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P. Poupin1, D. N’Diaye2, F. Chaumier3,4, A. Lemaignen2, L. Bernard2, B. Fougère1,5


1. Division of Geriatric Medicine, Tours University Medical Center, Tours, France; 2. Division of Infectious Diseases, Tours University Medical Center, Tours, France; 3. Palliative Care Team, Tours University Medical Center, Tours, France; 4. UMR INSERM U1246 SPHERE, Tours University, Tours, France; 5. Education, Ethics, Health (EA 7505), Tours University, Tours, France.

Corresponding Author: Pierre Poupin, MD, Division of Geriatric Medicine, Tours University Medical Center, Tours, France, E-mail: poupinpierre@yahoo.fr, Phone: +33-643-166-637

J Frailty Aging 2021;in press
Published online April 26, 2021, http://dx.doi.org/10.14283/jfa.2021.16



Background: Long-term residential care facilities and nursing homes are known to be particularly vulnerable to viral respiratory diseases and have expressed the need for multidisciplinary collaboration to help manage outbreaks when they occur.
Method: In April 2020, Tours University Medical Center created a multidisciplinary mobile team to help local nursing homes deal with outbreaks of coronavirus disease 2019 (COVID-19). The team included a geriatrician, infectious disease experts, and palliative care specialists.
Results: On April 8th, 2020, the first intervention took place in a 100 residents nursing home with a total of 18 confirmed cases among 26 symptomatic residents and five deaths. The nursing home staffs’ main requests were a multidisciplinary approach, consensus decision-making, and the dissemination of information on disease management.
Conclusion: Three lessons emerged from this collaboration: (i) intensify collaborations between hospitals and nursing homes, (ii) limit disease transmission through the use of appropriate hygiene measures, broad screening, and the isolation of sick residents and sick employees, and (iii) provide sufficient human resources.

Key words: Viral respiratory disease, outbreak, nursing home, multidisciplinary collaboration.



In December 2019, a previously unknown type of severe acute respiratory syndrome emerged in the city of Wuhan (China) (1). In January 2020, the pathogen was isolated and described as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). The corresponding disease (coronavirus disease 2019, COVID-19) spread rapidly around the world and prompted the World Health Organization to declare a global pandemic on March 11th, 2020 (2). In France, the outbreak was declared officially on March 15th, 2020.
Long-term residential care facilities and nursing homes (NHs) are known to be particularly vulnerable to viral respiratory diseases (e.g., influenza) (3, 4). Due to frailty and comorbidities, older adults are more likely to experience severe and/or complicated forms of COVID-19, with a higher mortality rate (5). In France, a total of 142,852 confirmed cases had been reported by May 28th, 2020 (6). Of these, 33,646 were NH residents (leading to 13,806 deaths (7)) and 16,215 were NH staff members.
An NH is primarily a place to live and secondarily a place to receive medical care. Faced with this unprecedented health crisis, Tours University Medical Center (Tours, France) created a mobile multidisciplinary team (MMT) to help affected NHs deal with COVID-19 in a coordinated manner. To the best of our knowledge, MMTs have rarely been used to deal with COVID-19 outbreaks among older adults in our country.
The objective of the present report is to share our experience of this novel collaboration between an NH and a university medical center’s department of geriatric medicine.



Over the last decade, the concept of a mobile geriatric team has emerged in France and other countries in response to the constant requirement for cost-effective medical care that optimizes resources. During the pandemic, our mobile geriatric team was redeployed for (i) nasopharyngeal swab testing of NH residents with suspicious symptoms, and (ii) operation of a phone hotline (from 9am to 6pm, seven days a week) for NH medical staff.
Although the French government provided guidance on preventing SARS-CoV-2 from spreading within NHs (the prohibition of visits by family members, the closure of communal dining rooms, the serving of meals in the residents’ bedrooms, the suspension of group activities, etc.) and provided additional resources for NHs (8), it did not issue specific guidelines on how to manage an outbreak.
University medical centers have a role in coordinating and disseminating good practice in geriatric medicine within local NHs. In order to answer the most frequent requests from NH medical staff when an outbreak occurred (mainly information on disease management and on consensus decision-making for sick residents), the Geriatrics Department at Tours University Medical Center created a new entity: a multidisciplinary mobile team (MMT) comprising a geriatrician, two infectious disease experts, a palliative care nurse, and a palliative care physician. Each member’s role is summarized in Figure 1; the objective was to provide appropriate care for each resident by drawing on the MMT members’ expertise.

Figure 1. The MMT: composition and roles



On April 8th, 2020, the MMT’s first intervention took place in a 100-resident NH in the city of Tours. It was one of the 4 seriously affected NHs in the local Indre et Loire area, which has about 60 NHs in total. The MMT members and the NH’s physician, head nurse and director had an initial 5-hour meeting, during which questions from the NH staff members alternated with instructive presentations by the MMT members (Figure 2).

Figure 2. Structure of the initial meeting between the NH staff members and the MMT members


Each of the three floors in the NH was divided into 2 units, and there were 60 care staff. The COVID-19 outbreak in the NH had started about 2 weeks previously, and the first confirmed case in a resident was recorded on March 23rd. The disease spread rapidly to all units, giving a total of 18 confirmed cases among 26 symptomatic residents and 6 among the staff. Five of the 18 SARS-CoV-2-positive residents had died at that point. The change in the number of cases of COVID-19 during the two weeks before the MMT’s intervention is shown in Figure 3.

Figure 3. Cases of COVID-19 among NH residents during the 2 weeks before the start of the MMT’s intervention


Although around half of the staff members had developed symptoms of COVID-19, a shortage of tests prevented us from confirming these suspected cases. It appeared that the first case of COVID-19 in the NH was a staff member who subsequently tested positive for SARS-CoV-2. The staff member had come to work with respiratory symptoms, had not used personal protective equipment (PPE), and had been in close contact with the first of the residents to fall ill. Furthermore, the lack of knowledge about the risk of SARS-CoV-2 transmission by asymptomatic carriers and the sometimes contradictory guidance on PPE use (the use of a face mask, primarily) had resulted in confusion and inadequate behavior among the care staff.
The MMT’s infectious disease experts first outlined the procedures for outbreak management. The NH staff members were given detailed information on the mode of viral transmission and the main strategies for preventing further spreading: cohorting staff (to limit mixing and thus opportunities for transmission), limiting staff meetings or seminars, applying social distancing during staff meal breaks, and wearing face masks at all times. To preserve supplies, the use of PPE was optimized (2 disposable surgical face masks per day and per person). The MMT’s main recommendations are summarized in Table 1.

Table 1. Key recommendations by the MMT


With regard to specific medical care, the palliative care physician, the palliative care nurse, an infectious disease expert and the geriatrician were helped the NH’s medical staff to discuss medical decisions for each resident. This included asking whether the residents or their legal guardian or family had provided with advanced directives, and deciding whether the NH was able to meet residents’ medical needs. Even though most health facilities and hospitals were under pressure or even saturated, we considered that older patients should not be excluded from hospitalization on the basis of their age alone. We considered that hospital admission was relevant for patients with few comorbidities or a low level of dependence when clinical or laboratory criteria for severity were met or when other diagnoses had to be ruled out. If the patient agreed, he/she was admitted to hospital.
The French Geriatric and Gerontology Society (9) had developed a decision tree for COVID-19. Although the MMT considered this decision tree, decisions on hospitalization or the level of care also took account of clinical common sense and discussions between the MMT, the NH’s physician, and the head nurse. The patients and/or their legal guardian or family were kept informed about these discussions. In fact, most of the residents clearly expressed the wish to stay in their usual living environment (i.e. the NH). In other cases, patients appeared to be too frail and too severely ill to benefit from hospitalization.
With regard to treatment, the MMT considered whether or not antibiotic treatment was necessary and emphasized the importance of preventing dehydration, undernutrition, and loss of functional autonomy. The MMT reviewed the NH’s ability to provide oxygen therapy, palliative care, and end-of-life care. These procedures increased the burden of care and prompted the creation of COVID-19-only units.



Four key issues emerged from the MMT’s initial assessment: NH staff members (i) must know how to recognize the signs and symptoms of COVID-19, which are not the same in older adults as in younger adults, (ii) must be aware of how COVID-19 is transmitted and must use PPE appropriately; (iii) require information on patient management and a specific organizational structure for dealing with the COVID-19 outbreak, and (iv) require help with discussing medical decisions and the level of care.
Following our intervention, three NH residents were immediately hospitalized. Local health administrations were asked to reinforce the NHs’ staff. For example, scheduled surgical procedures in local hospitals and clinics were suspended and only emergency operations were carried out; this reduction in the level of activity freed up staff for temporary redeployment to NHs. Home hospital units also provided staff reinforcements for patients requiring a high level of care. The NH’s stocks of PPE, drugs and medical equipment were considered to be sufficient.
Collaboration between healthcare professionals appears to be crucial for developing guidance on the management of COVID-19: it combines the NH staff members’ knowledge of their residents and expertise in allocating resources within their own facilities, the geriatrician’s approach to caring for frail, older adults, the palliative care specialist’s expertise in end-of-life care, and the infectious disease specialist’s expertise on the management of infections. When an outbreak occurs, this emergency situation disrupts the NH’s organization. The NH staff member must then focus on acute medical care – a situation for which they are not prepared and which requires collaborative, adaptive strategies. The collaboration also improved our expertise in outbreak management. For example, screening for SARS-CoV-2 with a reverse transcriptase polymerase chain reaction (RT-PCR) assay (using nasopharyngeal swabs) became much more widely available about a week after our intervention in the NH. The NH’s coordinating physician and director asked all the residents and staff members to be tested. The screening detected a number of asymptomatic carriers among the residents and employees.
The residents who tested positive were isolated in a dedicated unit for two weeks or until they tested negative. The staff members who tested positive were asked to stay at home for two weeks. This broad nasopharyngeal swab screening program appeared to be very useful for controlling the outbreak. However, sensitive but less painful tests would be needed for regular testing, the detection of asymptomatic employees or residents, and thus the prevention of viral transmission. Approximately one month after all the NH staff and residents had been screened, the outbreak had been stabilized and no new cases were recorded.



Nursing homes are extremely vulnerable to contagious viral respiratory diseases such as COVID-19. Outbreaks can be dramatic, and preventing the virus from spreading is a priority (10). The COVID-19 pandemic has highlighted the need for collaboration between NHs and other health care facilities (11). The lessons that emerged from this initial collaboration can be summarized as followed:
1) Guidelines may help with consensus decision-making, the dissemination of information, and multidisciplinary collaboration.
2) Transmission of the virus must be limited by adopting appropriate hygiene measures (e.g. protective face masks), screening all NH residents and employees with an RT-PCR assay, and isolating all confirmed cases.
3) Sufficient human resources must be deployed quickly in these exceptional circumstances.

We hope that this feedback will help the authorities to provide useful, precise, specific guidelines on all aspects of managing COVID-19 outbreaks in NHs. A multidisciplinary MMT approach may help to develop appropriate strategies in NHs.


Acknowledgements: The authors thank the staff of the nursing home in which the intervention took place for their incredible dedication to the residents’ care. We thank Dr. David Fraser (Biotech Communication SARL, Ploudalmézeau, France) for copy-editing assistance and Eliane Sabourin for proofreading the manuscript.

Funding sources: This research did not receive any specific funding from agencies in the public, commercial, or not-for-profit sectors.

Conflicts of Interest: Dr. Adrien Lemaignen reports other from Gilead, non-financial support from Pfizer, personal fees from MSD, outside the submitted work. Pr Louis Bernard, Pr Bertrand Fougère, Dr Diama N’Diaye, Dr Chaumier and Dr Pierre Poupin declared no conflicts of interest.



