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Abstract Purpose of Review This review identifies exercise-based recommendations to prevent and manage frailty and fragility fractures from current clinical practice guidelines. We also critically assess recently published literature in relation to exercise interventions to mitigate frailty and fragility fractures. Recent Findings Most guidelines presented similar recommendations that included the prescription of individually tailored, multicomponent exercise programs, discouragement of prolonged sitting and inactivity, and combining exercise with optimal nutrition. To target frailty, guidelines recommend supervised progressive resistance training (PRT). For osteoporosis and fragility fractures, exercise should include weight-bearing impact activities and PRT to target bone mineral density (BMD) at the hip and spine, and also incorporate balance and mobility training, posture exercises, and functional exercise relevant to activities of daily living to reduce falls risk. Walking as a singular intervention has limited benefits for frailty and fragility fracture prevention and management. Summary Current evidence-based clinical practice guidelines for frailty, osteoporosis, and fracture prevention recommend a multifaceted and targeted approach to optimise muscle mass, strength, power, and functional mobility as well as BMD.

Malnutrition is a highly prevalent condition in older adults, and poses a substantial burden on health, social, and aged-care systems. Older adults are vulnerable to malnutrition due to age-related physiological decline, reduced access to nutritious food, and comorbidity. Clinical guidelines recommend routine screening for malnutrition in all older adults, together with nutritional assessment and individually tailored nutritional support for older adults with a positive screening test. Nutritional support includes offering individualised nutritional advice and counselling; oral nutritional supplements; fortified foods; and enteral or parenteral nutrition as required. However, in clinical practice, the incorporation of nutritional guidelines is inadequate and low-value care is commonplace. This Review discusses the current evidence on identification and treatment of malnutrition in older adults, identifies gaps between evidence and practice in clinical care, and offers practical strategies to translate evidence-based knowledge into improved nutritional care. We also provide an overview of the prevalence, causes, and risk factors of malnutrition in older adults across health-care settings.

Background: Sarcopenia is an age-associated skeletal muscle condition characterized by low muscle mass, strength, and physical performance. There is no international consensus on a sarcopenia definition and no contemporaneous clinical and research guidelines specific to Australia and New Zealand. The Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force aimed to develop consensus guidelines for sarcopenia prevention, assessment, management and research, informed by evidence, consumer opinion, and expert consensus, for use by health professionals and researchers in Australia and New Zealand. Methods: A four-phase modified Delphi process involving topic experts and informed by consumers, was undertaken between July 2020 and August 2021. Phase 1 involved a structured meeting of 29 Task Force members and a systematic literature search from which the Phase 2 online survey was developed (Qualtrics). Topic experts responded to 18 statements, using 11-point Likert scales with agreement threshold set a priori at >80%, and five multiple-choice questions. Statements with moderate agreement (70%–80%) were revised and re-introduced in Phase 3, and statements with low agreement (80%) were confirmed by the Task Force in Phase 4. Conclusions: The ANZSSFR Task Force present 17 sarcopenia management and research recommendations for use by health professionals and researchers which includes the recommendation to adopt the EWGSOP2 sarcopenia definition in Australia and New Zealand. This rigorous Delphi process that combined evidence, consumer expert opinion and topic expert consensus can inform similar initiatives in countries/regions lacking consensus on sarcopenia.

Sarcopenia, the age-associated decline in skeletal muscle mass and function, is a major cause of functional decline and mortality in older adults. Despite its importance, sarcopenia often remains unrecognized and inadequately managed in routine clinical care. A major hinderance to its clinical integration is the variation in diagnostic tools for sarcopenia. Diagnostic tools include those of the European Working Group on Sarcopenia in Older People (versions 1 and 2), those of the Asian Working Group for Sarcopenia (versions 1 and 2), and that of the Sarcopenia Definition and Outcomes Consortium. The management decision process of sarcopenia warrants an evaluation of risk factors such as a sedentary lifestyle, inadequate exercise, poor nutritional intake, smoking, depression and living circumstances. Herein, we provide an evidence-based update of the prevention and management of sarcopenia and propose practical information to facilitate the disease’s adoption into routine care. This Review provides an evidence-based update of the prevention and management of sarcopenia and proposes practical information to facilitate the disease’s adoption into routine care.

The COVID-19 pandemic has caused detrimental impacts on different population groups throughout the world. This study aimed to explore the impacts of the COVID-19 pandemic’s mandatory lockdown protocols on individual and social activities and mental health conditions of community-dwelling older people in Jakarta, Indonesia. A qualitative design using one-on-one in-depth interviews was employed to collect data from the participants (n = 24) who were recruited using the snowball sampling technique. Data analysis was guided by the five steps proposed in a qualitative data analysis framework, including familiarisation with the data, identification of a thematic framework, indexing the data, charting the data and mapping and interpreting the data. The findings showed that before the COVID-19 outbreak participants engaged in different kinds of regular individual and social activities. However, the COVID-19 outbreak and its mandatory lockdown protocols significantly influenced both their activities and social life, which led to social disconnection and financial difficulties for them. COVID-19 outbreak, mandatory lockdown protocols, and the disruption of individual and social activities of the participants also caused mental health challenges to them, including feelings of loneliness, loss, sadness, stress, and anger. The findings suggest that there is a need for intervention programs addressing the socio-economic and mental health impacts of the COVID-19 pandemic on older populations to help them cope with these challenges. Future studies involving large-scale older populations to comprehensively understand COVID-19 impacts on them are recommended.

