Fall 2023 Newsletter

By Robin McAtee, PhD, RN, FACHE – Director

Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Wow, I can’t believe fall is here.  Summer, as usual flew by very quickly.  Activities with the AGEC and our statewide partners are picking up once again as the days get shorter and the nights get a little cooler!  The fall semester for our academic partners has also begun and health professions students are once again busy in class and in clinical environments – taking care of our older adults!!

This fall quarter I will be reviewing the final “M” of the age-friendly framework of care; mentation. Throughout this year, we have reviewed the overall concept of the 4M’s framework, the first “M” of “what Matters” (the cornerstone of the framework), Medication, and in the summer, we reviewed Mobility.  The last one is Mentation.  We all are familiar with the many aspects of mentation, but we will do a quick review as we fold it into our 4M’s framework of age-friendly care!

Mentation has many facets and is very complex as we all know.  However, we must do our best as healthcare professionals to prevent, identify, treat and manage any conditions related to mentation including the most common mentation issues with older adults; dementia, depression, and delirium. 

In general, we must support cognitive functioning, independence, and dignity.  We must also assess for modifiable contributors to cognitive impairment.  This might include chronic conditions such as cardiovascular diseases, obesity, and diabetes; medications, social life factors, lack of physical activities, poor diet and hydration, extraneous environment factors, excessive stress, lack of quality sleep, hearing loss, and many others.  Some are of course modifiable and some are not.  But any factor that is modifiable and can be addressed, can certainly affect mentation.

We should also ask them and their caregivers about any confusion, memory loss, or mood changes while considering the requirement for further evaluations.  We should also consider social referrals and community type referrals that might address factors such as loneliness, transportation, and dietary needs.  Other referrals might also be need to address financial stress and concerns.  In summary, many factors affect mentation and many are modifiable.  We must ascertain the difference and adjust factors that can improve quality of life and what matters to the older adult.

Again, this was just a quick overview of “Mentation”, and there is a lot more to learn and apply with this “M”, but I hope it helps to inform and remind us to use the 4 M’s and to always consider each “M” within the context of What Matters Most.  If you want to learn more, additional information can be found at

https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Summer 2023 Newsletter

Mohamad Salamah

Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP

Every few years, a panel is assigned by the American Geriatrics Society (AGS) to update the AGS Beers Criteria^® for Potentially Inappropriate Medications (PIM) for older adults (65 years or older). In 2023, the criteria was updated with a revised list of medications that can be harmful to older adults. Since most older adults are on at least one or more prescription medications, it’s important to identify possible drug-drug interactions or any harm medications can cause in chronic conditions that are often associated with older adults. The goal of the 2023 AGS Beers Criteria^® is to minimize the possible exposure of older adults to PIMs by educating clinicians and patients about evaluating if the risks of certain medications are justified in the use of older adults.¹

The AGS Beers Expert Panel divides the list into 5 different categories:

1. Medications considered as potentially inappropriate in all older adults

2. Medications potentially inappropriate in patients with certain diseases or syndromes 

3. Medications to be used with caution 

4. Potentially inappropriate drug-drug interactions 

5. Medications whose dosages should be adjusted based on renal function.²

The 5-category system is similar to the 2019 Beers Criteria^®.³ The 2023 panel consisted of 12 experts that were involved in different healthcare fields such as nursing, medicine, and pharmacy. They investigated evidence on individual drugs published between 2017 to 2022 to determine how to update the 2019 AGS Beers Criteria^® which was based on previous evidence. Both lists used the Delphi method to cast their opinion and reach a final decision regarding the drugs to include.^1,3

Notable changes are seen in the 2023 AGS Beers Criteria^® following the recent update from the panel. For example, aspirin, which was previously used regularly in primary prevention of cardiovascular disease, was moved from the “use with caution” table and is now deemed as category 1, which is a PIM not recommended for use in all older adults. Older adults who are already on aspirin as primary prevention of cardiovascular disease are recommended to stop taking it as the risk outweighs the benefit.^1,3 Key changes in anticoagulants are likely the biggest headline of the new update (See Box 1). Warfarin is now listed as a medication to be avoided unless direct oral anticoagulants like apixaban are contraindicated when an initial therapy is needed for venous thromboembolism (VTE) or nonvalvular atrial fibrillation (AF). Rivaroxaban is now considered a medication to avoid in older adults for long-term treatment of nonvalvular AF and VTE due to risk for bleeding; before this update it was listed as a ‘use with caution’ medication for older adults.