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11. Stall NM, Farquharson C, Fan-Lun C et al. A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multi-Phase Emergency Response in Toronto, Canada. J Am Geriatr Soc. 2020, 2020 Jul;68(7):1376-1381.



C. Loecker, M. Schmaderer, L. Zimmerman


University of Nebraska Medical Center, College of Nursing, Omaha, NE, USA

Corresponding Author: Courtney Loecker, MSN, APRN-NP, AGACNP-BC, 985330 Nebraska Medical Center, Omaha, NE, USA, courtneyn.loecker@unmc.edu, 402-559-6571 phone, 402-472-7345 fax

J Frailty Aging 2021;in press
Published online April 14, 2021, http://dx.doi.org/10.14283/jfa.2021.14



Background: Frailty is a public health priority resulting in poor health outcomes and early mortality in older adults. Early identification, management, and prevention of frailty may reduce frailty trajectory into later life. However, little is known about frailty in younger adults.
Objective: Describe frailty prevalence, definitions, study designs, and components contributing to multidimensional frailty in 18 to 65-year-olds and impart guidance for future research, practice, and policies with potential to positively impact frail individuals.
Methods: Integrative review approach was selected to explore frailty allowing for inclusion of diverse methodologies and varied persepectives while maintaining rigor and applicability to evidence-based practice initiatives. CINAHL, Embase, PsycInfo, PubMed databases were searched for studies describing frailty in adults age 18 to 65. Articles were excluded if published prior to 2010, not in English, lacked frailty focus, or non-Western culture.
Results: Twelve descriptive correlational studies were included. No intervention or qualitative studies were identified. No standard conceptual definition of frailty was discovered. Studied in participants with health disparities (n=3) and chronic conditions (n=8); HIV was most common (n=4). Frailty prevalence ranged from 3.9% (313 of 8095) to 63% (24 of 38). Many factors associated with frailty were identified among physical (18) and social (14), and fewer among psychological (11) domains.
Conclusions: Universal frailty definition and multidimensional assessment tool is needed to generate generalizable results in future studies describing frailty in young and middle-aged adults. Early frailty identification by clinicians has potential to facilitate development and implementation of targeted interventions to prevent or mitigate frailty progression, but additional research is needed because risk factors in younger populations may be different than older adults.

Key words: Frail, medical frailty, disability, middle age, young adult.



Frailty, a physiologic decline that heightens vulneraiblity to stressors, is a public health priority according to the World Health Organization (1, 2). Frailty doubles the seven-year mortality rate in older adults, and up to 5% of deaths could be delayed if frailty was prevented (3, 4). Associated with increased risk for falls, disability, hospitalizations, increased costs, and early mortality (2, 4, 5), frailty is traditionally described in the elderly emphasizing functional decline seen with aging (4, 6). However, recent literature describes frailty as multifactorial inclusive not only of physical, but also social and psychological constructs, occurring on a continuum regardless of age (7, 9). A life-course approach has prompted researchers to explore frailty in younger adults with potentially modifiable risk factors that persist into older age (10, 12). Younger adults with comorbidities and lower psychosocial health demonstrate high frailty trajectory into older age (10, 11), but frailty and associated risk factors in earlier life are not well understood because most frailty research targets older adults (4, 8)..
Frailty identification is predominantly based on a physical phenotype (2) or accumulation of deficits approach (6), although both have been criticized for clinical impracticality (13, 14). Inconsistent definitions and myriad frailty tools complicate the arduous but seemingly beneficial task of frailty identification (8, 13-14). Helping to guide clinical decision-making or care planning around elective surgeries or procedures, frailty assessments have utility in clinical settings where biologic age can be a poor prognostic indicator (5, 15-16).
Adult Medicaid expansion represents an arena in which frailty assessment is especially important among younger adults (19 to 64-year-olds whose income is at or below 138% of the federal poverty level) (17). Individual states are required to define medical frailty intended to protect benefits for those with complex health care needs who do not qualify based on a disability. Improper determination could have dire consequences in a group of socioeconomically disadvantaged adults likely to have higher than average frailty rates (18). Failure to identify medical frailty could result in unmet needs or deprivation of key benefits succumbing to worse outcomes and higher costs. On the other hand, over-identification may result in wasted resources and excess expenditures.
Once identified, earlier targeted interventions have potential to prevent or mitigate frailty progression. Earlier health promotion or targeted population approaches in younger vulnerable adults may confer greater impact than directing strategies toward frailer older adults (12, 19-20). In a study that aimed to quantify frailty risk factors in over 6,000 middle-aged adults, unhealthy behaviors accounted for 30% of the socioeconomic gradient. Smoking, alcohol, activity, and diet have been identified as potentially modifiable frailty risk factors, but how and why risk factors develop in early adulthood remains unknown (10, 11). Another large cohort study observed age 65 as the turning point; frailty increased twice as fast after age 65 suggesting interventions may be more effective before old age (21). Evidence points toward opportunity to intervene early, but we need a better understanding of frailty in younger adults to help explain risk factors and their relationships. Therefore, the purpose of this integrative review is to synthesize literature to describe frailty prevalence, definitions, study designs, and components contributing to multidimensional frailty (physical, psychological, social) in 18 to 65-year-olds and impart guidance for future research, practice, and policies that has potential to positively impact frail individuals. This exploratory work also intends to support future inquiries surrounding medical frailty among Medicaid adult expansion beneficiaries in pursuit of a more cohesive characterization of frail young and middle-age adults.



Search Strategy

An integrative review approach was selected to explore the phenomenon of frailty in lieu of other review types (e.g., systematic, meta-analysis) because it allows for inclusion of diverse methodologies (e.g., experimental and non-experimental, quantitative and qualitative) while employing rigorous methods to explore a broad topic from many viewpoints rather than focusing on a specific clinical question (22). Findings from integrative reviews enhance holistic understanding of complex topics like frailty and can be applied to clinical practice and health care policy (22). Whittemore & Knafl’s (22) integrative review methodology was thus utilized to conduct a comprehensive search following steps of the PRISMA checklist (23). A sentinel frailty model expanding the concept to include tripartite domains of frailty and determinants of health was published in 2010 (7), followed by acknowledgement of frailty as a public health priority (1) thus prompting a search of articles from inception (February 2020) dating back to January 2010.
Databases CINAHL, Embase, PsycInfo, and PubMed were searched using subject search terms “frail*” or «medically frail» or «medical frailty,» and full text search terms «young old» or «young adult» or «middle old» or «middle age.» In addition, “psychological frailty» or «social frailty” or “physical frailty” as described in the theoretical Frailty Framework among Vulnerable Populations (FFVP) (9) were used as full text search terms individually and combined with aforementioned terms. The FFVP is a theoretical framework derived from extant frailty and vulnerability frameworks, empirical literature, and expert consultation recognizing multidimensional constructs of frailty (physical, psychological, social) among vulnerable populations regardless of age [9]. Adult Medicaid expansion beneficiaries represent young and middle-aged adults who may lack resources rendering them vulnerable, or at increased risk for frailty, and similar frailty domains may be evident among that population. Bibliographies of relevant articles were further hand searched. Efforts were thus made to include all articles addressing frailty specifically in 18 to 65-year-olds.

Selection Criteria

Articles were included in the review if they were published in English dating back to 2010 and described frailty in adults age 18 to 65 years. Age range representing Medicaid adult expansion beneficiaries (19 to 64 years) was expanded to include 18 and 65-year-olds because multiple studies would have been otherwise excluded. Qualitative and quantitative research was included as part of the integrative methodology. Western cultures were a criterion based on the knowledge that frail Medicaid adult expansion beneficiaries are recipients of traditional Western medicine favored in the United States and reflective of Western culture (e.g., evidence-based diagnosis and guideline-driven treatment recommendations based on symptom recognition, physical exam, and diagnostic confirmation) (24). Articles were excluded if they were dissertations, theses, abstracts, editorials, lacked a frailty focus (e.g., if frailty was not a variable or outcome but merely mentioned in text), if the study included “frail elderly” with “elderly” defined as greater than 65 years, or if the aim of this review was not addressed. Studies inclusive of those > 65 were intentionally omitted because it was felt including the elderly would misdirect the purpose of the review.

Data Abstraction

Study design, setting, country, sample size, baseline/defining participant characteristics, and physical, psychological, and social factors associated with frailty were abstracted. Frailty definitions, measurement tools, and prevalence of frailty and/or prefrailty were also gleaned from each study.



Study Selection

A total of 569 records were identified, 42 duplicates were removed, and 527 records were screened for eligibility through title and abstract review. Of those screened, 137 records, plus one record identified from a hand search of relevant articles’ bibliographies, totaling 138 underwent full-text review (see Figure 1). Of those 138 studies, 12 met criteria and were included in the review. A flowchart of the search strategy and selection criteria is depicted in Figure 1. Studies included in the review are summarized in Appendix A.

Figure 1. PRISMA diagram (23) depicts a flowchart of search strategy and selection criteria


Appraisal of Study Quality

Study appraisal was conducted using Joanna Briggs Institute (JBI) critical appraisal checklist (25) independently and agreed upon by a second author. The 8-item checklist was utilized for critical appraisal across all studies with a uniform approach to allow for comparison. The tool was felt to be appropriate because all studies contained primarily cross-sectional descriptive data. Initially designed for appraising cross-sectional analytical studies in systematic reviews, the tool is also used for appraising more broad topics such as those described in an integrative review (25). The appraisal results and JBI checklist are detailed in Appendix B and C, respectively. Percentage “yes” responses were calculated, omitting any “non-applicable” responses, and results ranged from 42% (26) to 100% (27). Criteria deemed “unclear” were similar among studies and may be attributed to heterogeneity of frailty tools and lack of ‘gold standard.’ Most studies did not clearly report reliability and validity for tool(s) (n=10) data (27- 36). In general, studies were considered of moderate to high quality evidence; all meeting nearly half (at least 42%), and majority meeting more than half (57%) of JBI criteria (27-33, 35-37). All articles were thus included in the review.

Defining Characteristics of Studies

Studies were primarily descriptive correlational (n=12) (26-37). Variations among these study designs included a prospective cohort of participants that attended a maximum of eight study visits every six months (29). Another included a prospective subset of participants that attended a follow-up visit approximately 3.5 years after baseline (36). Two authors described longitudinal associations of participants at baseline and one time point, six years and nine years, respectively (26, 32). A descriptive pilot study was included (36). Matched cohorts were compared in four descriptive correlational studies (26, 28-29, 32), and the remainder were single cohort cross-sectional (27, 30-31, 33-37).
Half of studies (n=6) included participants that were part of larger cohort studies, (28, 32-35, 37), and two samples were part of the same larger study involving adults infected with human immunodeficiency virus (HIV) (28, 34). Most studies were conducted in the continental United States (n=9) located in urban areas of the Midwest (26, 32, 36), Maryland (37) and California (27-29, 34). International study settings were the United Kingdom (35), Austria (31), and Turkey [30]. Sample sizes ranged widely from 38 to 8,095 participants. Age of participants ranged from 18 to 65 years at the time of baseline data collection. Mean age was reported by nine authors and ranged from 38.9 to 58.7 years. A study sample comprised only of women had the youngest mean age (38.9 years) of all studies (27). Follow-up periods in the two studies reporting prospective and longitudinal outcomes ranged from six months to nine years, respectively. Loss to follow-up was reported in studies that assessed mortality in relation to frailty; seven of 222 and 42 of 2541 participants (26, 37).