COVID-19 has rapidly impacted societies on a global scale, with older people among the most affected. To care for older people living in their own homes, female family caregivers play a pivotal role. The current study aimed to explore the actions of female family caregivers and the challenges they faced in taking care of older people living at homes during the COVID-19 pandemic in Belu district, Indonesia. This qualitative study involved twenty female family caregivers, who were recruited using a combination of purposive and snowball sampling techniques. Findings were grouped into two main categories: (i) actions of female family caregivers in taking care of older adults during the COVID-19 pandemic. These included limiting both visitations of extended family members and older adults’ activities outside homes; explaining the virus to older adults and controlling their access to news, social media and smartphones; providing nutrition, supplement and maintaining daily diets; and (ii) challenges they faced in taking care of older adults included excessive fear of contracting COVID-19 and possibility of transmitting it to older people; feeling stressed; tired and overburdened. The study highlights the significant role family caregivers played to protect older people living at home. The findings can inform government to develop intervention programs that address and support the needs of both family caregivers and older people living at home.

Ebony T Lewis,1– 3 Margaret Williamson,1,4 Lou P Lewis,5 Danielle Ní Chróinín,6,7 Elsa Dent,8 Maree Ticehurst,5,9 Ruth Peters,2,3 Rona Macniven,1 Magnolia Cardona10,11 1School of Population Health, Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia; 2School of Psychology, Faculty of Science, University of New South Wales, Sydney, NSW, Australia; 3Neuroscience Research Australia (NeuRA), Sydney, NSW, Australia; 4Centre for Primary Health Care and Equity, Faculty of Medicine & Health, University of New South Wales, Sydney, NSW, Australia; 5Matraville Medical Centre, Sydney, NSW, Australia; 6Department of Geriatric Medicine, Liverpool Hospital, Sydney, NSW, Australia; 7South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; 8Torrens University Australia, Adelaide, SA, Australia; 9Royal Prince Alfred Hospital, Sydney, NSW, Australia; 10Institute for Evidence-Based Healthcare, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia; 11Gold Coast Hospital and Health Service, Gold Coast, QLD, AustraliaCorrespondence: Ebony T Lewis, School of Population Health, Faculty of Medicine & Health, University of New South Wales, Level 3, Samuels Building, Gate 11, Botany Street, Sydney, NSW, 2052, Australia, Tel +612 9065 2068, Email ebony.lewis@unsw.edu.auPurpose: Frailty is a prevalent condition in older adults. Identification of frailty using an electronic Frailty Index (eFI) has been successfully implemented across general practices in the United Kingdom. However, in Australia, the eFI remains understudied. Therefore, we aimed to (i) examine the feasibility of deriving an eFI from Australian general practice records and (ii) describe the prevalence of frailty as measured by the eFI and the prevalence with socioeconomic status and geographic remoteness.Participants and Methods: This retrospective analysis included patients (≥ 70 years) attending any one of > 700 general practices utilizing the Australian MedicineInsight data platform, 2017– 2018. A 36-item eFI was derived using standard methodology, with frailty classified as mild (scores 0.13– 0.24); moderate (0.25– 0.36) or severe (≥ 0.37). Socioeconomic status (Socio-Economic Indexes for Areas (SEIFA) index)) and geographic remoteness (Australian Statistical Geography Standard (ASGC) remoteness areas) were also examined.Results: In total, 79,251 patients (56% female) were included, mean age 80.0 years (SD 6.5); 37.4% (95% CI 37.0– 37.7) were mildly frail, 16.7% (95% CI 16.4– 16.9) moderately frail, 4.8% (95% CI 4.7– 5.0) severely frail. Median eFI score was 0.14 (IQR 0.08 to 0.22); maximum eFI score was 0.69. Across all age groups, moderate and severe frailty was significantly more prevalent in females (P < 0.001). Frailty severity increased with increasing age (P < 0.001) and was strongly associated with socioeconomic disadvantage (P < 0.001) but not with geographic remoteness.Conclusion: Frailty was identifiable from routinely collected general practice data. Frailty was more prevalent in socioeconomically disadvantaged groups, women and older patients and existed in all levels of remoteness. Routine implementation of an eFI could inform interventions to prevent or reduce frailty in all older adults, regardless of location.Keywords: primary health care, family practice, frailty, electronic health records, geriatric assessment, aged

Objectives: To develop guidelines, informed by health-care consumer values and preferences, for sarcopenia prevention, assessment and management for use by clinicians and researchers in Australia and New Zealand. Methods: A three-phase Consumer Expert Delphi process was undertaken between July 2020 and August 2021. Consumer experts included adults with lived experience of sarcopenia or health-care utilisation. Phase 1 involved a structured meeting of the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Sarcopenia Diagnosis and Management Task Force and consumer representatives from which the Phase 2 survey was developed. In Phase 2, consumers from Australia and New Zealand were surveyed online with opinions sought on sarcopenia outcome priorities, consultation preferences and interventions. Findings were confirmed and disseminated in Phase 3. Descriptive statistical analyses were performed. Results: Twenty-four consumers (mean ± standard deviation age 67.5 ± 12.8 years, 18 women) participated in Phase 2. Ten (42%) identified as being interested in sarcopenia, 7 (29%) were health-care consumers and 6 (25%) self-reported having/believing they have sarcopenia. Consumers identified physical performance, living circumstances, morale, quality of life and social connectedness as the most important outcomes related to sarcopenia. Consumers either had no preference (46%) or preferred their doctor (40%) to diagnose sarcopenia and preferred to undergo assessments at least yearly (54%). For prevention and treatment, 46% of consumers preferred resistance exercise, 2–3 times per week (54%). Conclusions: Consumer preferences reported in this study can inform the implementation of sarcopenia guidelines into clinical practice at local, state and national levels across Australia and New Zealand.

