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Background: Screening tools such as calf circumference (CC) and Yubi-wakka (finger-ring) test have been recognized as effective tools by Asian Working Group for Sarcopenia 2019 (AWGS'19) for sarcopenia screening but their comparative agreement, diagnostic performance and validity are unclear., Objectives: This study aims to determine: (i)agreement between calf and finger-ring circumference, (ii)diagnostic performance for low muscle mass and AWGS'19 sarcopenia diagnosis, (iii)correlation with muscle mass, strength, and physical performance, and (iv)association with frailty, life space mobility and physical activity., Methods: We studied 187 healthy community-dwelling older adults (mean age=66.8+7.0years) from the GERILABS-2 study. CC was measured via (i) both calves in sitting and standing positions, and (ii) Yubi-wakka test by encircling the thickest part of the non-dominant calf with index fingers and thumbs of both hands. We performed Cohen's kappa to check for agreement, area under receiver operating characteristic curve (AUC) to compare diagnostic performance, partial correlations adjusted for age and gender to compare convergent validity, and logistic regression to determine predictive validity for outcome measures., Results: Sarcopenia prevalence was 24.0% (AWGS'19). Yubi-wakka identified 16.6% of participants as screen-positive ("smaller"), showing moderate agreement only with non-dominant sitting CC measurements (k=0.421,p<0.001) and having lower diagnostic performance in determining low muscle mass (AUC=0.591 vs 0.855-0.870,p<0.001; sensitivity=57.1% vs 75.5-90.8%; specificity=58.4% vs 70.8-80.9%) and sarcopenia diagnosis (AUC=0.581 vs 0.788-0.818,p<0.001; sensitivity=55.6% vs 57.5-71.8%; specificity=74.4% vs 75.6-88.9%) compared to CC measurements. Yubi-wakka correlated significantly with muscle mass, grip strength and knee extension but not physical performance. When adjusted for age, gender and hypertension, Yubi-wakka was significantly associated with frailty (OR=3.96,95%CI:1.09-14.38), life space mobility (OR=2.38,95%CI:1.08-5.24) and physical activity (OR=2.50,95%CI:1.07-5.86)., Discussion and Conclusions: Yubi-wakka provides a self-administered, low-cost and practicable community screening tool for sarcopenia. Our study affirmed the convergent and predictive validity of Yubi-wakka, albeit with lower sensitivity and specificity in diagnostic performance compared to CC measurements., Competing Interests: The researchers claim no conflicts of interest.

Competing Interests: None to declare.

Background: Poor oral health is known to be associated with adverse outcomes, but the frequency and impact of poor oral health on older adults in the acute inpatient setting has been less well studied., Objectives: We examined the association between oral health, frailty, nutrition and functional decline in hospitalized older adults., Design: Retrospective cross-sectional study., Setting and Participants: We included data from 465 inpatients (mean age 79.2±8.3 years) admitted acutely to a tertiary hospital., Methods: We evaluated oral health using the Revised Oral Assessment Guide (ROAG), frailty using the Clinical Frailty Scale (CFS), malnutrition risk using the Nutritional Screening Tool (NST) and functional status using a modified Katz Activities of Daily Living (ADL) scale. We examined cross-sectional associations of oral health with frailty, malnutrition risk and functional decline on admission, followed by multivariate logistic regression models evaluating the association between poor oral health and the aforementioned outcomes., Results: 343 (73.8%), 100 (21.5%) and 22 (4.7%) were classified as low, moderate and high risk on the ROAG, respectively. Poorer oral health was associated with greater severity of frailty, functional decline on admission and malnutrition risk. Abnormalities in ROAG domains of voice changes, swallowing difficulty, xerostomia, lips and tongue appearance were more frequently present at greater severity of frailty. Poor oral health was associated with frailty [odds ratio (OR): 1.76, 95% confidence interval (CI) 1.05-2.97; P=0.034]; malnutrition risk [OR: 2.76, 95% CI 1.46-5.19, P=0.002] and functional decline [OR: 1.62, 95% CI 1.01-2.59, P=0.046]., Conclusions: Poor oral health is significantly associated with frailty, malnutrition risk and functional decline in older inpatients. Oral health evaluation, as part of a comprehensive geriatric assessment may be a target for interventions to improve outcomes. Further research including longitudinal outcomes and effectiveness of specific interventions targeted at oral health are warranted in older adults in the inpatient setting., Competing Interests: All the authors have no conflict of interest or financial disclosure of note.