Frailty Definitions

A standard conceptualization of frailty was not recognized, but similarities suggested frailty is a multisystem (29, 34-36) age-related (29, 32-35, 37) syndrome (27, 30, 33, 37) characterized by vulnerability (28-29,32,34) to stressors (26, 28) that increases risk for adverse health outcomes (26-28, 30, 34, 37) and mortality (27, 32, 37). Physical attributes of Fried’s criteria are described as characterizing frailty by two authors (32-33). Accumulation of health deficits was an alternate approach to defining frailty (36). Physical, psychological, and social domains were specifically named by two authors (27, 36), and each domain was defined separately in one of the two articles (27). Prefrailty is simply described as “an early stage of frailty” (31) or “prodromal frailty” (37).

Frailty Operationalized

Fried’s criteria was utilized most often (n=9) (28-30, 32, 33, 35, 36). Also referred to as Fried’s Frailty Phenotype or Fried’s Frailty Index, Fried’s criteria defines frailty as the presence of at least three of the following criteria; weakness, slowness, shrinking (unintended weight loss), low activity level, and exhaustion. Prefrailty is the presence of at least two of the five criteria (2). Of the nine studies that operationalized frailty citing Fried’s criteria, five adapted criteria to meet the purpose or needs of the study or population (28, 29, 32, 33, 35). For example, “low lean muscle mass” was calculated using x-ray absorptiometry in childhood cancer survivors and a benchmark served as “unintended weight loss,” defined by Fried (2) as self-reported weight loss of 10 pounds or more in the past 12 months (32). Another study involving men with and without HIV categorized participants as frail if any one of Fried’s criteria was met (28). In a sample of English general practice patients, Fried’s criteria was adapted into a questionnaire and data was collected via mailed correspondence (35). The Frailty Instrument for Primary Care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI), a tool based on Fried’s criteria plus a sex-specific calculation, was used to operationalize frailty in a sample of patients with rheumatoid arthritis (31).
The second most common tools to measure frailty were the Frailty Index, a calculation of accumulated health deficits (n=2) (26, 36), and the FRAIL scale (n=2) (26, 37) which consists of self-reported fatigue, resistance (ability to climb 10 stairs), ambulation (ability to walk a quarter mile), number of illnesses, and loss of weight. One author adapted ‘loss of weight’ criteria to an inquiry about appetite (37).
Another study operationalized frailty using the 15-item Tilburg Frailty Indicator to assess specific domains of physical, psychological, and social frailty (27). The Study of Osteoporotic Fractures (SOF) scale (26) and the Comprehensive Frailty Assessment Instrument (CFAI) were also used to measure frailty (36).
Most studies measured frailty using only one tool (n=10) (27-29, 30, 31-34, 37); however, another study measured frailty using four tools (FRAIL, SOF, Fried’s criteria, and Frailty Index) (25). One study used two tools (CFAI and Fried’s Criteria) and created seven evidence-based questions (36). Measuring frailty using different tools in the same study sample of adults seeking care at free clinics yielded different results; 24 of 38 participants were determined frail using the CFAI versus 4 of 38 according to Fried’s criteria (36).
To operationalize prefrailty, Fried’s criteria was used most often (n=3) (28, 32, 35), but the CFAI (n=1) [36] and SHARE-FI (n=1) (31) were also utilized. Measuring prefrailty using different tools in a single sample also yielded different results; the CFAI determined only eight of 38 participants prefrail, but Fried’s criteria determined 21 of 38 participants prefrail (32).
Measurement data were gleaned from medical records and collected during study visits, mailed questionnaires (35), and home-based assessments (25).

Prevalence of Frailty

Frailty prevalence varied depending on the population, tool(s), and criteria used. Of those studies that reported frailty and prefrailty, prevalence ranged from 3.9% (313 of 8095) to 63% (24 of 38) (n=8) and 11% (125 of 1122) to 55% (21 of 38) (n=7), respectively (28, 30-33, 35-37). The table in Appendix D outlines each study’s author, publication year, purpose, frailty and prefrailty prevalence (if reported), and tool(s) used to measure frailty.
Some authors alternatively compared frailty among matched cohorts (n=3) (26,29,34). The proportion of “men who have sex with men” that converted to a positive frailty phenotype was 12% of HIV infected men versus 9% of HIV non-infected men (29). Mean frailty index scores were higher in a cohort of middle-aged African American diabetics compared to non- diabetics (26). A stepwise pattern of frailty index scores from more frail to less frail was described among three cohorts of comorbid HIV positive methamphetamine users, non-users, and a control group (34). One author quantified frailty with subscales of physical, psychological, and social frailty in homeless, formerly incarcerated women (27).

Factors Associated with Frailty

Factors associated with frailty were identified among nearly all studies and divided among physical, psychological, and social frailty domains (see Appendix A) guided by the FFVP (9). One descriptive study did not perform correlational statistics, so the strength or direction of variables were not described (36).
Physical domain. The most common factor identified was age (n=6) (27, 29, 30, 32, 33, 37), followed by HIV infection (n=3) (28, 29, 34), pain (n=2) (27, 31), diabetes (n=2) (26, 29), and higher BMI (n=2) (32, 36). Other factors were polypharmacy (37), functional limitations (26), comorbidities (34), kidney disease (29), hepatitis C infection (29), higher rheumatoid arthritis disease activity and longer duration (31), female gender (37), lower BMI (32), and prior radiation (32). Elevated cytokines (26) and laboratory abnormalities including decreased serum vitamin D, hemoglobin, and albumin levels in the setting of chronic kidney disease (26).
Psychological domain. Depressive symptoms (n=3) (27-29), illicit drug use (n=2) (27, 34), and smoking (n=2) (29, 32) were most commonly associated with frailty. Higher perceived stress (28), lower self-rated health (37), lower personal mastery, lower grit, lower optimism (28], emotional regulation difficulty, witnessed violence, and post-traumatic stress disorder symptoms (27] were also described as contributors to frailty.
Social domain. Unemployment (n=2) (31, 35) and lower education (n=2) (29,3 7) were most commonly associated with frailty in the social domain. Many other factors were reported; poverty (37), lower social support (28), black race (29), more likely to disclose HIV status to family (33), adverse employment outcomes, not coping at work, sick leave, health related job loss, homelessness, incarceration (27), negative interactions (28), and prior violence (27) were also associated with frailty.



This review aimed to synthesize literature to gain a better understanding of the current state of the science of frailty in young and middle-aged adults. We identified 12 studies that examined frailty in adults age 18 to 65 years. We expected to find frailty examined in vulnerable younger adult populations with comorbidities or disabilities, but frailty was also described in adults with health disparities (27, 36-37) underscoring the importance of considering socioeconomic contributions to frailty development in younger adults. Frailty prevalence ranged from 3.9% (313 of 8095) (35) to 63% (24 of 38) (36), proportions similarly reported in community-dwelling older adults (4% to 59%) depending on criteria and tool(s) utilized [38]. One explanation for this may be the lack of a uniform frailty definition, measurement tool, and criteria being adapted to meet the needs of a study or population.
The large variation of prefrailty prevalence described in the same sample using different tools (55% using CFAI versus 11% using Fried’s criteria) (36) may be explained by literature confirming unidimensional versus multidimensional tools captures different components of frailty (39). These findings further support the need for a uniform frailty measurement to enable relative comparisons. Of the six studies that described prefrailty, the proportions of prefrail participants were described as higher than frail participants with the exception of a study examining frailty in hemodialysis patients (53% frail, 18% prefrail) (30). Younger adults with advanced kidney disease may especially benefit from early frailty identification and intervention.
No universal frailty definition was recognized, but similar themes suggested frailty is a multidimensional state of reduced adaptability associated with age resulting in health-related adverse outcomes. This finding is consistent with recent literature highlighting the absence of a universal frailty definition and emerging evidence to support multiple overlapping domains of frailty (8, 9). Most authors used Fried’s physical phenotype to operationalize frailty despite discovering a number of social and psychological factors associated with frailty. Frailty in young and middle-aged adults compared to elderly may conceivably look different and potentially require an alternative operational definition. For example, grip strength as a single frailty measure (40) may be of less utility in younger adults compared to elderly. However, authors of the original investigations included in this review frequently adapted measurement tools to suit their population which is also a routine practice among studies inclusive of older adults (13, 14, 41). Our findings suggest a comprehensive standardized tool may capture additional frailty attributes specific to younger adults and allow for comparison across studies. Modifications for specific clinical needs or settings may also be beneficial based on the proportion of studies that modified existing frailty measures. The lack of reported reliability and validity of tools used by authors suggest validation of frailty tools in younger populations is also needed.
Prefrailty was measured most often using the physical phenotype, and consistently lacked explanation or definition. Implications of prefrailty were difficult to extrapolate without a conceptual meaning behind the reason for measurement. Although logical interpretation of prefrailty suggests the concept is a worthy focus of future frailty prevention and/or progression to a frail state, particularly given its prevalence described in this review (29, 30, 32, 34, 36, 37). All authors examined some aspect what contributed to frailty, but few described traditional outcomes (2, 42) like falls (26), functional status (26), and mortality (26, 32, 37). We recommend additional longitudinal studies to examine outcomes of frailty in young adults.
Factors associated with frailty in physical, psychological, and social domains were identified similar to those described in the FFVP (9). HIV infection, diabetes, and chronic kidney disease are described as health-related risk factors owing to frailty (9) and may represent valid health concerns for non-geriatric adults in the form of opportunistic infections, neuropathy, heart disease, or poor bone health. Early identification of health-related risk factors can allow for self-management interventions. Chronic disease can parallel biological mechanisms thought to contribute to frailty and accelerated aging in the form of chronic inflammation or hormone dysregulation reflective of HIV infection (43) or type 2 diabetes (44). Keeping viral loads undetectable through medication adherence or optimal blood sugar control with lifestyle changes may prove beneficial earlier in life. Unemployment (31, 35) is a situational frailty risk factor in the FFVP (9) that has potential to affect physical and/or mental health. Depressive symptoms and behaviors including illicit drug use and smoking are described as frailty risk factors in both the FFVP and this review. Depressive symptoms may influence all three frailty domains (9). Additional research is needed to untangle relationships among frailty risk factors and discover opportunities to favorably intervene.
A literature review examining frailty in older adults reported the most common components across physical, psychological, and social frailty domains were mobility, balance, nutrition, and cognitive function (39). In this review, the most common factors associated with frailty across all three domains, aside from older age, an expected finding (27, 29, 30, 32, 33, 37), were; unemployment (31, 35) lower education (29, 37), depressive symptoms (26, 27, 28), HIV (28, 29, 34), pain (27, 31), diabetes (24, 25), and abnormal BMI (32, 37). As young adults age with diabetes or HIV, unemployment may contribute to the inability to pay for preventative care or treatment of acute illness. Living with a chronic disease and/or unemployment may trigger depressive symptoms and result in further detriment, disability, or frailty. Early detection of frailty risk factors in an individual who is likely to experience frailty progression into older age thus presents an opportunity to intervene.
Existing literature clearly demonstrates patterns of increased health care costs and utilization associated with frailty in aging adults (45-47). This review offers new insight into frailty prevalence and factors associated with frailty among adults age 18 to 65 years. Based on these results, we suggest consideration of early frailty screening in younger adults with health disparities or chronic conditions, especially those with advanced kidney disease, HIV, diabetes, depressive symptoms, chronic pain, or obesity. Our findings are complimented by existing literature suggesting earlier frailty identification may be beneficial to develop targeted interventions (3, 48-51).
Intervention and qualitative studies were not identified suggesting there is much work to be done. Exercise and nutrition interventions to slow or reverse frailty have been described in older adults with some success (20, 52). Frail older adults have relayed the importance of social support and spirituality to ward off frailty (53, 54), but few studies incorporate experiences according to frail individuals. Adult Medicaid expansion beneficiaries represent a population of vulnerable younger adults in which attention to frailty is especially needed. Determination of medically frail individuals is important to preserve benefits but overidentification could waste resources. Informing policy makers about frailty in this population could thus support guidelines for accurate determination. Development and testing of tailored interventions are also important to consider given the increasing population of aging adults with comorbid conditions, but additional research is needed.