Changes also occurred in the class of anticholinergics, which should be avoided in older adults to reduce the cumulative anticholinergic burden that can cause an increased risk of falls, constipation, delirium and possibly dementia. In the 2019 criteria, all anticholinergics were listed together, but are now split up into the categories of Antihistamines, Central Nervous System (antiparkinson anticholinergics), and Gastrointestinal (antispasmodics).^{1, 3}

There were also changes in medications used for the treatment of diabetes. All sulfonylureas are now recommended to avoid in favor of newer antidiabetic agents to decrease the risk of prolonged hypoglycemia, cardiovascular death and stroke, which are more likely to occur with sulfonylureas. However, of the newer agents, sodium-glucose cotransporter-2 inhibitors are recommended to be used with caution due to the increased risk of euglycemic diabetic ketoacidosis and urogenital infections in older adults.¹

The 2023 AGS Beers Criteria^® can aid practicing clinicians as well as other healthcare professionals in deciding appropriate therapies for older adults; however, it should be noted that the criteria does not apply in the case of hospice. Additionally, the criteria are focused on medications that are available in the U.S. rather than worldwide.² This is important to address since there are other medications worldwide that can also prove to be more harmful than helpful to older adults which the AGS Beers Criteria^® may not cover. The goal for the 2023 AGS Beers Criteria^® remains to improve the quality of care and life for older adults by guiding healthcare professionals in selecting optimal medications for treating older adults.

References:

1. American Geriatrics Society 2023 updated AGS Beers Criteria^® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;1‐30. DOI: 10.1111/jgs.18372      
2. Meyer K. Mook H. What’s on tap: 2023 Beers Criteria update. Pharmacy Today July 2023. www.pharmacist.com › DesktopModules › EasyDNNNewsWhat’s on tap: 2023 Beers Criteria update – pharmacist.com (Accessed August 16, 2023)

Summer 2023 Newsletter

By Robin McAtee, PhD, RN, FACHE – Director

Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

This quarter I will be continuing my writing about the 4M’s framework of Age-Friendly care.  We have reviewed the overall concept of the 4M’s framework, the first “M” of “what Matters” (the cornerstone of the framework) and last quarter we reviewed Medication.  This summer quarter we will move on to Mobility.

As you can guess, “mobility” involves a LOT!  It is critical to what matters and can be greatly impacted by medications!  Here we can see how all of these “M’s” intertwine and are co-dependent.  So, when reviewing Mobility, we need to first assess, recognize and document limitations.  First, some factors that increase the mobility risk factors include; aged 65+, female, obesity, chronic physical conditions such as arthritis, diabetes and other joint conditions or injuries.  Risk factors also include mental conditions such as depression, dementia, delirium, to just name a few.  The main goal is to ensure that the older adult moves safely in every day circumstances to maintain function and do “What Matters” to them.  So next, one would screen for mobility limitations and then work to create safe everyday environments including the use of adaptive equipment when appropriate.

We also need to work with the entire geriatric team to consider the other 4 M’s such as assessing any medications that may sedate the older adult, cause postural hypotension, cause dizziness, or contribute to other factors that might impair mobility and therefore decrease their ability to do what Matters.  In addition, other appropriate measures might include a consult to physical and or occupational therapy.

Mobility is vital for us all to do what Matters, it is no different for an older adult.  However, with older adults, there are many more contributing factors and information that must be considered.

This was just a quick overview of “Mobility”, and there is a lot more to learn and apply with this “M”, but I hope it helps to inform and remind us to use the 4 M’s and to always consider each “M” within the context of What Matters Most.  If you want to learn more, additional information can be found at

https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Spring 2023 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Hello everyone, and I hope I can say Happy Spring and it sticks around!  As you know, for the past couple of quarters I have been discussing the 4M’s framework of Age-Friendly care.  We have reviewed the overall concept of the 4M’s framework and the first “M” of “what Matters” which is the cornerstone of the framework. This quarter, we will move on to another “M”, Medication. As well all know, older adults take more prescribed medications than any other age group in the United States. Many take medications to treat multiple chronic illnesses and others to help prevent certain illnesses or to improve function.  