Background Rapid frailty screening remains problematic in primary care. The diagnostic test accuracy (DTA) of several screening instruments has not been sufficiently established. We evaluated the DTA of several screening instruments against two reference standards: Fried’s Frailty Phenotype [FP] and the Adelaide Frailty Index [AFI]), a self-reported questionnaire. Methods DTA study within three general practices in South Australia. We randomly recruited 243 general practice patients aged 75+ years. Eligible participants were 75+ years, proficient in English and community-dwelling. We excluded those who were receiving palliative care, hospitalized or living in a residential care facility. We calculated sensitivity, specificity, predictive values, likelihood ratios, Youden Index and area under the curve (AUC) for: Edmonton Frail Scale [EFS], FRAIL Scale Questionnaire [FQ], Gait Speed Test [GST], Groningen Frailty Indicator [GFI], Kihon Checklist [KC], Polypharmacy [POLY], PRISMA-7 [P7], Reported Edmonton Frail Scale [REFS], Self-Rated Health [SRH] and Timed Up and Go [TUG]) against FP [3+ criteria] and AFI [>0.21]. Results We obtained valid data for 228 participants, with missing scores for index tests multiply imputed. Frailty prevalence was 17.5% frail, 56.6% prefrail [FP], and 48.7% frail, 29.0% prefrail [AFI]. Of the index tests KC (Se: 85.0% [70.2–94.3]; Sp: 73.4% [66.5–79.6]) and REFS (Se: 87.5% [73.2–95.8]; Sp: 75.5% [68.8–81.5]), both against FP, showed sufficient diagnostic accuracy according to our prespecified criteria. Conclusions Two screening instruments—the KC and REFS, show the most promise for wider implementation within general practice, enabling a personalized approach to care for older people with frailty.

Frailty is a complex age-related clinical condition characterised by a decline in physiological capacity across several organ systems, with a resultant increased susceptibility to stressors. Because of the heterogeneity of frailty in clinical presentation, it is important to have effective strategies for the delivery of care that range across the continuum of frailty severity. In clinical practice, we should do what works, starting with frailty screening, case identification, and management of frailty. This process is unarguably difficult given the absence of an adequate evidence base for individual and health-system interventions to manage frailty. We advocate change towards individually tailored interventions that preserve an individual's independence, physical function, and cognition. This change can be addressed by promoting the recognition of frailty, furthering advancements in evidence-based treatment options, and identifying cost-effective care delivery strategies.

The term sarcopenia was introduced in 1988. The original definition was a “muscle loss” of the appendicular muscle mass in the older people as measured by dual energy x‐ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC‐F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease‐related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age‐related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age‐related and disease‐related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life‐long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.

Sarcopenia is a disease related to accelerated loss of skeletal muscle and subsequent decline in functional capacity. It affects approximately 13% of the world's population aged over 60 years. Sarcopenia is primarily managed and prevented through a combination of exercise prescription combined with appropriate nutritional strategies. This review outlines diagnostic and case finding/screening tools for age-related (primary) sarcopenia used in research and clinical practice. Diagnostic tools critically reviewed include those of the: European Workgroup for Sarcopenia (EWGSOP) versions 1 and 2; Asian Working Group for Sarcopenia (AWGS) versions 1 and 2; Foundation for the National Institutes of Health (FNIH); and the Sarcopenia Definition and Outcomes Consortium (SDOC). Criteria used by diagnostic tools (muscle mass, muscle strength and physical functioning/performance) are also detailed. Case-finding tools include the SARC-F questionnaire, Ishii's formula and Goodman's screening grid. Additionally, this review discusses the strengths and weaknesses of each diagnostic and case-finding tool, and examines their ability to reliably predict adverse clinical outcomes and patient responses to potential therapies.

The authors apologize for a typing error that occurred in the September 2020 article that changes the meaning of a sentence.

BACKGROUND/OBJECTIVES: Frailty, loneliness, and social isolation are all associated with adverse outcomes in older adults, but little is known about their combined impact on mortality.DESIGN: Prospective cohort study.SETTING: The Longitudinal Aging Study Amsterdam.PARTICIPANTS: Community-dwelling older adults aged 65 and older (n = 1,427).MEASUREMENTS: Frailty was measured with the frailty phenotype (Fried criteria). Loneliness was assessed with the De Jong Gierveld Loneliness Scale. Social isolation was operationalized using information on partner status, social support, and network size. Two categorical variables were created, for each possible combination regarding frailty and loneliness (FL) and frailty and social isolation (FS), respectively. Mortality was monitored over a period of 22 years (1995-2017). Survival curves and Cox proportional hazard models were used to study the effects of the FL and FS combinations on mortality. Analyses were adjusted for sociodemographic factors, depression, chronic diseases, and smoking.RESULTS: Frailty prevalence was 13%, and 5.9% of the sample were frail and lonely, and 6.2% frail and socially isolated. In fully adjusted models, older adults who were only frail had a higher risk of mortality compared with people without any of the conditions (hazard ratio [HR] range = 1.40-1.48; P CONCLUSION: Frail older adults are at increased risk of mortality, but this risk is even higher for those who are also lonely or socially isolated. To optimize well-being and health outcomes in physically frail older adults, targeted interventions focusing on both subjective and objective social vulnerability are needed.