There were limitations to the present review. An existing theoretical framework (9) was utilized to help provide key search terms which may have introduced bias. Use of extant literature may pose a challenge to realizing aspects of frailty outside the framework, and potential findings may not have been elucidated in this review. A theoretical framework can also link findings to existing literature when studying a broad and comprehensive concept like frailty (55). Few studies have examined frailty in non-geriatric populations suggesting this area of research is in early stages, so including only peer-reviewed articles may have omitted unpublished data currently in development. Limiting the age range of study participants may have omitted studies inclusive of both frail younger and older adults; however, our intent was to explore frailty in those consistent in age with Medicaid adult expansion beneficiaries. Excluding studies published prior to 2010 may have eliminated literature that could have possibly contributed additional facets of frailty recognized among younger adults. Finally, one-third of articles examined frailty in adults with HIV. Generalization may be limited owing to the disproportionate number of studies involving HIV positive adults.



Frailty prevalence in young and middle-aged adults was similar to community-dwelling older adults, although factors associated with frailty across domains may differ. Presence of many physical and social, and fewer psychological factors associated with frailty suggest a multidimensional problem, but frailty was most often measured using a physical phenotype. Heterogeneity of frailty definitions, criteria, and tools used to measure frailty among samples with various health conditions and disparities created challenges in making relative comparisons across studies.
A universal frailty definition and multidimensional assessment tool that can be feasibly implemented in a variety of young and middle-aged populations is needed to conduct studies that can generate generalizable results. A robust understanding of factors associated with frailty in young and middle-aged adults is needed to assist with early detection, proper determination of medical frailty, and development of targeted interventions to prevent and/or mitigate frailty progression.


Disclosure statement: We have no disclosures.

Ethical Standards: This article does not contain studies with human participants performed by any of the authors.





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N. Sosowska, M. Pigłowska, A. Guligowska, B. Sołtysik, T. Kostka

Department of Geriatrics Healthy Ageing Research Centre, Medical University of Lodz, Lodz, Poland

Corresponding Author: Natalia Sosowska, Department of Geriatrics Healthy Ageing Research Centre, Medical University of Lodz, Lodz, Poland, natalia.sosowska@umed.lodz.pl
J Frailty Aging 2021;in press
Published online April 12, 2021, http://dx.doi.org/10.14283/jfa.2021.13



Purpose: Several diagnostic algorithms exist to detect sarcopenia in older adults. We compared the prevalence of sarcopenia according to the selected diagnostic algorithms.
Methods: This cross-sectional study compared the European Working Group of Sarcopenia in Older People (EWGSOP) 2010, updated EWGSOP 2019, the Foundation for National Institutes of Health (FNIH) and the International Working Group on Sarcopenia (IWGS) criteria in 778 outpatients of the Geriatric Clinic aged 60 to 89 years. Bioimpedance analysis (BIA) to estimate muscle mass, hand-held hydraulic dynamometer to measure muscle strength, the TUG test and gait speed to assess physical function were used.
Results: The prevalence of sarcopenia varied from 0% to 6.43% depending on the algorithm. For the majority of associations between the different definitions of sarcopenia the agreement was null or fair (Cohen’s kappa between 0.2 and 0.4). Moderate agreement (Cohen’s kappa between 0.4 and 0.6) was found for only three relationships. Nevertheless, for these three relationships, McNemar’s test has given different results, indicating that even in the moderately agreeing algorithms, the shared diagnoses of sarcopenia concerned only part of subjects.
Conclusions: According to diagnostic algorithms the prevalence of sarcopenia is low in independent community-dwelling older adults. The agreement between the different definitions is poor.

Key words: Sarcopenia; walking speed, Timed Up and Go, handgrip, BIA.



Sarcopenia is a disease affecting skeletal muscles. The term refers to the age-related muscle mass loss, deterioration of muscle function, and consequently physical capacity decline (1). In 1989 the term «sarcopenia» was used for the first time by Rosenberg as a combination of two words: Greek «sarx» for body (meat) and «penia» for loss, what refers to a noticeable decrease in muscle mass with age (2). The pathophysiology of sarcopenia includes decreasing number of muscle fibres, physical inactivity, hormonal changes, concomitant diseases and other potential reasons like a role of the gut microbiome (3).
The prevalence of sarcopenia is similar in women and men and sarcopenia is widespread especially amongst older, physically weak patients with osteoporosis and deteriorated health conditions (4, 5). The main and the most important manifestation of the problem is daily activity disfunction and recurring fall incidents (6). Increasing life expectancy and consecutive older population growth make the problem of sarcopenia more important than ever before (7). Exercise intervention, especially resistance training, is the best established method of the prevention and treatment of sarcopenia (8).
In 2010 The European Working Group of Sarcopenia in Older People (EWGSOP) created the operational diagnostic criteria for identification of people with sarcopenia (9). Then, in 2019 the document was updated, and the new definition was launched [10]. In the meantime, the Foundation for National Institutes of Health (FNIH) (11) and the International Working Group on Sarcopenia (IWGS) (6) presented their own definitions. Such a variety of different diagnostic criteria creates a problem of choosing the most sensitive and specific algorithm.
Several studies comparing different diagnostic criteria were performed (12-18). However, most of them do not include all definitions of sarcopenia mentioned above. Therefore, the aim of the present study was to compare the prevalence of sarcopenia according to selected diagnostic algorithms in a large population of older subjects.


Material and methods


The study was performed in 778 outpatients of the Geriatric Clinic of the Medical University of Lodz, Poland, aged 60 to 89 years who volunteered to participate in the study. The inclusion criteria were age 60 years and over, living in the community, logical contact that allows to understand the instructions, ability to walk, and written consent to participate in the study. We excluded patients who were not able or refused to perform necessary tests, not able to stand, with serious psycho-cognitive impairment, post recent hand surgery or inflammation in this location as well as those with an implemented pacemaker. The study flow chart has been presented in the Figure 1.

Figure 1. The flow chart of the study


The study was approved by the Bioethics Committee of the Medical University of Lodz and complies with the Declaration of Helsinki and Good Clinical Practice Guidelines.

Muscle mass

Bioimpedance analysis (BIA) was used to estimate muscle mass with AKERN BIA 101 device (Akern, Italy). The measurements were taken in the morning, with patients who have completed a minimum 4 hours fasting, in a supine position, between the patient’s wrist and ankle, on the right side of the body. Body mass and body height of participants were assessed with the RADWAG personal scale weight (WPT60_150OW) (Radwag Balances and Scales, Radom, Poland). The obtained raw BIA data: resistance (R, Ohm) and reactance (Xc, Ohm), as well as sex, body mass and body height were used to calculate skeletal muscle mass (SM) (19) and skeletal muscle index (SMI) (20), as well as to estimate appendicular skeletal muscle mass (ASM) (21) and appendicular lean mass (ALM) (22).

Muscle strength

The Jamar hand-held hydraulic dynamometer (model F12-0600) was used to measure muscle strength according to the standardized protocol (23). Patient in standing position repeated tests 3 times with each hand. The best score was used for analysis.

Physical performance

To assess physical function, the TUG test and gait speed were used. In TUG test, the time that participant needed to rise from a chair, walk 3 meters, turn around, walk back and sit down on the chair was recorded (24). Gait speed was assessed with the 4-meter Walking Test in 163 subjects (25). TUG test was performed in all the participants. To calculate gait speed values, the TUG test of 163 subjects was correlated with their gait speed (24, 26). For this correlation 0.8 m/s gait speed corresponded with 12.6s in TUG test while gait speed of 1 m/s with TUG of 9.9 s. Thereupon, these cut-off points of TUG test were used in the analysis for all the algorithms. TUG cut-off point of 20 seconds was also used as the performance measure for all the algorithms.

Sarcopenia algorithms

On the basis of the obtained data, the prevalence of sarcopenia was assessed according to different existing definitions: the EWGSOP (2010) (9), EWGSOP2 (2019) (10), FNIH (11) and IWGS (6). Additionally, some algorithms were used in different suggested variants.

The 2010 EWGSOP algorithm

In EWGSOP (2010) definition (9) Janssen formula to assess skeletal muscle mass was used (19), and SMI was calculated on the basis of Janssen et al. (19) The SMI cut-off points suggested by Janssen (20) as well as Chien (27) were used in the algorithm. According to this algorithm (9) patients were diagnosed as “sarcopenic” when they obtained the following results: 1) normal physical function, low muscle strength and low muscle mass; or 2) low physical function and low muscle mass.

The 2019 EWGSOP algorithm

In EWGSOP2 (2019) algorithm [10] ASM was presented in kilograms (kg) and kg divided by squared meters (kg/m2). According to this definition, sarcopenia was diagnosed in patients with low muscle strength and low muscle mass, whereas severe sarcopenia was diagnosed in patients who presented low muscle strength, low muscle mass and poor physical function. Additionally, probable sarcopenia was diagnosed according to the algorithm.

FNIH algorithm

On the basis of the FNIH definition patients were defined as sarcopenic when they presented low muscle strength and low muscle mass (11). As suggested, the ALM was presented as ALM/BMI. The cut-off points suggested by Cawthon et al. (28) were used.

IWGS algorithm

In the IWGS definition (6) the ALM divided by the height squared (ALM/ht²) was used with cut-off points of ≤ 7.23 kg/ m² in men and ≤ 5.67 kg/m² in women (6). According to the IWGS definition sarcopenia is diagnosed amongst patients with poor physical function and low muscle mass (6).
The cut-off points used in selected algorithms of sarcopenia are presented in Table 1. Algorithms for sarcopenia case findings and the number of patients diagnosed with sarcopenia according to different algorithms have been presented in Figures 2, 3, 4 and 5.

Table 1. Cut-off points according to selected algorithms of sarcopenia

Figure 2. EWGSOP 2010 algorithm. The number of patients with the risk of sarcopenia

J – Janssen cut-off points; C – Chien cut-off points

Figure 3. EWGSOP 2019 algorithm. The number of patients with the risk of sarcopenia

Figure 4. FNIH algorithm. The number of patients with the risk of sarcopenia

Figure 5. IWGS algorithm. The number of patients with the risk of sarcopenia


Statistical methods

Statistical analysis was performed using the Statistica (13.1) software (StatSoft). Cohen’s kappa and Mc Nemar’s test were used to compare the agreement between the different definitions of sarcopenia. Fleiss kappa was used to assess the overall concordance rate between the nine definitions of sarcopenia. Sample size required for the contingency tables in the category 2×2 to detect a difference between the two Cohen’s kappa coefficient values (K1 and K2) of 0.2 (K1=0.0 vs K2=0.2) is 194, while a difference of 0.3 (K1=0.0 vs K2=0.3), 0.4 (K1=0.0 vs K2=0.4) and 0.5 (K1=0.0 vs K2=0.5) will yield a minimum sample size of 85, 47 and 29, respectively. The level of significance was set at p < 0.05.



The characteristics of the patients have been presented in Table 2. Mean age of the studied population was 72 years and almost two third were women.