Therefore, the “M” of medication first means that as the practitioner, you must have a complete list of all the medications that your patients are taking; over, behind, and around the counter! Examining their medications to increase their awareness about potential side effects and drug to drug interactions, while also identifying ways to potentially reduce the number of medications they are taking when possible. Practitioners, patients, caregivers, and family members all need to know and understand that as our bodies change with age, our bodies also process medications differently. In addition, older adult bodies react to drugs differently than younger bodies, even if they have been on that medication for decades. 

Medications used to treat one condition may also make another condition worse. For example, older adults with memory problems may have worsening symptoms caused by medicines used to treat another symptom or condition. Therefore, it is important that all providers who prescribe medications know about all of the medical conditions and medications that their patient is taking.  

That’s why expert attention to Medications—one of the “Ms” of age-friendly care—is such a critical part of an older adult’s care. Therefore, we can now add this to the cornerstone of age-friendly care, What Matters. So, when you are reviewing and/or prescribing medications, not only should you consider all that we have discussed here, but make sure to consider What Matters to the older adult. One medication may improve a condition or symptom they have, but how do the side effects, financial effects, or other “effects”, affect What Matters most to them? 

This was just a quick overview of “Medication”, and there is a lot more to learn and apply with this “M”, but I hope it helps to inform and remind us to use the 4 M’s and to always consider each “M” within the context of What Matters Most.  If you want to learn more, additional information can be found here.

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Winter 2023 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Happy New Year! Can you all believe it is 2023 and we have been enduring COVID and all that has entailed for almost three years? However, we are all learning to live with it better and getting out and enjoying things again. The AGEC programs are thriving and our community partners are busy once again. It is wonderful to see older adults congregating and enjoying each other’s company again! We are also having full classes where programs based on evidence are being taught and activities being enjoyed. In addition, as we begin this new year, our academic partners are working with health professions students to ensure many complete their degrees this spring. We can all look forward to having more healthcare professionals begin their careers knowing more about how to appropriately care for older adults.

This quarter, I want to talk to you a little more about what we started discussing last quarter, the 4M’s of Age-Friendly Care. I introduced that concept last quarter and this time I want to delve into one of those 4M’s a little more and subsequently discuss one more in-depth in each quarter this year.  The first one we will review here is “What Matters”.  This is what all the other “M’s” focus around. As I mentioned in the last Directors Desk, this is where the conversation with the patient, family, and caregiver(s) begins. The healthcare team should discuss the older adult’s health outcome goals and care preferences, including end-of-life care, across all settings. Their goals and preferences then direct the overall plan of care. Ideally, this should be asked at almost every visit, just to ensure priorities haven’t changed. What matters most to someone certainly changes with time, age, and of course life events. This month it might be caring for a disabled spouse, but if that spouse passes away, then what matters also changes, so as healthcare professionals, we need ask. 

What matters should be inclusive, individualized, holistic, person-centered, patient-centered, respectful, prognosis-centered, collaborative, responsive, integrative, and of course, achievable. It also helps clinicians to build trust, treat older adults with humility and respect, maintain a patient-centered approach, create effective and actionable healthcare conversations, and frequently decreases unwanted care and treatments. Knowing what matters drives patient care goals.  So just ask: what matters, what is most important to you in this stage of your life, and how can I, as a healthcare professional, help you achieve your goals?

This was just a quick overview of “What Matters”, but I hope helps to inform and remind us all of why we are healthcare professionals and why we should always ask and listen to our patients first. If you want to learn more, additional information can be found here.

If you would like more information or training regarding the 4M’s of Age-Friendly Care, please contact the AGEC.

Fall 2022 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Happy fall to everyone! I know most of us are very happy to see the trees turning and the temperatures dropping. The AGEC and partners have started fall programs and classes and are very busy. This quarter I want to talk a little more in-depth about the AGEC’s clinical focus on the 4M’s framework of Age-Friendly Care. 