BACKGROUND: Air pollution has been associated with various health outcomes. Its effect on hand-grip strength, a measurement of the construct of muscle strength and health status, remains largely unknown. METHODS: We used the survey data from 31,209 adults ≥ 50 years of age within Wave 1 of the Study on Global AGEing and Adult Health in six low- and middle-income countries. The outdoor concentration of fine particulate matter pollution (PM2.5) was estimated using satellite data. Domestic fuel type and ventilation were used as indicators of indoor air pollution. We used multilevel linear regression models to examine the association between indoor and outdoor air pollution and hand-grip strength, as well as the potential effect modifiers. RESULTS: We found inverse associations between both indoor and outdoor air pollution and hand-grip strength. Each 10 μg/m3 increase in 3 years' averaged concentrations of outdoor PM2.5 corresponded to 0.70 kg (95% CI: -1.26, -0.14) lower hand-grip strength; and compared with electricity/liquid/gas fuel users, those using solid fuels had lower hand-grip strength (β = -1.25, 95% CI: -1.74, -0.75). However, we did not observe a statistically significant association between ventilation and hand-grip strength. We further observed that urban residents and those having a higher education level had a higher association between ambient PM2.5 and hand-grip strength, and men, young participants, smokers, rural participants, and those with lower household income had higher associations between indoor air pollution and hand-grip strength. CONCLUSION: This study suggests that both indoor and outdoor air pollution might be important risk factors of poorer health and functional status as indicated by hand-grip strength.

Frailty in older adults is a complex condition in which only a minor external stressor may cause severe complications leading to death. In the context of the recent devastating bushfires in Australia and the worldwide COVID-19 pandemic, recognising and protecting those affected has magnified the impact and public health importance of frailty. Effects of frailty include bodily deterioration and the failure of physiological systems to cope with changes in the environment. Frailty prevalence is around 9–17% in community-dwelling older adults aged 65 years and over and renders an older adult at heightened risk of adverse outcomes such as infections, hospitalisation, pre-mature admission to care facilities, and mortality. Although the physiological and functional decline that occurs with frailty usually occurs gradually over a number of years, this functional decline can occur rapidly when external stressors are present.

Objectives: Studies conducted among older people have shown that frailty is a common condition associated with an array of adverse outcomes. The aims of this study were to identify the prevalence and associations of frailty in older people residing in several aged care facilities located in Queensland, Australia. Methods: The database used for this study was drawn from the Aged Care Funding Instrument (ACFI) database of an Australian aged care provider, and contained data from ten aged care facilities in Queensland, Australia. A modification of an eFI originally developed by Clegg and colleagues and based on Rockwood’s Frailty Index (FI) of cumulative deficits was used to identify frailty. Results: In total, 592 participants aged 75 years and over were included in the study (66.6% female). Median (IQR) age was 88.0 (9.0) years. Frailty prevalence among the sample was 43.6%, with 46.3% pre-frail and 10.1% not frail. In a multivariate logistic regression analysis incorporating three different models, frailty was significantly associated with three ACFI domains (Nutrition, Depression and Complex Health Care), along with facility size, consistently across two models. In the third model, frailty was also significantly associated with arthritis, diabetes, hypertension, osteoporosis and vision problems, along with male gender. Conclusion: There is a need to develop frailty identification and management programs as part of standard care pathways for older adults residing in aged care facilities. Aged care facilities should consider regular frailty screening in residential aged care residents, along with interventions addressing specific issues such as dysphagia and depression.

[See related article at [www.cmaj.ca/lookup/doi/10.1503/cmaj.181151][2]][2] KEY POINTS Frailty is a dynamic state of heightened vulnerability to stressors. It is a multidimensional syndrome that places individuals at risk for adverse health outcomes, including falls, disability, admission to

Background/aims In clinical trials, it is not unusual for errors to occur during the process of recruiting, randomising and providing treatment to participants. For example, an ineligible participant may inadvertently be randomised, a participant may be randomised in the incorrect stratum, a participant may be randomised multiple times when only a single randomisation is permitted or the incorrect treatment may inadvertently be issued to a participant at randomisation. Such errors have the potential to introduce bias into treatment effect estimates and affect the validity of the trial, yet there is little motivation for researchers to report these errors and it is unclear how often they occur. The aim of this study is to assess the prevalence of recruitment, randomisation and treatment errors and review current approaches for reporting these errors in trials published in leading medical journals. Methods We conducted a systematic review of individually randomised, phase III, randomised controlled trials published in New England Journal of Medicine, Lancet, Journal of the American Medical Association, Annals of Internal Medicine and British Medical Journal from January to March 2015. The number and type of recruitment, randomisation and treatment errors that were reported and how they were handled were recorded. The corresponding authors were contacted for a random sample of trials included in the review and asked to provide details on unreported errors that occurred during their trial. Results We identified 241 potentially eligible articles, of which 82 met the inclusion criteria and were included in the review. These trials involved a median of 24 centres and 650 participants, and 87% involved two treatment arms. Recruitment, randomisation or treatment errors were reported in 32 in 82 trials (39%) that had a median of eight errors. The most commonly reported error was ineligible participants inadvertently being randomised. No mention of recruitment, randomisation or treatment errors was found in the remaining 50 of 82 trials (61%). Based on responses from 9 of the 15 corresponding authors who were contacted regarding recruitment, randomisation and treatment errors, between 1% and 100% of the errors that occurred in their trials were reported in the trial publications. Conclusion Recruitment, randomisation and treatment errors are common in individually randomised, phase III trials published in leading medical journals, but reporting practices are inadequate and reporting standards are needed. We recommend researchers report all such errors that occurred during the trial and describe how they were handled in trial publications to improve transparency in reporting of clinical trials.