Table 2. Characteristics of the patients


The number of patients with sarcopenia and agreement between all analysed algorithms is presented in the Table 3. According to the EWGSOP 2010 definition, more sarcopenic individuals were found while Janssen cut-off points were used (6.43%) in comparison to Chien cut-off points (2.83%). Using the EWGSOP 2019 algorithm, 0.13% (ASM in kg/m²) and 1.54% (ASM in kg) of subjects were diagnosed as sarcopenic. Moreover, 0% (ASM in kg/m²) and 0.64% (ASM in kg) of patients were found as “sarcopenia severe”, but 4.37% as “probable sarcopenia”. The percentage of patients with sarcopenia according to the FNIH definition was 0.77% and according to IWGS criteria was 1.28%.
Cohen’s kappa (standard error for kappa) have been presented in the higher-right part of the Table 3. Number of patients with sarcopenia in a cross-table design (number of patients diagnosed with sarcopenia concomitantly in the two algorithms) and McNemar’s test have been shown in the lower-left part of the Table 3.

Table 3. Number of patients with sarcopenia and agreement between selected algorithms. Cohen’s kappa (standard error for kappa) have been presented in the higher-right part of the Table. Number of patients with sarcopenia in a cross-table design (number of patients diagnosed with sarcopenia concomitantly in the two algorithms) and McNemar’s test have been shown in the lower-left part of the Table

d – different; *p ≤ 0,05; **p ≤ 0,01; ***p ≤ 0,001; ns – not significant or values less than 0 for Cohen’s kappa


For the majority of associations the agreement was null (slight) or fair (Cohen’s kappa between 0.2 and 0.4). Moderate agreement (Cohen’s kappa between 0.4 and 0.6) was found for only three relationships. Nevertheless, for these three relationships, McNemar’s test has given different results, indicating that even in the moderately agreeing algorithms, the shared diagnoses of sarcopenia concerned only part of subjects. Lack of difference with McNemar’s test between some of the algorithms was due to the very small number of diagnosed sarcopenia cases. Cohen’s kappa for these associations was null or fair. Furthermore, an overall Fleiss kappa was 0.145 (standard error 0.00598), which means that global concordance rate between the nine definitions of sarcopenia is null (slight).
When TUG cut-off point of 20 seconds was used as the performance measure for all the algorithms, the number of patients with sarcopenia for EWGSOP 2019 algorithm has changed only for “Severity, ASM in kg” option. Likewise, the number of patients with sarcopenia has diminished when applying the TUG 20 seconds cut-off point for EWGSOP 2010 and IWGS algorithms. It did not substantially change the agreement indicators between those algorithms which remained poor.



In this study we have compared several definitions of sarcopenia in the largest so far Central-European population of older adults. Our data indicate that the overall agreement between those algorithms of sarcopenia definition is poor. This makes the message of geriatricians to the general medical community really diffused and hampers further use of sarcopenia as an important geriatric syndrome.
Available data in the literature present inconsistent results on the performance of screening methods for sarcopenia. The prevalence of sarcopenia varied from 5.7% to 16.7% depending on one of the five applied definitions in 306 community-dwelling subjects aged 74.8±5.9 years (29). The prevalence of probable sarcopenia at age 69 was 19% according to EWGSOP 2019 definition in1686 participants of the British National Survey of Health and Development (30). The prevalence of sarcopenia is higher in older and institutionalised subjects. Zeng et al. (15) presented the study about the prevalence of sarcopenia in 277 nursing home residents using 4 diagnostic criteria. The prevalence of sarcopenia was 32.5%,34.3%, 38.3%, and 31.4% according to the EWGSOP 2010, Asia Working Group for Sarcopenia (AWGS), IWGS, and FNIH criteria (15). In 249 older Spanish aged 84.9±6.7 years, 60.1% of the participants had sarcopenia and 58.1% had severe sarcopenia according to the EWGSOP 2019, while 63% had sarcopenia and 61.2%, severe sarcopenia according to the EWGSOP 2010 (14). On the other hand, sarcopenia prevalence according to EWGSOP 2010 (27.7%) was significantly higher than with EWGSOP 2019 (18.1%) in 144 older inpatients (12). In 114 patients with liver cirrhosis, 30.7% suffered from pre-sarcopenia and 36% from sarcopenia based on the EWGSOP 2010 definition, while with the EWGSOP 2019 definition, 3.5% were diagnosed with pre-sarcopenia and 16.7% with sarcopenia (31). The study carried out in patients with gastric cancer after gastrectomy showed similar prevalence of sarcopenia but suggests that sarcopenia defined by EWGSOP 2019 criteria better predicts clinical outcomes than that defined by EWGSOP 2010 criteria (32). In the recent large study, the prevalence of the disease has been shown to be low among the Canadian senior population and the agreement between IWGS, FNIH and EWGSOP 2019 definitions in diagnostic process of sarcopenia was poor (33).
One important issue is that the prevalence of sarcopenia prevalence varies with muscle strength or function definitions, and with population-specific vs. standard cut-off values (34). In 2,099 ambulatory community-dwelling older Korean adults the prevalence of probable sarcopenia (2.2%), confirmed sarcopenia (1.4%) and severe sarcopenia (0.8%) was low according to EWGSOP 2019 criteria (35). Differences in the prevalence of sarcopenia occurred depending on the criterion used, such as indicators of muscle strength or muscle mass (35). Amongst 248 older Turkish patients with endocrinological problems sarcopenia prevalence was 11.7% with EWGSOP 2019, and 41.1% by the use of regional grip strength thresholds for EWGSOP 2019 with body mass index adjustments for SM (36). In the present study, we used original cut-off points of selected algorithms. Nevertheless, adopting different muscle mass, muscle strength or performance criteria would have caused changes in the prevalence of sarcopenia. Furthermore, simplified diagnostic algorithms, e.g. without gait speed, are recently being sought (37).
Available literature shows that the agreement between existing definitions of sarcopenia is rather small. A slight to moderate agreement across five diagnostic definitions of sarcopenia was found, except the substantial agreement (Cohen’s kappa 0.71) observed when comparing the EWGSOP 2010 and IWGS definitions (29). Subsequent study about prevalence of the sarcopenia in 483 Chinese community-dwelling older people has shown a lack of consistency in the application of the EWGSOP 2019 definition in comparison with EWGSOP 2010, AWGS, IWGS and FNIH definitions (16). The prevalence of EWGSOP 2019-defined sarcopenia (men: 6.5%; women: 3.3%) was lower than that defined by the EWGSOP 2010 (men: 22.3%; women 11.7%), AWGS (men: 10.9%; women: 8.0%), and IWGS (men: 24.5%; women: 11.0%) criteria, but higher than FNIH criteria (men: 6.0%; women: 1.7%) (16). Another paper analysed the relationship between the criteria used in the old and the new EWGSOP definitions amongst 127 renal transplantation patients. There was a fair agreement between the two definitions when muscle strength measurement was performed by handgrip test, while the slight agreement was found for the Five Times Sit to Stand Test (13). In the study of Savas et al., the comparison of EWGSOP 2010 versus EWGSOP 2019 was not possible due to lack of sarcopenic patients with height adjustment (36).
In the present study the prevalence of sarcopenia was generally low in our community-dwelling older subjects. Furthermore, the prevalence of sarcopenia differed with EWGSOP 2010 definition depending on the SMI cut-off points and with EWGSOP 2019 criteria depending on algorithm (ASM presented in kg or in kg/m2, severe sarcopenia, probable sarcopenia). Overall agreement between all the selected definitions of sarcopenia was poor, suggesting further prospective studies and search for a more uniform algorithm of diagnosing sarcopenia.
Our study has some limitations. We were not able to conduct tests amongst people with severe dementia or those who due to mobility problems were not able to be present at our clinic and perform all the tests. Therefore, relatively young, high-functioning volunteer outpatients of the geriatric clinic participated in the study and the prevalence of sarcopenia was generally lower than in the literature, especially as compared to institutionalised older adults. Body composition cut-off values are usually based on DEXA, so it is not clear that these cut-off values can also be the same when measured by BIA. The study was conducted in a Central-European population and results may be different in other cultures. Nevertheless, the key strengths of the present study are careful recruitment procedures and large population studied.



An important difference in the diagnosis of sarcopenia according to diagnostic algorithms was found. These results support data from several previous studies (12, 13, 16, 17, 31)that there is a substantial mismatch in sarcopenia case finding between different algorithms. Further prospective studies and search for uniform definition are needed in order to present a robust algorithm of this important geriatric syndrome to the general medical community.

Key summary points

Aim: To investigate agreement between several diagnostic criteria of sarcopenia in community-dwelling older adults.
Findings: The prevalence of sarcopenia varied from 0% to 6.43% depending on the algorithm. The agreement between different definitions of sarcopenia was poor for the majority of associations.
Message: In independent community-dwelling older adults, the prevalence of sarcopenia is low and the agreement between the different definitions is poor according to the existing diagnostic algorithms. Further search for uniform definition is needed in order to present a robust algorithm of this important geriatric syndrome to the general medical community.


Acknowledgements: This study was supported by Grant 503/6-07701/503-61-002 from the Medical University of Lodz.

Conflict of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee: the Ethics Committee of the Medical University of Lodz, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.



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M. Gyenes1, I.-Y. Wang2, S.K. Sinha2,3,4

1. School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland; 2. Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Canada; 3. Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Canada; 4. Division of Geriatrics and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA

Corresponding Author: Michelle Gyenes, School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland, michellegyenes@rcsi.ie, @michellegyenes; Samir Sinha, Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto, Canada, samir.sinha@sinaihealth.ca @DrSamirSinha
J Frailty Aging 2021;in press
Published online April 30, 2021, http://dx.doi.org/10.14283/jfa.2021.11



OBJECTIVES: Unintentional weight loss (UIWL) is common among older adults but lacks standardized methods for its diagnosis and management. With a limited understanding on how geriatricians actually address UIWL, we conducted a survey to examine how they diagnose and manage it, and their opinions regarding the use of ice cream to address it.
DESIGN, SETTING, AND PARTICIPANTS: An international descriptive, cross-sectional, online survey conducted over a 16-week period in 2019 involving 1131 geriatricians in clinical practice across 51 countries.
MEASUREMENTS: We collected information around respondent demographics, use of screening tools and diagnostic investigations, and pharmacological and non-pharmacological approaches to address UIWL.
RESULTS: 89.1% of respondents reported frequently seeing UIWL. The most common methods reportedly used to evaluate UIWL were performing a comprehensive history and physical examination (97.4%) and assessing for cognitive impairment (86.5%). 74.2% noted that they routinely prescribed oral nutritional supplements and 71.6% involved non-medical professional(s) to help manage UIWL. While 50.4% reported recommending ice cream to their patients with UIWL, only 30.6% reported being aware of other colleagues recommending it. Geriatricians in practice for 30+ years were significantly more likely to recommend ice cream (P < 0.05). A thematic analysis of qualitative responses identified that prescribing ice cream tended to align both with patient preferences and socio-economic realities. CONCLUSION: While a majority of geriatricians surveyed routinely prescribe ONS and involve others to manage UIWL, at least half are also recommending ice cream. A key practice amongst experienced geriatricians, the use of ice cream could be better acknowledged as a practical and cost-effective way to address UIWL.

Key words: Geriatrics practice, malnutrition, weight loss, ice cream.