In 2017, The John A. Hartford Foundation and the Institute for Healthcare Improvement (IHI), in partnership with the American Hospital Association and the Catholic Health Association of the United States, had a vision and plan to infuse healthcare with a new concept called age-friendly care. The IHI defined age-friendly care as care that “Follows an essential set of evidence-based practices; Causes no harm; and Aligns with What Matters to the older adult and their family or other caregivers”. Therefore, if a healthcare system wants to become certified as an Age-Friendly Health System, they must provide care that meets evidence-based elements of high-quality care, known as the “4Ms,” to all older adults in their system.  

The 4Ms are: What Matters, Medication, Mentation, and Mobility. The first M regarding What Matters is regarded as essential and if done properly, all of the M’s revolve around it. All care should center around what Matters most to the older adult.  This is where the conversation with the patient, family, and caregiver(s) begins. The healthcare team should discuss the older adult’s health outcome goals and care preferences, including end-of-life care, across all settings. Their goals and preferences then dictate the overall plan of care.  Medication, should be age-friendly and not compromise mentation, mobility or What Matters. Mentation is the next M where providers should work to prevent, identify, treat and manage dementia, delirium, depression, and other conditions that affect the mind. Finally, Mobility is considered. The team should ensure safe movement and function that supports what matters to the older adult and what promotes meaningful activities.  This was a simplified and quick summary of the age-friendly framework and I would encourage you all to learn more.  More information can be found at https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf.

The AGEC has a wonderful rural clinical partner that is essential to our success with implementing age-friendly care, ARcare. ARcare is a federally qualified healthcare clinic (FQHC) network that works tirelessly in rural communities to ensure patients are able to benefit from accessible, affordable, quality, routine medical care.  Services from ARcare include primary care, behavioral health, pharmacies, community outreach programs, and more. When approached in late 2018 about being part of the AGEC, ARcare staff were enthusiastic and embraced the concepts inherent in the 4M’s framework of Age-Friendly Care.  Since beginning the partnership in 2019, Dr. Leah Tobey, our AGEC Clinical Coordinator, has taught this framework in six ARcare rural clinics. She continues to update new staff, work on quality improvement projects, and helps with rural community projects. To date, the ARcare network has five clinics that are certified level I or II as Age-Friendly by the Institute for Healthcare Improvement. We are proud of ARcare and their work with making their care age-friendly and we would encourage all who provide care to older adults to consider these 4Ms. 

If you would like more information or training regarding the 4M’s of Age-Friendly care, please contact the AGEC.

Fall 2022 Newsletter

By Lisa C. Hutchison, Pharm.D., MPH, BCPS, BCGP
University of Arkansas for Medical Sciences (UAMS) College of Pharmacy

Weight loss is often identified during hospitalization when older adults are assessed. Up to 60% of hospitalized older adults are malnourished or at risk for malnutrition, and this is associated with threefold increased costs and co-morbidities such as pressure injuries, infections, and falls.1 Length of stay and mortality increase as a result. Appetite often diminishes when illness develops and patients are admitted to the hospital. Families and caregivers become more vigilant as their loved one has an acute illness, requesting interventions that would improve appetite and nutritional status.

Non-pharmacological methods often implemented during hospitalization to combat nutritional deficits usually include addition of protein/calorie supplements. An approach used less often is to liberalize the diet. For example, a low sodium diet is a standard order for individuals with cardiac disease. A low sodium diet can significantly decrease blood pressure in individuals with hypertension by 4.5mmHg/2.4mmHg on average,2 but a recent randomized controlled trial, SODIUM-HF, did not verify dietary sodium restriction to 1500mg/day was associated with a reduction in mortality or cardiovascular hospitalization/emergency department visits in ambulatory care patients over a year.3 Removing a dietary sodium restriction and encouraging family members and caregivers to select food items the patient likes should be considered. Mealtime is often a social event, and having family or friends eat along with the older adult can improve the amount of food ingested.

Careful review of a patient’s medication list may reveal drug therapy that is contributing to anorexia. Drugs well-known to cause anorexia include amiodarone, SSRI’s, SNRi’s, phenothiazines, opioids, acetylcholinesterase inhibitors, and digoxin.4 Drug-induced nausea may present with anorexia. Stopping these medications, or reducing them to their lowest effective dose, may aid in restoring a patient’s appetite. Another contributor may be drug-induced constipation which can present as anorexia. Finally, some medication regimens include a large number of oral tablets or capsules with a volume that equates to a small meal. A focused attempt to reduce pill burden or to spread out their administration may help to improve appetite.