Acute respiratory infections cause significant morbidity and mortality accounting for 5.8 million deaths worldwide. In Australia, influenza-like illness (ILI), defined as cough, fever and fatigue is a common presentation in general practice and results in reduced productivity and lost working days. Little is known about the epidemiology of ILI in working-age adults. Using data from the ASPREN influenza surveillance network in Australia (2010–2013) we found that working-age adults made up 45.2% of all ILI notifications with 55% of samples positive for at least one respiratory virus. Viruses most commonly detected in our study included influenza A (20.6%), rhinovirus (18.6%), influenza B (6.2%), human meta-pneumovirus (3.4%), respiratory syncytial virus (3.1%), para-influenza virus (2.6%) and adenovirus (1.3%). We also demonstrated that influenza A is the predominant virus that increases ILI (by 1.2% per month for every positive influenza A case) in working-age adults during autumn–winter months while other viruses are active throughout the year. Understanding the epidemiology of viral respiratory infections through a year will help clinicians make informed decisions about testing, antibiotic and antiviral prescribing and when the beginning of the ‘flu season’ can be more confidently predicted.

OBJECTIVES: Low socioeconomic position (SEP) is related to many health-related conditions in older adults. However, there is a lack of knowledge on the association between SEP and malnutrition, a condition with serious consequences for older people in terms of quality of life and adverse health events. In the current study, we investigated socioeconomic inequalities in malnutrition and sub-domains of malnutrition in a sample of Spanish older adults.DESIGN: Cross-sectional population-based study.SETTING: Urban area of Albacete, Spain.PARTICIPANTS: 836 participants over age 70 from the first measurement wave (2007-2009) of the Frailty and Dependence in Albacete (FRADEA) study, a population-based cohort study.MEASUREMENTS: Educational level and occupational level were the indicators of SEP. Nutritional risk was measured with the Mini Nutrition Assessment® Short Form (MNA®-SF). Logistic regression analyses were performed.RESULTS: For both socioeconomic indicators there was a statistically significant association with nutritional risk (OR low education=1.99, 95% CI=1.18-3.35; OR low occupational level=1.71, 95% CI=1.08-2.72). However, these associations disappeared after adjusting for age and sex (OR low education=1.51, 95% CI=0.88-2.60 ; OR low occupational level=1.32, 95% CI=0.80-2.17). In adjusted models, statistically significant associations between SEP and sub-domains of the MNA®-SF were observed, but these associations were not consistent across socioeconomic indicators.CONCLUSIONS: This study found that malnutrition is a condition that can appear in any older adult, regardless of their socioeconomic group. These findings suggest that interventions to prevent malnutrition in older adults can be targeted at a general older population, and do not have to be SEP specific.

Aim Nutritional screening may not always lead to intervention. The present study aimed to determine: (i) the rate of nutritional screening in hospitalised older adults; (ii) whether nutritional screening led to dietitian consultation and (iii) factors associated with malnutrition. Methods In this prospective study of patients aged ≥70 years admitted to a Geriatric Evaluation and Management Unit (GEMU), malnutrition was screened for using the Mini Nutritional Assessment Short Form (MNA-SF) and identified using the Mini Nutritional Assessment (MNA). Results Of the 172 patients participating in the study, 53 (30.8%) patients were malnourished, and 84 (48.8%) were at risk of malnutrition. Mean (SD) age was 85.2 (6.4 years), with 131 patients (76.2%) female. Nutritional screening was performed for all patients; however, it was incomplete in 59 (34.3%) because of omission of the anthropometric measurement. Overall, 62 (36.0%) of the total number of patients were seen by the dietitian, which included 26 (49%) of malnourished patients, 27 (32%) of at-risk patients and 9 (26%) of the well-nourished patients. No patients lost >1% of body weight during GEMU stay. Malnourished patients were more likely to be frail, have poor appetite, depression, and have lower levels of: albumin, cognition, physical function, grip strength and quality of life. Conclusions The full benefits of nutritional screening by MNA-SF may not be realised if it does not result in malnourished patients receiving a dietitian consultation. However, it is possible that enrichment of the foodservice with high protein/high-energy options minimised patient weight loss in the GEMU.

frailty is a central concept in geriatric medicine, yet its utility in the Emergency Department (ED) is not well understood nor well utilised. Our objectives were to develop an ED frailty index (FI-ED), using the Rockwood cumulative deficits model and to evaluate its association with adverse outcomes. this was a large multinational prospective cohort study using data from the interRAI Multinational Emergency Department Study. The FI-ED was developed from the Canadian cohort and validated in the multinational cohort. All patients aged ≥75 years presenting to an ED were included. The FI-ED was created using 24 variables included in the interRAI ED-Contact Assessment tool. there were 2,153 participants in the Canadian cohort and 1,750 in the multinational cohort. The distribution of the FI-ED was similar to previous frailty indices. The mean FI-ED was 0.26 (Canadian cohort) and 0.32 (multinational cohort) and the 99th percentile was 0.71 and 0.81, respectively. In the Canadian cohort, a 0.1 unit increase in the FI-ED was significantly associated with admission (odds ratio (OR) = 1.43 [95% CI: 1.34-1.52]); death at 28 days (OR = 1.55 [1.38-1.73]); prolonged hospital stay (OR = 1.37 [1.22-1.54]); discharge to long-term care (OR = 1.30 [1.16-1.47]); and need for comprehensive geriatric assessment (OR = 1.51 [1.41-1.60]). The multinational cohort showed similar associations. the FI-ED conformed to characteristics previously reported. A FI, developed and validated from a brief geriatric assessment tool could be used to identify ED patients at higher risk of adverse events.