Unintentional weight loss (UIWL), defined as an involuntary decline in body weight (1), is experienced by between 15-25% of older adults (1–5) and has been associated with adverse health outcomes, including an increased risk of functional decline, hospitalization, and mortality (2, 6-8). Existing research has helped identify risk factors and etiologies for UIWL in older adults, which are typically multi-factorial. These include physiological determinants, such as disease- or medication-related effects, psychological factors such as depression or bereavement, and social determinants, such as low socio-economic status and decreased social activity; UIWL often involves a combination of these (6-12). UIWL occurs in community-dwelling older adults, in those receiving home care, in acute hospital settings, and in individuals living in long-term care homes (13). Despite being relatively common, the definition of UIWL remains ambiguous and accepted standardized methods for its diagnosis and management do not exist. UIWL is typically described as weight loss over a specified time period, such as a 5% loss of body weight over 6-12 months (2, 9, 10, 12), a decrease >3kg in the past 3 months (13), a 5% decline in 30 days or a 10% decline in a greater than 6 month period (6, 7).
The diagnosis of UIWL is essentially supported by the administration of malnutrition screening tools, along with a detailed history-taking and clinical examination, followed by additional investigations if required (6, 9, 13, 14). There is diagnostic association between unintentional weight loss and malnutrition, as described by the Global Leadership Initiative on Malnutrition in 2018, who proposed UIWL as one of the five majority criteria for diagnosing malnutrition (15). Despite this link, a recent review conducted by Power et al. (2018) found that of the 34 malnutrition screening tools used in older adults, 25 did not use appropriate reference standards (16). Validation studies for several of the tools yielded different results, questioning the overall validity of some tools (16) which further complicates the appropriate assessment of malnutrition and UIWL in older adults. To our knowledge no standardized guidelines to assess for and treat UIWL exist or have been widely adopted; as such, physician practices likely differ internationally (4, 13, 14).
The first-line treatment of UIWL typically involves a non-pharmacological approach, where patients are encouraged to eat their favorite foods and snack frequently to supplement their daily dietary intake (3, 17). If food supplementation is ineffective, oral nutritional supplements (ONS) or pharmacologic agents are often prescribed; however, evidence supporting the use of ONS has traditionally been of low quality, and compliance associated with their use is reportedly low (16). The use of pharmacologic agents to promote weight gain in older adults experiencing UIWL also remains controversial and is primarily employed on a case-by-case basis, mostly due to adverse effects associated with their use (7).
One non-pharmacological approach that has yet to be understood and empirically measured is the prescribing of ice cream by geriatricians. Dairy food supplementation has specifically been found to reduce malnutrition risk in older populations (17-19). For over a decade, physicians have been alluding to the prescribing of ice cream to their patients to promote weight gain (20). Furthermore, ice cream has been introduced in case reports as a meal supplement for older adults experiencing UIWL as early as the late 20th century (22-25). While ice cream may not be an ideal meal supplement for all older adults, particularly those with diabetes or lactose intolerance, it does appear to promote compliance and accommodate patient dietary preferences. Older adults often experience dysphagia, xerostomia, and anorexia (26-29), all risk factors contributing to reduced oral intake, malnutrition and weight loss. Nostalgia, ease of swallowing, cold temperature, “mouthfeel”, and the unique ability to match patient preferences with adequate caloric intake have all been suggested (30, 31) as potential reasons why encouraging the consumption of ice cream can be effective in promoting weight gain in older patients experiencing UIWL.
Despite the relatively high prevalence of UIWL in older adults, and the robust body of existing literature around the causes of and management strategies for UIWL, we are not aware of any research that explores how geriatricians throughout the world are actually assessing and managing this challenge in their patients. Furthermore, while prescribing ice cream has been briefly mentioned as a potential strategy to promote weight gain in nutritional guidelines and research papers, the practice has yet to be examined empirically to determine its scope and utility. To address this gap, we developed a survey to determine the self-reported practices of geriatricians around the world to assess and manage UIWL in their patients and their opinions regarding the use of ice cream to address it.



Literature Review

A literature search was conducted to determine existing studies surrounding UIWL in older adults, geriatrician methods for assessment and management of UIWL, and the use of ice cream to promote weight gain in patients experiencing UIWL. The search criteria included the following terms: “unintentional weight loss”; “unexplained weight loss”; “malnutrition”; “involuntary weight loss”; “geriatric”; “older adult”; “elderly”; “ice cream”; “oral nutritional supplements”; and “nutrition”, using MEDLINE, PubMed, PSYCInfo, AccessMedicine, and Cochrane Library. A grey literature search was further conducted using Google Scholar to obtain policy documents and additional reports. Literature related to the assessment and management of unintentional weight loss was included if it pertained to older adults or other vulnerable groups, as well as literature that referred to the prescribing of ice cream to treat UIWL in any population.

Survey Development

An English-language survey was developed for this study based on a literature review to explore existing studies surrounding UIWL in older adults, geriatrician methods for assessment and management of UIWL, and the use of ice cream to promote weight gain in patients experiencing UIWL. The survey was pilot tested by a team of academic geriatricians at Sinai Health System in Toronto, Canada for content and usability before being distributed internationally in accordance with SAGE research methods (32). The final 38-item survey (see Appendix A) also collected demographic information about training and practice settings of the survey respondents. Multiple choice and free text open response questions to obtain qualitative responses were utilized in the design of this survey. It was created and distributed using Survey Monkey, a well-established online survey tool that restricts surveys from being completed more than once from the same IP address, and was approved for use by the Mount Sinai Hospital Research Ethics Committee.

Geriatrician Engagement

We used several methods to engage geriatricians in completing the survey. These included working with over a dozen national and international societies to recruit their members through various channels to encourage completion of this web-based survey. The Survey Monkey link was shared via e-mail, newsletter and social media platforms over a 16-week period between August and November 2019.

Survey Response Data Analysis

A descriptive analysis of participant characteristics was performed. An analysis of the multiple choice response data was based on creating dummy variables to corresponding potential answers. Statistical significance among categorical variables was determined using the Pearson’s chi-squared test and followed by a Bonferroni post hoc multiple comparison where appropriate. All tests were 2-tailed and a p value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS Statistics version 26.0 (IBM Corp., Armonk, NY). The data were reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement. Responses to open-ended survey questions were coded and categorized for a qualitative analysis. Braun and Clarke’s six phases of thematic analysis were used to generate codes and search for, review, and define themes (33).



Respondents Demographic Information

In total, 1,131 responses were received from geriatricians in active clinical practice across 51 countries (see Appendix B for by-country breakdown of respondents). The countries with the greatest representation were the United States (n=233; 20.6%), Australia (n=160; 14.2%), and Italy (n=121; 10.7%).
66.3% (n=748) of respondents practiced in inpatient settings, 59.2% (n=668) practiced in outpatient/ambulatory settings and 30.2% (n=341) practiced in residential and other community-based settings. 548 (48.7%) respondents reported practicing in academic settings and 577 (51.3%) reported practicing in non-academic settings. Close to half of respondents had been practicing geriatric medicine for fewer than 10 years (n=547, 48.4%), with 24.3% (n=275) practicing between 10-19 years, 16.5% (n=186) practicing between 20-29 years, and 10.5% (n=119) practicing for more than 30 years.

Assessment/Management of UIWL in Older Adults

Among respondents, 933 (89.1%) reported that UIWL is commonly seen in their practice. 55.4% (n=592) reported that they screen their patient’s nutritional status between 76-100% of the time, while 23.2% (n=257) screen 51-75% of the time, 12.4% (n=137) screen 26-50% of the time, and 9.2% (n=102) screen 1-25% of the time. 21 (1.9%) respondents reported that they never screen their patients’ nutritional status. The most common screening tools used in the routine assessment of nutritional status were the Mini-Nutritional Assessment (n=499, 56.9%), the Malnutrition Universal Screening Tool (n=137, 15.6%) and the Subjective Global Assessment (n=100, 11.4%).
Geriatricians who reported practicing in primarily academic (p = 0.002) and inpatient (p = 0.004) settings were significantly more likely to routinely screen for UIWL than those in non-academic and primarily outpatient/ambulatory or residential and other community-based settings (Table 1). The two most common clinical practices reported in evaluating UIWL were conducting a comprehensive history and physical examination (n = 1,017; 97.4%) and assessing for cognitive impairment (n = 903; 86.5%). The most common laboratory, imaging, and other investigations reportedly used in suspected UIWL were a complete blood count (n=974, 94.2%), followed by thyroid function tests (n=937, 90.6%) and renal function tests (n=899, 86.9%).

Table 1. Characteristics of Survey Participants Associated with UIWL Related Practices


The reported routine management of UIWL among respondents involved the prescription of ONS, the referral to another non-medical professional, and the recommendation of specific dietary modifications. 772 (74.2%) respondents reported prescribing ONS in treating UIWL, while 15.6% (n=177) of respondents reported not prescribing ONS. Of those prescribing ONS, 24.1% (n=248) reported prescribing ONS to their patients 76-100% of the time, whereas 32.1% (n=317) reported 51-75% of the time, 25.2% (n=247) reported 26-50% of the time, and 17.0% (n=168) reported less than 25% of the time. In total 745 (71.6%) geriatricians reported making a referral to another non-medical professional as a means to manage UIWL. The most common non-medical professional that geriatricians reported referring patients with UIWL to were dieticians (n=889, 85.6%), followed by speech-language pathologists (n=527, 50.7%) and social workers (n=444, 42.7%).
69.2% (n=720) of respondents reported recommending specific dietary modifications to manage UIWL. The most common non-pharmacological interventions reportedly recommended by the respondents comprised of: optimizing energy intake (for example maximizing high-caloric foods at meals, eating smaller meals more often, eating favorite foods and snacks, providing finger foods) (n=932, 91.0%); minimizing dietary restrictions (n=816, 79.7%); and ensuring adequate oral health (n=673, 65.7%). The majority of survey respondents reported that they did not prescribe medications to treat UIWL (n=741, 72.7%). Of those that did (n=278, 27.3%), the most commonly reported prescribed medication was mirtazapine (n=233; 84.1%), followed by megestrol acetate (n=46; 16.6%).

Utilizing Ice Cream to Address UIWL in Older Adults

50.4% (n=540) of respondents reported having prescribed ice cream to their patients experiencing UIWL. Several demographic factors were identified as being associated with the likelihood of prescribing ice cream. Geriatricians in Italy (p < 0.0001), Singapore (p< 0.01), and the United States (p < 0.0001) were significantly more likely to have prescribed ice cream to their patients experiencing UIWL. Geriatricians in Australia (p < 0.0001), the Czech Republic (p < 0.05), Germany (p < 0.05), Japan (p < 0.0001), Turkey (p < 0.05) and the United Kingdom (p < 0.05) were significantly less likely to have prescribed ice cream (Figure 1). Respondents who reported practicing geriatric medicine for over 30 years were significantly more likely to have reported prescribing ice cream to their patients (p < 0.001) than those who practiced less than 30 years; practicing geriatric medicine for less than 10 years was associated with a significantly lower likelihood of having prescribed ice cream (p < 0.0001) (Table 1). Additionally, geriatricians who reported practicing in inpatient settings were more likely to have reported recommending ice cream for UIWL (p = 0.001) than geriatricians practicing in outpatient/ambulatory or residential and other community-based settings (Table 1).


Figure 1. Percent Likelihood of Prescribing Ice Cream and Country of Practice

Australia (p<0.0001), Czech Republic (p=0.014), Germany (p=0.025), Italy (p<0.0001), Japan (p<0.0001), Singapore (p=0.007), Turkey (p=0.039), UK (p=0.025), USA (p<0.0001_216) had significant differences. Sample size varied across different countries. The Czech Republic, Germany, Japan, Singapore, Turkey, UK had the number of respondents below 50 (Appendix C). Rx indicates prescription.


Of those who did not report prescribing ice cream (n=499), the majority explained that they did not because they had never heard of this strategy (n=303, 60.7%). 44% of respondents who reported that they did not prescribe ice cream reported that they would be more likely to prescribe ice cream if there was evidence to support this practice. Only 18 geriatricians responded that they will never prescribe ice cream (3.6%). Of the geriatricians reporting that they did prescribe ice cream, the vast majority reported not prescribing a specific quantity, but rather encouraging their patients to eat ice cream as a meal supplement (n=384, 75.7%). 205 (44.8%) respondents who reported prescribing ice cream further indicated that they would consider prescribing ice cream more often if some evidence existed to support this practice. Of all geriatrician respondents, 69.4% (n=699) reported not being aware of their colleagues prescribing ice cream as a meal supplement to promote weight gain.