Medications are sometimes used off-label to stimulate appetite and induce weight gain in older adults. Most commonly used are mirtazapine, megestrol, and dronabinol.4,5 Dronabinol works as a cannabinoid to increase appetite, but as would be expected, causes significant central nervous system side effects. Megestrol is approved by the US Food and Drug Administration for anorexia or cachexia associated with AIDS or cancer. As a synthetic progestin, it can increase appetite, however, small studies and retrospective data show mixed results with increasing weight or strength in older adults. So while it may cause increased dietary intake, any gain of weight is likely increased body fat. Megestrol can increase blood pressure, blood glucose, and risk for thromboembolism.

Mirtazapine is a popular choice for improving appetite due to its safety profile. This antidepressant is relatively well-tolerated with significant side effects of marked sedation, xerostomia, increased cholesterol, and constipation. Increased appetite as a side effect is reported in 17% of patients, therefore, clinicians began trying it in older adults for anorexia.6 Most studies have been in older adults with depression, and results were mixed. A retrospective study of hospitalized patients evaluating use of mirtazapine, megestrol and dronabinol showed improvement in percentage meal intake but no differences between these agents. A control group was not included so authors were unable to assess the effect of other changes, particularly the effect of improvement in admission disease/symptoms.7

So what is best practice? The Choosing Wisely campaign suggests we optimize social supports, provide feeding assistance, and clarify patient goals and expectations instead of prescribing appetite stimulants or high-calorie supplements for treatment of anorexia in older adults.8 Furthermore, we should first assess if this symptom is an adverse drug event of an already prescribed medication. Finally, as with all medications, if pharmacological interventions are subsequently tried, periodic assessment of benefit and risk is important to consider if the appetite stimulant should be continued.

References:

1. Shrader E, Baumgartel C, Gueldenzoph, et al. Nutritional status according to Mini Nutritional Assessment is related to functional status in geriatric patients—independent of health status. J Nutri Health Aging, 2014; 18:257-63.
2. Lai JS, Aung YN, Khalid Y, Cheah SC. Impact of different dietary sodium reduction strategies on blood pressure: a systematic review. Hypertens Res, 2022; doi: 10.1038/s41440-022-00990-5. Online ahead of print.
3. Ezekowitz JA, Colin-Ramirez E, Ross H, et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF):an international, open-label, randomized, controlled trial. Lancet, 2022; 399:1391-1400.
4. Cheung NC, Noviasky JA, Ulen KR, Brangman SA. Efficacy and safety of megestrol in the hospitalized older person. Sr Care Pharm, 2022; 37:284-92.
5. Fox CB, Treadway AK, Blaszczyk AT, Sleeper RB. Megestrol acetate and mirtazapine for the treatment of unplanned weight loss in the elderly. Pharmacotherapy, 2009; 29:383-97.
6. Mirtazapine In: Lexicomp® Wolters Kluwer Copyright 2022 UpToDate, Inc.
7. Howard ML, Hossaini R, Tolar C, Gaviola ML. Efficacy and safety of appetite-stimulating medications in the inpatient setting. Ann Pharmacother, 2019; 53:261-7.
8. American Geriatrics Society/American Board of Internal Medicine Foundation. Choosing Wisely. www.ChoosingWisely.org.

Summer 2022 Newsletter

By Robin McAtee, PhD, RN, FACHE, Director, Arkansas Geriatric Education Collaborative (AGEC), a Geriatric Workforce Enhancement Program (GWEP) at the University of Arkansas for Medical Sciences (UAMS) Donald W. Reynolds Institute on Aging (DWR IOA)

Wow, what a “hot” summer we are all experiencing.  Therefore, I want to send out a special “thank you” to all of you who are out there serving and caring for our older adults!  This is dangerous weather for anyone, especially for our vulnerable older adults.  So, “thank you” to all healthcare professionals who continue to serve!

Our academic partners have been very persistent in their work throughout the spring and summer and are working diligently to fulfill summer obligations while preparing for a new academic year.  So “thank you” also to our collaborators at ASU, UCA, Hendrix, and the Arkansas College of Health Education, we are looking forward to another exciting academic year with you and your students. 