Frailty is a state of vulnerability resulting from cumulative decline in many physiological systems during a lifetime. It is progressive and considered largely irreversible, but its progression may be controlled and can be slowed down and its precursor -pre-frailty- can be treated with multidisciplinary intervention. The aim of this narrative review is to provide an overview of the different ways of measuring frailty in community settings, hospital, emergency, general practice and residential aged care; suggest occupational groups who can assess frailty in various services; discuss the feasibility of comprehensive geriatric assessments; and summarise current evidence of its management guidelines. We also suggest practical recommendations to recognise frail patients near the end of life, so discussions on goals of care, advance care directives, and shared decision-making including early referrals to palliative and supportive care can take place before an emergency arises. We acknowledge the barriers to systematically assess frailty and the absence of consensus on best instruments for different settings. Nevertheless, given its potential consequences including prolonged suffering, disability and death, we recommend identification of frailty levels should be universally attempted in older people at any health service, to facilitate care coordination, and honest discussions on preferences for advance care with patients and their caregivers.

Introduction Sarcopenia poses a significant problem for older adults, yet very little is known about this medical condition in the hospital setting. The aims of this hospital-based study were to determine: (i) the prevalence of sarcopenia; (ii) factors associated with sarcopenia; and (iii) the association of sarcopenia with adverse clinical outcomes post-hospitalisation. Methods This is a longitudinal analysis of consecutive patients aged ≥70 years admitted to a Geriatric Management and Evaluation Unit (GEMU) ward. Sarcopenia was classified using the European Working Group on Sarcopenia in Older People (EWGSOP) algorithm, which included: handgrip strength, gait speed, and muscle mass using Bioelectrical Impedance Analysis (BIA). Outcomes were assessed at 12-months post-hospital discharge, and included both mortality and admission to a hospital Emergency Department (ED). Kaplan-Meier methods were used to estimate survival, with Cox proportion hazard models then applied. All regression analyses controlled for age, sex, and co-morbidity. Results 172 patients (72% female) with a mean (SD) age of 85.2 (6.4) years were included. Sarcopenia was present in 69 (40.1%) of patients. Patients with sarcopenia were twice as likely to die in the 12-months post-hospitalisation (HR, 95% CI = 2.23, 1.15–4.34), but did not have an increased likelihood of ED admission. Conclusions Sarcopenia showed an independent association with 12-month post-hospital mortality in older adults. With the new recognition of sarcopenia as a medical condition with its own unique ICD-10-CM code, awareness and diagnosis of sarcopenia in clinical settings is paramount.

With age, the prevalence of musculoskeletal conditions increases markedly. This rural-based study determined the benefits of two approaches for managing musculoskeletal conditions: a multiple-component 'Self-management Plus' intervention, and usual care. The intervention combined self-management education with physical activity and health professional support. 6-month outcomes included: Clinical Global Impression-Improvement Scale (CGI-IS) and Quality of Life (QoL). A total of 145 people were recruited; mean (SD) age was 66.1 (11.1) and 63.3 (10.9) years for intervention and control groups respectively. The intervention resulted in greater improvements in global functioning (CGI-IS mean (SD) = 3.2 (1.3)) than usual care (CGI-IS mean (SD) = 4.2 (1.5)). There was no difference in QoL improvement between study groups. A multiple-component 'Self-management Plus' intervention had a positive effect on physical functioning for older adults with musculoskeletal conditions. However, recruitment and retention of participants was problematic, which raises questions about the intervention's feasibility in its current form.Journal of Frailty and Aging 2017;6(4):212-215

ObjectiveThe task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.MethodsThese recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care.Recommendations for Screening and AssessmentThe task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation).Recommendations for ManagementA comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Introduction: Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet few intervention studies have addressed the specific care needs of this vulnerable, high-risk population. This paper presents Mater Aged Care in an Emergency (MACIAE), a service dedicated to supporting aged care facility residents, their families, facility carers and GPs, with the goal of providing a seamless care transition in order to ensure the highest and safest standard of care with the upmost compassion and dignity. The program was designed with patients and families/ carers, ACFs, local general practices, Primary Health Networks, ambulance services, hospital providers and researchers. Methods: The study was implemented 2013-2016. All older adults presenting from ACFs to the ED of Mater Hospital Brisbane, Australia were included. The evaluation was a pre/post design using retrospective baseline data from hospital records, and prospectively collected post-implementation data. The objectives were to determine whether this intervention significantly impacted on patient outcomes and organisational outcomes. Ethics approval for the study was obtained through the Mater Research Ethics Committee. Results: This study demonstrates the significant improvements can be achieved by a specific aged care service working across the continuum. Participants (n=1130) were from over 200 ACFs. Intervention resulted in 30% drop ward admissions; reduced LOS from 6.5 to 4.0 days (national average 8.0 days); reduced 28-day representation rates from 17.8% to 4.6%; 88% of patients commenced on an End of Life pathway were able to be transferred to their environment of preference; and, there were over 300 Advanced Care Plans implemented. Satisfaction from acute, primary care and ACF providers was very high. A cost-benefit analysis demonstrated a 10:1 outcome. Discussion: This study demonstrates significant improvements were achieved by integration of an acute frail older person service into an ED, which works with families, primary health and social care to implement strategies to meet the needs of this population. Lessons learnt: Key to implementing and sustaining this model of integrating care are leadership; culture – it makes or breaks it; time – it takes longer than you think; data - speaks louder than words; and, passion - to keep you going through the tough times. Limitations: The present study involved a pre-post implementation study design, therefore we cannot speculate whether or not our results were entirely due to the MACIAE service implementation. Future studies should consider implementation of a Randomised Controlled Trial. We also note that this study was implemented in only one hospital. Suggestions for future research: In January 2018, the Older Person Centred Care Team formed, merging three existing teams, focused on managing frail and older patients and families/carers across the continuum. Current research is focused on rapid assessment of frailty, embedding a case management approach to support care closer to home and involving patients/ families/ carers in decisions about a model that meets their future needs.