Figure 2. Percent Likelihood of Prescribing Ice Cream and Routine Screening of Nutritional Status

Screening the nutritional status of patients 1-25% of the time (p=0.003), 26-50% of the time (p=0.043), and 76-100% of the time (p<0.0001) had significant differences. Rx indicates prescription.

Figure 3. Percent Likelihood of Prescribing Ice Cream and Routine Screening for UIWL

Rx indicates prescription.

Significant correlations were found between the reported likelihood of prescribing ice cream and approaches to assessing and managing UIWL. Respondents who reportedly screened the nutritional status of their patients 76-100% of the time were found to be significantly more likely to prescribe ice cream (p < 0.0001), while geriatricians who reported screening for nutritional status between 26-50% (p<0.05) and 1-25% (p<0.01) of the time were significantly less likely to have reported prescribing ice cream (Figure 2). Similarly, those who reported routinely screening for UIWL in their practices were significantly more likely to have prescribed ice cream (p < 0.001) (Figure 3). Finally, a reported awareness of their colleagues prescribing ice cream to patients experiencing UIWL was significantly associated with a higher likelihood of the geriatrician respondents prescribing ice cream (p < 0.0001) (Figure 4).

Figure 4. Percent Likelihood of Prescribing Ice Cream and Awareness of Colleagues Prescribing Ice Cream

Rx indicates prescription.


Geriatrician responses to the open-ended survey questions further contributed to this study’s qualitative thematic analysis. The following themes were identified pertaining to UIWL management and the use of ice cream: support of and alignment with patient preferences, acknowledging ethno-cultural and socio-economic factors, addressing specific etiologies of UIWL and the concept of “recommending” vs. “prescribing” a specific food.



Our international survey demonstrated that almost 90% of geriatricians reported commonly seeing UIWL in their practices; accordingly, over half reported screening the nutritional status of their patients more than 75% of the time. In understanding how geriatricians address this common problem, our survey showed that the majority follow a methodological evaluative approach that most commonly involves performing a comprehensive history and physical examination, assessing for cognitive impairment and depression, conducting laboratory investigations, and conducting a detailed medication review.
In order to treat UIWL, it further became clear that the majority of geriatricians do not prescribe medications to their patients but are more likely to prescribe ONS and seek the support of other healthcare professionals such as dieticians, social workers, speech-language pathologists, and dentists. According to our survey results, more geriatricians tended to report prescribing ONS (n=772, 74.2%) than recommending specific dietary changes (n=720, 69.2%). This finding, however, is inconsistent with existing ‘food first’ oriented guidelines (34-38), which recommend that ONS should typically not be used as a first-line treatment for malnutrition, and instead appropriate snacking routines and the fortification of foods should be used as initial treatments (34-39). While recent research has shown both improved quality of life and economic benefits to ONS use in long-term care or nursing home settings, there is less evidence supporting the use of ONS compared to the use of dietary advice and food supplementation strategies in community settings (17, 34, 35). In recommended care pathways, the possible prescription of ONS remains secondary to the assessment of malnutrition, setting treatment goals, and the provision of food fortification advice (18, 34-39).
Our study is the first to specifically examine ice cream prescribing to address UIWL and to report a 50.4% prescribing prevalence rate amongst geriatricians internationally to promote weight gain in their patients experiencing UIWL. Unsurprisingly, geriatricians who reported recommending ice cream were significantly more likely to be aware of their colleagues engaging in the practice. However, interestingly, while over half of the geriatricians surveyed have reportedly recommended the use of ice cream, only 30% reported being aware of their colleagues doing the same. Furthermore, it was clear that geriatricians, particularly with 30+ years of experience, felt more comfortable ascribing to the practice of prescribing ice cream compared to their less experienced colleagues.
While ice cream prescribing has been a seemingly surreptitious practice among many geriatricians to date, it became evident that this research survey began prompting a discussion surrounding the topic, including the practice’s potential benefits to patients. The prescribing of ice cream to manage UIWL seems to support the common theme of delivering more patient-centred care among many geriatricians, who felt that the ability to choose between brands and flavours helps to better align treatments with patient goals and preferences. Similar research has been conducted in other areas of medicine, including oncology, with reported decreased levels of anxiety and depression and improved quality of life having been achieved when ice cream was used (40). From an economic perspective, research supports the further exploration of the management of UIWL in older adults through the use of food supplementation. Recent reports have found that promoting choice in nursing home settings using a ‘food first’ approach had numerous economic benefits (41). One study found that increasing food budgets in nursing homes decreased the risk of malnutrition, thus proving to be ultimately cost-effective (42).
From the responses to our survey’s open-ended questions, it became evident that some geriatricians felt that there is an important distinction between “recommending” and “prescribing” a food, and that ethno-cultural and socio-economic factors are important considerations in determining which foods or supplements should be recommended to older adults. Furthermore, while many respondents acknowledged that prior to completing the survey, they had never heard of the practice of using of ice cream to address UIWL, several respondents indicated that they would now start recommending its use.
A key strength of this study is its large sample size, the largest known international survey of geriatricians on any topic known to date, that further allowed for distinct country and regional differences to be appreciated. A methodological weakness of this study was its sampling procedure which could have also introduced a potential for bias. While the survey tool specifically mentions geriatricians as its target group, there is a possibility that other professionals could have filled out the survey. Additionally, each geriatrics society had different policies, protocols and methods for promoting and circulating surveys amongst their members, which potentially allowed for differential country level response rates. A common weakness in study designs involving surveys is the potential for response bias (43). It is possible that geriatricians choosing to respond to our survey had a particular interest in or experience in managing UIWL or the prescribing of ice cream. These potential biases were mitigated as much as possible by obtaining a large sample size, to further ensure this study’s survey responses were representative and consistent. Finally, this is the first international survey on geriatrician practices regarding management of UIWL. As the survey was developed in English, we recognize that language barriers may have limited the volume of respondents surveyed from non-majority English speaking countries. This sample bias could further limit the capability of conclusions drawn about international geriatrician practice. Further study allowing better international engagement is required.
UIWL is commonly diagnosed and treated by geriatricians, with at least half of those surveyed describing they have recommended ice cream in the past to address it. The results of this survey can be used to further develop the evidence base and future potential guidelines for the assessment and management of UIWL in older adults that better emphasizes a ‘food first’ approach to treatment. Furthermore, geriatricians including both those that do and do not prescribe ice cream, reported that their likelihood of prescribing it would likely increase if there were greater evidence or even supportive guidance to further encourage and promote the practice. Finally, the practical value of prescribing ice cream or other calorie-rich desserts as a meal supplement for patients with UIWL that promotes a cost-effective and likely more preferred ‘food first’ approach should also be further explored.


Acknowledgments: We would like to thank Drs. Goldlist, Liberman, Romanovksy, and Stall at Sinai Health System for reviewing the draft survey. We would like to thank Nicoda Foster at Sinai Health System for guidance and assistance throughout the project. We would like to thank the Savlov and Schmidt families for supporting the Savlov/Schmidt Summer Scholars Program at Sinai Health System/University Health Network. We would like to thank the Royal College of Surgeons in Ireland (RCSI), University of Medicine & Health Sciences, for their support of MG in pursuing this research. We would like to thank the following geriatrics societies for distributing the survey to their members: Canadian Geriatrics Society (CGS), American Geriatrics Society (AGS), European Geriatric Medicine Society (EuGMS), Danish Geriatric Society (DGS), Icelandic Geriatrics Society (IGS), the Irish Society of Physicians in Geriatric Medicine (ISPGM), Israel Geriatric Society (IGS), South African Geriatrics Society (SAGS), Australian and New Zealand Society for Geriatric Medicine (ANZSGM), the Finnish Gerontological Society (FGS), the Czech Society of Gerontology and Geriatrics, the Austrian Society of Geriatrics and Gerontology, the Italian Society of Gerontology and Geriatrics (SIGG), the Singapore Geriatrics Society (SGS), the Hong Kong Geriatrics Society (HKGS), and the Malaysian Society for Geriatric Medicine (MSGM).


Conflicts of Interest: None to disclose.

Author Contributions: M.G. and S.S. contributed to the study design, survey development, data analysis and manuscript preparation. I.W. contributed to the data analysis and manuscript preparation.

Sponsor’s Role: None.

Ethical Standards: This research study was approved by the Mount Sinai Hospital Research Ethics Committee.




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R.C. Castrejón-Pérez

Instituto Nacional de Geriatría, National Institutes of Health, Health Ministry, Mexico

Corresponding Author: R.C. Castrejón-Pérez, Instituto Nacional de Geriatría, National Institutes of Health, Health Ministry, Mexico, rc.castrejon.perez@gmail.comrcastrejon@inger.gob.mx

J Frailty Aging 2021;in press
Published online March 30, 2021, http://dx.doi.org/10.14283/jfa.2021.10


Dear Editor,

The studies exploring the association between oral conditions and Frailty status are increasing in number, and many manuscripts have been published during the last couple of years. Even when Everaars et al. (1) manuscript is cross-sectional, it contributes to the knowledge by confirming the association between oral conditions and Frailty despite the selected strategy for measuring Frailty since authors added the interview Groningen Frailty Index and the Frailty Index (computed with data extracted from the Electronic Medical Record) to the most frequently used Frailty Phenotype and Kihon checklist (2).
The reviews by Hakeem et al. (2) and Torres et al. (3) summarised the oral characteristics (objective and subjective) associated with Frailty among older persons. However, oral problems occur simultaneously and interact with each other, resulting in a complex of oral conditions with a potentially adverse effect on oral functioning and compromising diet quality and nutritional status. Therefore, Everaars et al. add a diamond in the rock by referring to Oral Complications, implying the cumulative characteristic of oral conditions and the interaction between oral conditions and general conditions (such as sarcopenia) as suggested by Azzolino et al. (4)
The first measurement considering a cluster of oral conditions or oral complications is the Oral Frailty measurement, which in recent years is gaining popularity. It was first introduced in 2017 (5) and operationalized in 2018 (6) by combining the measurement of six oral characteristics (the number of teeth, chewing ability, articulatory motor skill for «ta,» tongue pressure, self-reported difficulty in eating tough foods, and self-reported difficulty in swallowing) into a single measurement. This combination resulted in a novel evaluation for Multidimensional Oral Function considering three dimensions (clinical characteristics, objective functional measurement, and self-reported), which additionally demonstrated predictability for Physical Frailty, Sarcopenia, Disability, and Mortality. (6)
Nutrition is among the most recognized factors associated with Frailty’s development, and it seems to be the main link between oral conditions and Frailty. The evidence linking oral conditions and Frailty is increasing with cross-sectional and prospective approaches. The main solo oral conditions associated with Frailty are the number of teeth, which by itself is associated with chewing difficulties and the need for removable dental prostheses, among others. Several interventions aiming to treat and manage the older persons’ Frailty status have been published focusing on nutritional interventions and exercise; however, none included an oral component (education or treatment) as part of the intervention.
Everaars et al.’s (1) findings are consistent with previous studies on the association between oral conditions and older persons’ Frailty status under cross-sectional and prospective approaches. Therefore, it is relevant to consider older people’s oral conditions to design and plan person-centered and populational-centered interventions and to design the older persons’ frailty treatment or management. It is also relevant to investigate the potential effect of oral interventions on older persons’ Frailty status.

Conflicts of Interest: I declare that I have no conflict of interest.