The AGEC has also been busy over the past few months. We are very excited to reintroduce the hands-on Alzheimer’s & Dementia Experience which has been on hold since the beginning of the pandemic, early in 2020. We had our first program in May with Saline Memorial Behavioral Health and we had 30 healthcare participants. Another program is schedule for August!  Community programs were also busy in the spring and have continued this summer, both virtually and in-person. With a new collaboration with Arkansas Colleges of Health Education in Fort Smith, we have begun releasing a series on social media of 26 short videos in partnership their School of Occupational Therapy students and faculty, covering a variety of adaptive equipment for older adults around the home and their communities – click here to visit our Facebook page and see. We have also been very successful in the continuation of dementia support groups via phone, Zoom, and in-person where more than 130 caregivers were reached over the past quarter. AGEC Learn from Home Series continues where a different AGEC community program is presented every month via Zoom. We also continue our regular activities such as Ageless Grace, Tai Chi, and many evidence-based programs with our partners including UAMS Centers on Aging, CareLink AAA, and multiple senior centers.

Try to stay cool the rest of the summer!!

Summer 2022 Newsletter

By David Church, PhD, CSCS*D
Department of Geriatrics, College of Medicine
University of Arkansas for Medical Sciences

Skeletal muscle mass, function, and strength decline with increasing age, a condition that has been coined “sarcopenia”¹. Sarcopenia increases the risk of deleterious health conditions and represents a major financial cost to healthcare systems. Among older adults who are hospitalized, those with sarcopenia on admission are 5-fold more likely to incur higher hospital costs than those who do not.² The economic burden of sarcopenia on the US healthcare system is considerable, with one estimate of the total annual cost of hospitalization for sarcopenic individuals being USD $40.4 billion³. From a clinical practice perspective, individuals with sarcopenia are at a greater risk of falling, reduced mobility and independence, and 95% more likely to be hospitalized as compared to those without sarcopenia³.

The term sarcopenia, coined in 1989, refers to the loss of muscle mass¹. Since then, greater insights into muscle strength, mass, and function have developed. It has been demonstrated that low muscle mass is associated with weakness, and that weakness is strongly associated with function and disability. However, low muscle mass alone is weakly or not associated with function and disability^2–5. As a result, current sarcopenia definitions incorporate measures aimed at muscle mass, strength, and function. The majority of sarcopenia research focuses on prevention and treatment.  Of this work, there is even less attention given to the standardization of assessment and diagnostic criteria. Multiple working groups of experts have weighed in, including those previously mentioned^2,6,7; however, there are also the National Institute on Aging (NIA), the Foundation for the National Institutes of Health funded Sarcopenia Definitions and Outcomes Consortium (SDOC)⁴, and the Asian Working Group for Sarcopenia (AWGS)⁵. While important initiatives, the results have led to different definitions and clinical assessments for the same disease. Further, when looking into one working group, SDOC, the level of agreement amongst 13 different position statements varies widely⁴. Thus, uncertainty surrounding the definition and outcomes of sarcopenia is high even amongst international experts. Most striking is the fact that current diagnostic criteria and cutoffs only identify individuals with sarcopenia, NOT those “at risk” for sarcopenia. This is an important failing of the current diagnostic tests as these cut off points indicate the patient’s increased risk for falls, while independence, quality of life, and longevity are decreased^2–4,8,9. Further, the regression and management of sarcopenia becomes a major economic burden to the healthcare system³. At this point, the best possible outcome is to slow the progression of the disease. In fact, the recent Sarcopenia Definitions and Outcomes Consortium (SDOC) states that since low grip strength and usual gait speed are independent predictors of falls, mobility limitations, hip fractures, and mortality in community-dwelling older adults, they should be included in the definition of sarcopenia⁴. Thus, current techniques and diagnostic criteria can only identify sarcopenia after a physical/functional impairment has occurred. As a result, clinicians must treat and manage the disease, as opposed to identifying susceptible individuals and taking preventative steps. Stated differently, clinicians are hoping to slow the rate of decline rather than maintain or improve muscle health.