Purpose of review Undernutrition in older adults is associated with frailty, functional decline, and mortality. The ‘anorexia of ageing’ is the age-related appetite and weight loss underpinning such undernutrition. This review examines the latest evidence for its prevention and treatment.Recent findings Existing nutritional therapies for the anorexia of ageing include supporting nutritional intake with fortified food or supplements, including protein, omega-3 fatty acids, multivitamins, and vitamin D. The Mediterranean diet provides high fat intake and nutrient density in a moderate volume of colourful and flavoursome food and is strengthening in evidence for healthy ageing. Studies of the gut microbiome, which potentially regulates normal appetite by acting on the brain–gut communication axis, are pertinent. Utilisation of the genetic profile of individuals to determine nutritional needs is an exciting advancement of the past decade and may become common practice.Summary Prevention or early treatment of the anorexia of ageing in older adults is critical. Latest evidence suggests that once significant weight loss has occurred, aggressive nutritional support may not result in improved outcomes.Current Opinion in Clinical Nutrition & Metabolic Care: January 2019 - Volume 22 - Issue 1 - p 44–51

Malnutrition (undernutrition) remains one of the most serious health problems for older people worldwide. Many factors contribute to malnutrition in older people, including: loss of appetite, polypharmacy, dementia, frailty, poor dentition, swallowing difficulties, social isolation, and poverty. Malnutrition is common in the hospital setting, yet often remains undetected by medical staff. The objective of this review is to compare the validity and reliability of Nutritional Screening Tools (NSTs) for older adults in the hospital setting. We also provide an overview of the various nutritional screening and assessment tools used to identify malnutrition in hospitalised older adults. These include: Subjective Global Assessment (SGA), the Mini Nutritional Assessment (MNA), MNA-short form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Simplified Nutritional Appetite Questionnaire (SNAQ), Geriatric Nutrition Risk Index (GNRI) and anthropometric measurements. The prevalence and outcomes of malnutrition in hospitalised older adults are also addressed.

Purpose The purpose of this paper is to explore the findings from empirical research conducted with women managers about their careers and to propose a template or blueprint for how individuals and organisations might create a better career environment for women. Design/methodology/approach This paper draws on a research study that included interviews with 20 senior women managers from a range of sectors and countries and a self-completion survey questionnaire completed by 1,402 women. Findings The paper illustrates the difficulties that women continue to face in the workplace and how terms such as leadership, management and team leader may be gender biased. There is a need for employers and for individuals to consider a variety of different approaches to help create a more positive career environment for women. Research limitations/implications The findings have implications for career development structures and talent management processes within organisations. They also would be useful for professional associations. Practical implications The template proposed offers a useful guide to help organisations reflect on possible gender bias in career development structures. Originality/value This paper adds to the understanding of the issues that women managers face and highlight the practical changes employers could make to help address these issues.

One of the leading causes of morbidity and premature mortality in older people is frailty. Frailty occurs when multiple physiological systems decline, to the extent that an individual's cellular repair mechanisms cannot maintain system homeostasis. This review gives an overview of the definitions and measurement of frailty in research and clinical practice, including: Fried's frailty phenotype; Rockwood and Mitnitski's Frailty Index (FI); the Study of Osteoporotic Fractures (SOF) Index; Edmonton Frailty Scale (EFS); the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) Index; Clinical Frailty Scale (CFS); the Multidimensional Prognostic Index (MPI); Tilburg Frailty Indicator (TFI); PRISMA-7; Groningen Frailty Indicator (GFI), Sherbrooke Postal Questionnaire (SPQ); the Gérontopôle Frailty Screening Tool (GFST) and the Kihon Checklist (KCL), among others. We summarise the main strengths and limitations of existing frailty measurements, and examine how well these measurements operationalise frailty according to Clegg's guidelines for frailty classification - that is: their accuracy in identifying frailty; their basis on biological causative theory; and their ability to reliably predict patient outcomes and response to potential therapies.

Objectives The aim of this study was to examine the association between physical frailty and social functioning among older adults, cross-sectionally and prospectively over 3 years. Study design The study sample consisted of 1115 older adults aged 65 and over from two waves of the Longitudinal Aging Study Amsterdam, a population based study. Main outcome measures Frailty was measured at T1 (2005/2006) using the criteria of the frailty phenotype, which includes weight loss, weak grip strength, exhaustion, slow gait speed and low physical activity. Social functioning was assessed at T1 and T2 (2008/2009) and included social network size, instrumental support, emotional support, and loneliness. Results Cross-sectional linear regression analyses adjusted for covariates (age, sex, educational level and number of chronic diseases) showed that pre-frail and frail older adults had a smaller network size and higher levels of loneliness compared to their non-frail peers. Longitudinal linear regression analyses adjusted for covariates and baseline social functioning showed that frailty was associated with an increase in loneliness over 3 years. However, the network size and levels of social support of frail older adults did not further decline over time. Conclusions Frailty is associated with poor social functioning, and with an increase in loneliness over time. The social vulnerability of physical frail older adults should be taken into account in the care provision for frail older adults. Conclusions Frailty is associated with poor social functioning, and with an increase in loneliness over time. The social vulnerability of physical frail older adults should be taken into account in the care provision for frail older adults. Refereed/Peer-reviewed

Objectives: Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR). Methods: To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefitharm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process. Recommendations: We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Hospital Emergency Departments (EDs) experience high presentation rates from older adults residing in Aged Care Facilities (ACFs), yet very few intervention studies have addressed the care needs of this population group. We designed and implemented a nurse-led model of care for older adults from ACFs, and determined its impact on patient outcomes. This 12-month pre–post intervention study was conducted during 2013–2014, with follow-up during 2015–2016. Participants included all older adults presenting from ACFs to the ED of Mater Hospital Brisbane (MHB), Australia. Frailty status was determined using the Clinical Frailty Scale (CFS). All participants were frail (n = 1130), with 19% severely frail, 55% very-severely frail, and 26% terminally ill. The intervention resulted in several improvements in patient outcomes, including significant reductions in ward admissions and 28-day representation rates. Significant improvements can be achieved by integration of an acute frail older person service into an ED.