Background: The Emergency Department Interventions for Frailty (EDIFY) program was developed to deliver early geriatric specialist interventions at the Emergency Department (ED). EDIFY has been successful in reducing acute admissions among older adults., Objectives: We aimed to examine the effectiveness of EDIFY in improving health-related quality-of-life (HRQOL) and length of stay (LOS), and evaluate EDIFY's cost-effectiveness., Design: A quasi-experiment study., Setting: The ED of a 1700-bed tertiary hospital., Participants: Patients (≥85 years) pending acute hospital admission and screened by the EDIFY team to be potentially suitable for discharge or transfer to low-acuity care areas., Intervention: EDIFY versus standard-care., Measurements: Data on demographics, comorbidities, premorbid function, and frailty status were gathered. HRQOL was measured using EQ-5D-5L over 6 months. We used a crosswalk methodology to compute Singapore-specific index scores from EQ-5D-5L responses and calculated quality-adjusted life-years (QALYs) gained. LOS and bills in Singapore-dollars (SGD) before subsidy from ED attendances (including admissions, if applicable) were obtained. We estimated average programmatic EDIFY cost and performed multiple imputation (MI) for missing data. QALYs gained, LOS and cost were compared. Potential uncertainties were also examined., Results: Among 100 participants (EDIFY=43; standard-care=57), 61 provided complete data. For complete cases, there were significant QALYs gained at 3-month (coefficient=0.032, p=0.004) and overall (coefficient=0.096, p=0.002) for EDIFY, whilst treatment cost was similar between-groups. For MI, we observed only overall QALYs gained for EDIFY (coefficient=0.102, p=0.001). EDIFY reduced LOS by 17% (Incident risk ratio=0.83, p=0.015). In a deterministic sensitivity analysis, EDIFY's cost-threshold was SGD$2,500, and main conclusions were consistent in other uncertainty scenarios. Mean bills were: EDIFY=SGD$4562.70; standard-care=SGD$5530.90. EDIFY's average programmatic cost approximated SGD$469.30., Conclusions: This exploratory proof-of-concept study found that EDIFY benefits QALYs and LOS, with equivalent cost, and is potentially cost-effective. The program has now been established as standard-care for older adults attending the ED at our center., Competing Interests: None declared by the authors.

Objectives: To present the local evidence and final recommendations of the Clinical Practice Guidelines workgroup convened by the Chapter of Geriatricians and the Society for Geriatric Medicine Singapore. The aim is to develop contextualized evidence-based recommendations that facilitate adoption of the Asian Working Group for Sarcopenia (AWGS) 2019 consensus into current practice in Singapore., Methods: The workgroup drew upon the AWGS'2019 consensus, updated literature review of Singapore studies till 31 Dec 2020, and evidence from recent systematic reviews. From 40 local studies included for data extraction, we constructed evidence tables organized as: definition and epidemiology; diagnosis and evaluation; and treatment and intervention. Twenty recommendations - case-finding, diagnosis, treatment, prevention, research - were developed, and graded for strength and quality using the GRADE approach. Consensus from an expert panel(N=23) was achieved after two rounds of the modified Delphi process., Results: The local prevalence of sarcopenia among community-dwelling older adults ranged from 13.6% to 25%. Most studies adopted the AWGS'2019 and AWGS'2014 criteria. Reported case finding tools include SARC-F, calf circumference (CC) and SARC-CalF. Gender-specific AWGS cut-offs for appendicular skeletal mass were used to define low muscle mass. Different protocols and dynamometers were used to assess handgrip strength, whilst gait speed and 5-times chair stand were commonly used to assess physical performance., Recommendations: We conditionally recommend a case-finding approach in at-risk older adults using validated case-finding tools. Screen-positive individuals should be assessed for 'possible sarcopenia' and underlying causes. For diagnosis, we conditionally recommend using the AWGS'2019 algorithm, and dual-energy X-ray absorptiometry when necessary to determine low lean mass for a confirmatory diagnosis of sarcopenia. For treatment, we strongly recommend resistance-based exercises and conditionally recommend a quality protein-rich diet/protein supplementation, with Vitamin D supplementation for insufficiency (<30 micrograms/L). For prevention, we recommend regular resistance-based physical activity and adequate protein intake (≥1.0g/kg bodyweight). We encourage more research to address local evidence gaps., Competing Interests: None declared by all authors.