Skeletal muscle amino acid metabolism dictates muscle health and functionality. Altered amino acid metabolism lead to decrements in muscle mass, quality, and performance⁸. Our laboratory, as well as others, have documented that the circulating essential amino acids (EAA) response to protein ingestion determines muscle amino acid metabolism^10,11. This well-established phenomenon allows us characterize potential nutritional biomarkers following an EAA challenge in order to determine the state of muscle health. As no additional equipment will be required the proposed EAA challenge represents a potential low-cost solution to classifying patients’ skeletal muscle health. This initiative will leverage the well-established physiological role EAA play in muscle metabolism and health within the existing clinical infrastructure (i.e., basic phlebotomy procedures). The extrapolation of this work will be the development of a simple analytical tool that would provide clinicians the ability to discern alterations in muscle metabolism and health prior to a loss of function or overt development of sarcopenia.

References

1.            Rosenberg IH. Sarcopenia: origins and clinical relevance. J Nutr. 1997 May;127(5 Suppl):990S-991S. PMID: 9164280

2.            Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, Cooper C, Landi F, Rolland Y, Sayer AA, Schneider SM, Sieber CC, Topinkova E, Vandewoude M, Visser M, Zamboni M, Writing Group for the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), and the Extended Group for EWGSOP2. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16–31. PMCID: PMC6322506

3.            Goates S, Du K, Arensberg MB, Gaillard T, Guralnik J, Pereira SL. Economic Impact of Hospitalizations in US Adults with Sarcopenia. J Frailty Aging. 2019;8(2):93–99. PMID: 30997923

4.            Bhasin S, Travison TG, Manini TM, Patel S, Pencina KM, Fielding RA, Magaziner JM, Newman AB, Kiel DP, Cooper C, Guralnik JM, Cauley JA, Arai H, Clark BC, Landi F, Schaap LA, Pereira SL, Rooks D, Woo J, Woodhouse LJ, Binder E, Brown T, Shardell M, Xue QL, DʼAgostino RB, Orwig D, Gorsicki G, Correa-De-Araujo R, Cawthon PM. Sarcopenia Definition: The Position Statements of the Sarcopenia Definition and Outcomes Consortium. J Am Geriatr Soc. 2020 Jul;68(7):1410–1418. PMID: 32150289

5.            Chen LK, Woo J, Assantachai P, Auyeung TW, Chou MY, Iijima K, Jang HC, Kang L, Kim M, Kim S, Kojima T, Kuzuya M, Lee JSW, Lee SY, Lee WJ, Lee Y, Liang CK, Lim JY, Lim WS, Peng LN, Sugimoto K, Tanaka T, Won CW, Yamada M, Zhang T, Akishita M, Arai H. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc. 2020 Mar;21(3):300-307.e2. PMID: 32033882

6.            Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, Martin FC, Michel JP, Rolland Y, Schneider SM, Topinková E, Vandewoude M, Zamboni M, European Working Group on Sarcopenia in Older People. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul;39(4):412–423. PMCID: PMC2886201

7.            Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, Compher C, Correia I, Higashiguchi T, Holst M, Jensen GL, Malone A, Muscaritoli M, Nyulasi I, Pirlich M, Rothenberg E, Schindler K, Schneider SM, de van der Schueren M a. E, Sieber C, Valentini L, Yu JC, Van Gossum A, Singer P. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017 Feb;36(1):49–64. PMID: 27642056

8.            Moore DR. Keeping Older Muscle “Young” through Dietary Protein and Physical Activity12. Adv Nutr. 2014 Sep 1;5(5):599S-607S. PMCID: PMC4188243

9.            Mitchell WK, Williams J, Atherton P, Larvin M, Lund J, Narici M. Sarcopenia, dynapenia, and the impact of advancing age on human skeletal muscle size and strength; a quantitative review. Front Physiol. 2012;3:260. PMCID: PMC3429036

10.          Church DD, Hirsch KR, Park S, Kim IY, Gwin JA, Pasiakos SM, Wolfe RR, Ferrando AA. Essential Amino Acids and Protein Synthesis: Insights into Maximizing the Muscle and Whole-Body Response to Feeding. Nutrients. 2020 Dec 2;12(12). PMCID: PMC7760188

11.          Pennings B, Boirie Y, Senden JMG, Gijsen AP, Kuipers H, van Loon LJC. Whey protein stimulates postprandial muscle protein accretion more effectively than do casein and casein hydrolysate in older men. Am J Clin Nutr. 2011 May;93(5):997–1005. PMID: 21367943