ObjectivesThe aim of this study was to investigate socioeconomic inequalities in frailty among older adults in six low- and middle-income countries (LMICs), and to examine to what extent chronic diseases account for these inequalities.Study designData were used from the Study on global AGEing and adult health (SAGE) wave 1 (2007–2010). Nationally representative samples of adults aged 50+ years from China, Ghana, India, Mexico, the Russian Federation and South Africa were analyzed (n = 31,174).Main outcome measuresEducational level and wealth were used as socioeconomic indicators. Frailty was assessed with modified criteria for the frailty phenotype. Self-reported disease diagnoses were used. A relative index of inequality (RII) was calculated to compare socioeconomic inequalities in frailty between countries.ResultsPeople in lower socioeconomic positions had higher prevalence rates of frailty. The largest inequalities in frailty were found in Mexico (RII 3.7, 95% CI 2.1–6.4), and the smallest inequalities in Ghana (RII 1.1, 95% CI 0.7–1.8). Mediation analyses revealed that the chronic diseases considered in this study do not explain the higher prevalence of frailty seen in lower socioeconomic groups.ConclusionsSubstantial socioeconomic inequalities in frailty were observed in LMICs, but additional research is needed to find explanations for these. Given that the population of older adults in many LMICs is expanding at a greater rate than in many high-income countries, our results indicate an urgent public health need to address frailty in these countries.Maturitas. Volume 115, September 2018, Pages 56-63

OBJECTIVES: To determine the prevalence of frailty in Emergency Departments (EDs); examine the ability of frailty to predict poor outcomes post-discharge; and identify the most appropriate instrument for routine ED use.METHODS: In this prospective study we simultaneously assessed adults 65+yrs admitted and/or spent one night in the ED using Fried, the Clinical Frailty Scale (CFS), and SUHB (Stable, Unstable, Help to walk, Bedbound) scales in four Australian EDs for rapid recognition of frailty between June 2015 and March 2016.RESULTS: 899 adults with complete follow-up data (mean (SD) age 80.0 (8.3) years; female 51.4%) were screened for frailty. Although different scales yielded vastly different frailty prevalence (SUHB 9.7%, Fried 30.4%, CFS 43.7%), predictive discrimination of poor discharge outcomes (death, poor self-reported health/quality of life, need for community services post-discharge, or reattendance to ED after the index hospitalization) for all identical final models was equivalent across all scales (AUROC 0.735 for Fried, 0.730 for CFS and 0.720 for SUHB).CONCLUSION: This study confirms that screening for frailty in older ED patients can inform prognosis and target discharge planning including community services required. The CFS was as accurate as the Fried and SUHB in predicting poor outcomes, but more practical for use in busy clinical environments with lower level of disruption. Given the limitations of objectively measuring frailty parameters, self-report and clinical judgment can reliably substitute the assessment in EDs. We propose that in a busy ED environment, frailty scores could be used as a red flag for poor follow-up outcome.

Background: This review provides an in-depth investigation into the difficulties facing older Australians when accessing health care services. Methods: A literature search was conducted in December 2016 using Academic Premier to identify relevant publications. Key search terms were accessibility, health service, older people and Australia. Papers published between 1999 and 2016 were included. Statements of accessibility were extracted and then grouped using the five dimensions of accessibility by Penchansky and Thomas (1981): availability, accessibility, accommodation, affordability and acceptability. Results: Forty-one papers were included. Availability issues identified were inadequate health care services, particularly for culturally and linguistically diverse (CALD) populations and those residing in rural areas. Accessibility issues included difficulties accessing transport to health care services, which in turn restricted choice of appointment time. Issues of accommodation identified were long waiting times for appointments with both general practitioners and medical specialists. Affordability was a common problem, compounded by multi-morbidity requiring high health care use. Issues of acceptability centred on the role of the family, feelings of shame when receiving care from a non-family member, traditional practices and gender sensitivity. Conclusions: The contribution of factors to health service accessibility varies according to an older person's geographical local and their accessibility to transport, as well as their level of multi-morbidity and cultural background. Improving access to health services could be improved by matching services to the population that they serve. Refereed/Peer-reviewed

The primary care setting is the ideal location for identifying the condition of frailty in older adults. The aim of this pragmatic study was twofold: (1) to identify data items to extract the data required for an electronic Frailty Index (eFI) from electronic health records (EHRs); and (2) test the ability of an eFI to accurately and feasibly identify frailty in older adults. In a rural South Australian primary care clinic, we derived an eFI from routinely collected EHRs using methodology described by Clegg et al. We assessed feasibility and accuracy of the eFI, including complexities in data extraction. The reference standard for comparison was Fried’s frailty phenotype. The mean (SD) age of participants was 80.2 (4.8) years, with 36 (60.0%) female (n = 60). Frailty prevalence was 21.7% by Fried’s frailty phenotype, and 35.0% by eFI (scores > 0.21). When deriving the eFI, 85% of EHRs were perceived as easy or neutral difficulty to extract the required data from. Complexities in data extraction were present in EHRs of patients with multiple health problems and/or where the majority of data items were located other than on the patient’s summary problem list. This study demonstrated that it is entirely feasible to extract an eFI from routinely collected Australian primary care data. We have outlined a process for extracting an eFI from EHRs without needing to modify existing infrastructure. Results from this study can inform the development of automated eFIs, including which data items to best access data from.