interprofessional educational session is possible with rapid-cycle improvement, inclusion of educators from a variety of learning institutions, and flexibility with curriculum to accommodate learners in various stages of training.

The Utility of Psoas Muscle Assessment in Predicting Frailty in Patients Undergoing Transcatheter Aortic Valve Replacement

Background. The rise in an ageing population has resulted in an increase in the prevalence of aortic stenosis. With the advent and rapid expansion in the use of transcatheter aortic valve replacements (TAVRs), patients with severe aortic stenosis, traditionally thought too high risk for surgical intervention, are now being treated with generally favourable results. Frailty is an important factor in determining outcome after a TAVR, and an assessment of frailty is fundamental in the identification of appropriate patients to treat. Objective. The objective of the study was to identify if the psoas muscle area is associated with frailty in TAVR patients and outcome after intervention. Method. In this prospective study, we measured outcomes of 62 patients who underwent TAVR procedures against the psoas muscle area and the Reported Edmonton Frail Scale (REFS). Our aim was to assess if psoas muscle assessment can be used as a simple method to predict frailty in our population group. Results. A total of 60 patients met the study criteria. Mean psoas-lumbar vertebral index was 0.61, with a lower value in the frail group. There was not a statistically significant correlation between the psoas measures, REFS score (indicative of frailty), and mortality. However, there was a statistically significant relationship between the psoas size and REFS score (p=0.043). Conclusion. Psoas assessment can be useful in providing additional information when planning for patients to undergo a TAVR and can be used as a screening tool to help identify frail patients within this high-risk group.

Delayed Disclosure of HIV Status and Lack of Resources Affect Older Persons during Care of Adult Family Members with AIDS-Related Illness in Rural Mpumalanga, South Africa

Purpose. This paper examines the older persons’ knowledge of HIV and AIDS and explores the effect of delayed disclosure of HIV status and lack of resources during care. Methods. The study site was health facilities in Thembisile Hani subdistrict, Mpumalanga Province, South Africa. Older persons aged 60 years and above were selected using purposive sampling for in-depth interviews. Thematic analysis was used to analyse the data. Results. Providing physical care to sick adults is labour intensive for the already weak older persons. They undertake the caring role within constraints arising from lack of resource such as gloves, diapers, and soap with which to perform the caring role. Taking care of the sick needed resources for specialized care and money for transport to the health facilities. This put a strain on the finances and rendered the older persons food insecure. Furthermore, disclosure of HIV status was delayed, and some older persons cared for the sick adult children without knowing that they were HIV-infected and had AIDS-related illnesses. The nondisclosure of their HIV status by the sick prevented them from taking precautionary measures to prevent the risk of infection during the provision of care. This was heightened by the limited knowledge of HIV/AIDS of the older persons. Conclusion. Older persons undertake the caring role with diligence under trying conditions due to lack of resources and the nondisclosure of HIV status of the adult children they take care of. Healthcare workers should educate older persons to take preventive precautionary measures when caring for family members even when there is no suspicion of HIV infection. In addition, access to the incapacity grants provided for individuals sick with AIDS-related illnesses could relieve the older persons from financial constraints.

Carotid Disease and Ageing: A Literature Review on the Pathogenesis of Vascular Senescence in Older Subjects

Aging is a natural process that affects all systems of the human organism, leading to its inability to adapt to environmental changes. Advancing age has been correlated with various pathological conditions, especially cardiovascular and cerebrovascular diseases. Carotid artery (CA) is mainly affected by age-induced functional and morphological alterations causing atheromatous disease. The evolvement of biomedical sciences has allowed the elucidation of many aspects of this condition. Symptomatic carotid disease (CD) derives from critical luminar stenosis or eruption of an atheromatous plaque due to structural modifications of the vessels, such as carotid intima-media thickening. At a histologic level, the aforementioned changes are mediated by elastin fragmentation, collagen deposition, immune cell infiltration, and accumulation of cytokines and vasoconstrictors. Underlying mechanisms include chronic inflammation and oxidative stress, dysregulation of cellular homeostatic systems, and senescence. Thus, there is an imbalance in components of the vessel wall, which fails to counteract exterior stress stimuli. Consequently, arterial relaxation is impaired and atherosclerotic lesions progress. This is a review of current evidence regarding the relationship of aging with vascular senescence and CD. A deeper understanding of these mechanisms can contribute to the production of efficient prevention methods and targeted therapeutic strategies.

Sarcopenia: Influence of Regional Skeletal Muscle Cutoff Points and Fat-Free Mass in Older Mexican People—A Pilot Study

Background. Variation in the prevalence of sarcopenia is related to the skeletal muscle index cutoff points applied. The objective of this pilot study was to examine the recruitment process for testing different sarcopenia definitions (ASMI cutoffs) in older Mexican adults. It explored whether the prevalence of sarcopenia decreased by applying ethnic- and gender-specific, DXA-derived appendicular skeletal muscle index (ASMI)-cutoff points in the definitions, as well as some associated factors in a sample of community-dwelling older Mexican people. Methods. This is a pilot feasibility study that included a convenience sample of 217 community-dwelling older adults. Volunteers underwent DXA measurements and an assessment of functional status based on hand grip strength and physical performance. Six definitions were formed based on the 2010 EWGSOP criteria, but using different cutoff points for each of the three components, including regional cutoff points for ASMI derived from young Mexican adults. Several risk factors for sarcopenia were also assessed. Results. The prevalence of sarcopenia varied according to the different definitions applied. The lowest level was found with the definition that applied regional ASMI-cutoff points (p<0.01). The sarcopenic older adults had significant lower body weight, fat mass, and fat-free mass (FFM) than the nonsarcopenic subjects. The risk of sarcopenia increased with age and low FFM (p<0.001). Conclusion. The present study demonstrates the feasibility of the main study, and our data support the notion that using regional ASMI cutoff points resulted in a low prevalence of sarcopenia. Therefore, it is preferable to estimate the prevalence of this condition using ethnic- and gender-specific cutoff points and to explore associated factors such as low FFM.