Background: Sarcopenia is an emerging disease that adversely impacts outcomes of older adults across the spectrum of fragility fractures. Few studies have examined sarcopenia in upstream fragility fractures such as the distal radius. Understanding the state of current evidence is essential in defining a research agenda in this critical area of sentinel distal radius fractures and sarcopenia., Objectives: The aim of this scoping review was to summarize existing literature on sarcopenia in distal radius fracture in older adults, and to identify research areas and gaps to guide future studies., Methods: We utilized the 5-stage framework of Arksey and O'Malley. We searched studies from 2010 to 2020 relating to «Sarcopenia» and «Distal radius fractures» in major databases. Two reviewers independently screened articles for inclusion and conducted full text reviews of shortlisted articles. We extracted data on research areas, key findings, and study limitations., Results: Thirteen studies met the inclusion and exclusion criteria. They covered the areas of epidemiology (N=9), risk factors (N=4), basic science (N=2), outcomes (N=1), and diagnostic modalities (N=1). There were no studies on screening/case finding, prognostic scoring, intervention, or health economics. Identified limitations included the lack of clear definition and diagnostic criteria for sarcopenia, and lack of, or inappropriate, control group. Majority of studies were retrospective or cross-sectional in study design., Conclusions: This scoping review on sarcopenia in distal radius fractures highlighted gaps in research areas and in the rigor of studies conducted, and the need for more prospective cohort and interventional studies. Building upon current consensus criteria, we propose setting a research agenda along the timeline of sarcopenia management, from screening through to intervention and follow-up, which will inform future research in this early disease cohort of fragility fractures., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest Author contribution statement: M.Y and H.N drafted the manuscript. All authors critically appraised and contributed to manuscript revision, approved the final version of the letter, and agree to be accountable for all aspects of the work.

Background: Despite emerging evidence about the association between social frailty and cognitive impairment, little is known about the role of executive function in this interplay, and whether the co-existence of social frailty and cognitive impairment predisposes to adverse health outcomes in healthy community-dwelling older adults., Objectives: We aim to examine independent associations between social frailty with the MMSE and FAB, and to determine if having both social frailty and cognitive impairment is associated with worse health outcomes than either or neither condition., Methods: We studied 229 cognitively intact and functionally independent community-dwelling older adults (mean age= 67.2±7.43). Outcome measures comprise physical activity; physical performance and frailty; geriatric syndromes; life space and quality of life. We compared Chinese Mini Mental State Examination (CMMSE) and Chinese Frontal Assessment Battery (FAB) scores across the socially non-frail, socially pre-frail and socially frail. Participants were further recategorized into three subgroups (neither, either or both) based on presence of social frailty and cognitive impairment. Cognitive impairment was defined as a score below the educational adjusted cut-offs in either CMMSE or FAB. We performed logistic regression adjusted for significant covariates and mood to examine association with outcomes across the three subgroups., Results: Compared with CMMSE, Chinese FAB scores significantly decreased across the social frailty spectrum (p<0.001), suggesting strong association between executive function with social frailty. We derived three subgroups relative to relationship with socially frailty and executive dysfunction: (i) Neither, N=140(61.1%), (ii) Either, N=79(34.5%), and (iii) Both, N=10(4.4%). Compared with neither or either subgroups, having both social frailty and executive dysfunction was associated with anorexia (OR=4.79, 95% CI= 1.04-22.02), near falls and falls (OR= 5.23, 95% CI= 1.10-24.90), lower life-space mobility (odds ratio, OR=9.80, 95% CI=2.07-46.31) and poorer quality of life (OR= 13.2, 95% CI= 2.38-73.4)., Conclusion: Our results explicated the association of executive dysfunction with social frailty, and their synergistic relationship independent of mood with geriatric syndromes, decreased life space and poorer quality of life. In light of the current COVID-19 pandemic, the association between social frailty and executive dysfunction merits further study as a possible target for early intervention in relatively healthy older adults., Competing Interests: The authors declare no conflict of interest.

Background: Sarcopenic obesity (SO) is associated with poorer physical performance in the elderly and will increase in relevance with population ageing and the obesity epidemic. The lack of a consensus definition for SO has resulted in variability in its reported prevalence, poor inter-definitional agreement, and disagreement on its impact on physical performance, impeding further development in the field. While sarcopenia definitions have been compared, the impact of obesity definitions in SO has been less well-studied., Objectives: To compare 3 widely-adopted definitions of obesity in terms of SO prevalence, inter-definitional agreement, and association with muscle function., Design: Cross-sectional., Setting: GERILABS study, Singapore Participants: 200 community-dwelling, functionally-independent older adults., Measurements: We utilized three commonly-used definitions of obesity: body mass index (BMI), waist circumference (WC) and DXA-derived fat mass percentage (FM%). Sarcopenia was defined using Asian Working Group for Sarcopenia criteria. For muscle function, we assessed handgrip strength, gait speed and Short Physical Performance Battery (SPPB). Subjects were classified into 4 body composition phenotypes (normal, obese, sarcopenic and SO), and outcomes were compared between groups., Results: The prevalence rate for SO was lowest for BMI (0.5%) compared to FM% (10.0%) and WC (10.5%). Inter-definitional agreement was lowest between BMI and WC (κ=0.364), and at best moderate between FM% and WC (κ=0.583). SO performed the worst amongst body composition phenotypes in handgrip strength, gait speed and SPPB (all p<0.01) only when defined using WC. In regression analyses, SO was associated with decreased SPPB scores (β=-0.261, p=0.001) only for the WC definition., Conclusion: There is large variation in the prevalence of SO across different obesity definitions, with low-to-moderate agreement between them. Our results corroborate recent evidence that WC, and thus central obesity, is best associated with poorer muscle function in SO. Thus, WC should be further explored in defining obesity for accurate and early characterization of SO among older adults in Asian populations., Competing Interests: The authors report no conflicts of interest in this work.

Background: It is unclear if the complex relationship between physical frailty and cognition varies across the severity of cognitive impairment., Objectives: We therefore aimed to explore if there are stage-specific differences in the relationship between frailty and cognitive impairment., Design: Cross-sectional study., Setting: A specialist Memory Clinic setting., Participants: Mild cognitive impairment (MCI) and mild-moderate Alzheimer's disease (AD) community-dwelling subjects., Measurements: We obtained data on demographics, multimorbidity, cognition-related measures, nutrition, neuroimaging measures, muscle mass, Vitamin D level, apolipoprotein - e (APOE) status and physical performance measures. Frailty measures of gait speed, hand grip strength, question on exhausation and weight loss, classified subjects according to the Buchmann criteria into non-frail and frail categories., Results: Forty-five MCI, 64 mild AD and 13 moderate AD subjects (total n=122) were studied. The prevalence of frailty for MCI, mild AD and moderate AD was 35.6%, 21.9% and 46.2% respectively, indicating a u-shaped trend. Significant differences were noted in fatigue, grip strength and gait speed frailty sub-items. Significant correlation of frailty with cognition were noted in mild-moderate AD (Spearman's coefficient 0.26, p<0.05) but not in MCI (0.01, p=0.6). No other differences in multimorbidity, Vitamin D, APOE, nutritional measures, white matter lesions were observed. Sarcopenia interestingly had an inverse stage-specific relationship unlike frailty., Conclusions: Our results suggest a U-shaped relationship between frailty and cognition, characterized by initial dissociation with cognitive impairment and subsequent convergence at later stages. Future studies incorporating immune markers and endocrine pathways with longitudinal follow-up could potentially elucidate intermediary mechanisms in the frailty cascade.