1. Everaars B, Jerković-Ćosić K, Bleijenberg N, de Wit NJ, van der Heijden G. Exploring Associations between Oral Health and Frailty in Community-Dwelling Older People. J Frailty Aging. 2021;10(1):56-62.
2. Hakeem FF, Bernabe E, Sabbah W. Association between oral health and Frailty: A systematic review of longitudinal studies. Gerodontology. 2019.
3. Torres LH, Tellez M, Hilgert JB, Hugo FN, de Sousa MD, Ismail AI. Frailty, Frailty Components, and Oral Health: A Systematic Review. J Am Geriatr Soc. 2015;63(12):2555-62.
4. Azzolino D, Passarelli PC, De Angelis P, Piccirillo GB, D’Addona A, Cesari M. Poor Oral Health as a Determinant of Malnutrition and Sarcopenia. Nutrients. 2019;11(12).
5. Kera T, Kawai H, Yoshida H, Hirano H, Kojima M, Fujiwara Y, et al. Classification of Frailty using the Kihon checklist: A cluster analysis of older adults in urban areas. Geriatr Gerontol Int. 2017;17(1):69-77.
6. Tanaka T, Takahashi K, Hirano H, Kikutani T, Watanabe Y, Ohara Y, et al. Oral Frailty as a Risk Factor for Physical Frailty and Mortality in Community-Dwelling Elderly. J Gerontol A Biol Sci Med Sci. 2018;73(12):1661-7.



P.J. Martin1, S. Billet1, Y. Landkocz1, B. Fougère2,3

1. Univ. Littoral Côte d’Opale, UR 4492, UCEIV, Unité de Chimie Environnementale et Interactions sur le Vivant, SFR Condorcet FR CNRS, F-59140 Dunkerque, France; 2. Division of Geriatric Medicine, Tours University Hospital, Tours, France; 3. Éducation, éthique, santé (EA 7505), Tours University, Tours, France.
Corresponding author: Dr. Sylvain Billet, Univ. Littoral Côte d’Opale, UR 4492, UCEIV, Maison de la Recherche en Environnement Industriel 2, 189A, Avenue Maurice Schumann, 59140 Dunkerque, France. Phone: +33-3 28 23 76 41, E-mail: sylvain.billet@univ-littoral.fr

J Frailty Aging 2021;in press
Published online March 13, 2021, http://dx.doi.org/10.14283/jfa.2021.8



The global COVID-19 pandemic has highlighted different vulnerability profiles among individuals. With the highest mortality rate, the elderly are a very sensitive group. With regard to the main symptoms, a failure of the respiratory system, associated with deregulation of the immune system, has been observed. These symptoms may also be encountered in chronic exposure of susceptible populations to air pollution, including exacerbation of the inflammatory response. Is there a relationship between age, pollution exposure and the severity of COVID-19? Although it is unclear how these parameters are related, the same pathways can be activated and appear to find a common mechanism of action in inflammation.

Key words: Inflammation, COVID-19, ageing, air pollution.




Acute inflammation is an immediate, rapid response to an attack on the body. When ­ as is usually the case ­ the inflammation is not excessive, it resolves itself after the harmful agent or pathogen has been destroyed or eliminated. Essentially, acute inflammation comprises four phases (1): homing of immune cells to the tissue; immune cell differentiation and activation in situ; a “switch» to suppressive cells; and a return to homeostasis. In contrast, chronic inflammation persists over time, does not resolve itself fully, and may damage the tissues concerned. It is known that both acute and chronic lung inflammation contributes to the harmful effects of inhaled pathogens or toxicants, and constitutes a pathogenic pathway in many lung diseases (2). Lung inflammation is characterized by two successive steps. Firstly, activated macrophages, neutrophils and T lymphocytes infiltrate into the airways. Secondly, chemokines, oxygen radicals, proteases and pro-inflammatory cytokines are produced. Cytokines include interleukin 6 (IL-6), tumor necrosis factor alpha (TNFα), and interleukin 12 (IL-12) (2, 3). The lung damage caused by excessive acute inflammation can lead to pulmonary fibrosis and can interfere with gas exchanges. Unresolved lung damage and chronic inflammation are frequently observed in acute respiratory distress syndrome, cystic fibrosis, chronic obstructive pulmonary disease (COPD), and asthma. When inflammation cannot be resolved properly, its characteristics change as more macrophages are recruited and the adaptive system starts to respond. In the worst cases, this inflammation can evolve into an often lethal cytokine storm (also referred to as «cytokine shock» or «cytokine release syndrome»). Although the links between ageing, atmospheric pollution and COVID-19 are difficult to pinpoint, there is evidence for common pathways based on deregulation of inflammation in particular. Despite the increasing number of publications on the emerging disease COVID-19, only one author has considered the possibility of a cross impact between these different factors and focused its analysis on the treatment of inflammation and thrombotic states (4). Therefore we propose a review that considers the mechanistic aspect that would underlie this common pathway.


Inflammation and COVID-19

A cytokine storm is a massive inflammatory phenomenon in which cytokine production is both excessive and self-sustaining (5). This phenomenon has been described in a broad range of infectious and non-infectious diseases, including some human respiratory tract diseases caused by coronaviruses (6). With regard to coronaviruses that have emerged in recent years, it has been shown that infection by Severe Acute Respiratory Syndrome (SARS) coronaviruses can result in the massive production of TNFα, IL-6 and IL-8, and that infection by Middle East Respiratory Syndrome (MERS)-related coronavirus leads to the production of IL-6, IL-1β, and IL-8 (6). In severe cases of COronaVIrus Disease 2019 (COVID-19), elevated blood levels of IL-1β, IL-6, IL-8, IL-12, interferon gamma (IFN-γ), granulocyte-macrophage colony-stimulating factor (GM-CSF) and TNFα-induced cytokines have been evidenced (7). Furthermore, lymphopenia is a universal feature in patients with COVID-19, and an analysis of T lymphocyte subsets shows a significant decrease in CD4+ and CD8+ T cells counts. Among the various cytokines involved in the cytokine storm, IL-6 and GM-CSF appear to have the most harmful effects in the exacerbation of inflammation, with (among other things) high blood pressure, tachycardia progressing to bradycardia, hypoxia, and pulmonary fibrosis. The subsequent acute respiratory distress syndrome can lead to multi-organ failure and death. Even at the beginning of the pandemic, physicians suspected that a cytokine storm was involved in the expression of the most severe forms of COVID-19.


Inflammation and ageing

Ageing and age-related diseases share some basic mechanistic components, many of which result in inflammation. The development of a chronic, sterile, low-grade inflammatory state contributes to the pathogenesis of age-related diseases (8). Biological ageing is the result of an accumulation of genetic and epigenetic changes that lead progressively to cell damage, impaired tissue function, vulnerability to stressors, low physiological reserves, and a more limited ability to maintain homeostasis (9). Although a single mechanism for the causes and progression of biological ageing has not been established, the most frequently cited etiologies are redox stress, immune system deregulation, mitochondrial dysfunction, glycation, hormonal changes, epigenetic modifications, and telomere attrition (10). The environment may also have a role in biological ageing by disrupting the homeostatic balance (11). Even though the involvement of the afore-mentioned factors is widely accepted, the cellular and molecular details of biological ageing have yet to be determined. Some studies have suggested that chronic inflammation accelerates biological ageing (12). Although the immune response that is characteristic of acute inflammation subsides within a few days, chronic inflammation is characterized by the release of elevated levels of pro-inflammatory cytokines in response to physiological and environmental stressors. This essentially shifts the immune system into a state of low-level activation (8). The chronically active immune system activity associated with advancing age has been termed “inflammatory ageing” or “inflammaging” (13–15). Although the detailed mechanisms have yet to be characterized, the pro-inflammatory cell phenotype associated with the upregulation of the inflammatory response with age has been found to have a role in the initiation and progression of age-related diseases such as cardiovascular disease, type II diabetes, frailty, sarcopenia, Alzheimer’s disease, osteoporosis, and cancer (16, 17).


Ageing and COVID-19

The COVID-19 pandemic is having a major impact on populations worldwide. Although all age groups are at risk of contracting COVID-19, older adults are the most at risk of severe disease as a result of age-related physiological changes and possible pre-existing conditions (18–20). A very recent report showed that the mean ± Standard Deviation (SD) age of patients with severe and critical forms of COVID-19 was 59.38 ± 16.54, with more than 50% over the age of 60 and a predominance of males (64.60%) (21). Similarly, over 50% of the deceased patients are aged 60 or over (21). A study published in The Lancet Infectious Diseases estimated that the proportion of infected people likely to be hospitalized increases with age, up to a maximum of 18.4% [95% confidence interval: 11.0-37.6] among people aged 80 or over (22). In Wuhan (China), patients over 65 years of age had a greater number of co-morbidities at baseline and displayed more severe symptoms (including multisystem failure and death) than younger patients did (23). Eight out of 10 deaths reportedly occur in people with at least one co-morbidity – particularly cardiovascular disease, hypertension, and diabetes, but also a range of other pre-existing chronic conditions that often appear with age (24). One explanation for this may be that immunosenescence in the older adult is associated with greater susceptibility to infectious disease (25). Hence, “inflammaging” can accentuate the harmful effects of SARS-CoV-2 infection. Conversely, an acute SARS-CoV-2 infection may worsen any chronic, age-related, pro-inflammatory conditions. When combined with immune senescence and the age- and sex-specific distributions of angiotensin-converting enzyme II (ACE 2) in the airway epithelium, this situation may accentuate the antiviral response to inflammation (53).


Air pollution and inflammation

As mentioned above, environmental factors can have a role in the occurrence of disease. Air pollution constitutes one of the best known environmental risk factors, and is thought to cause about 3.3 million premature deaths per year worldwide (26). Air pollution is composed of particles, gases, and bio-aerosols containing pollen and airborne microorganisms (viruses, bacteria, fungi, spores, etc.). A large number of studies have shown that exposure to air pollutants is associated with cardiovascular adverse events (27). Inflammation is very frequently cited as a cause of cardiovascular disease; it is not always associated with an infection and may be triggered by other “danger signals” referred to collectively as danger-associated molecular patterns. These patterns come from damaged or altered cells (e.g. cancer cells), chemical irritants (e.g. pollutants) and even physical disturbances (e.g. mechanical forces). This sterile inflammation may be associated with oxidative conditions that are potentially triggered or exacerbated by exposure to air pollution (28, 29). Oxidative stress is generally defined as a chronic shift in the intracellular redox balance towards oxidative conditions. It is initiated by reactive oxygen species (ROS) and reactive nitrogen species, and has a central role in many adverse health effects – particularly in the respiratory tract (3). High levels of ROS may exceed the cells’ antioxidant capacity and trigger a cascade of events closely associated with inflammation and, at higher concentrations, apoptosis and genetic and epigenetic alterations. Thus, increased activation of the transcription factor nuclear factor – kappa B by oxidative stress is involved in the regulation of a large number of genes controlling the inflammatory response (30). Furthermore, environmental exposure has been shown to increase levels of pro-inflammatory cytokines (e.g. IFNγ, IL 6, IL 8, IL 12, IL-1β, and TNFα) (31). The release of these cytokines into the lung and the peripheral blood leads to systemic inflammation and immune disorders (32–35). Exposure to air pollutants also increases the numbers of immune cells (neutrophils, lymphocytes and macrophages) that infiltrate into the lungs (36). Neutrophil recruitment to the lungs increases the inflammatory response and the resulting damage. During this pollutant-induced phase of inflammation, the number of macrophages also increases via differentiation of the infiltrated monocytes into M1 macrophages (37). Chronic exposure to pollutants such as fine particles (PM2.5) can raise levels of inflammatory markers such as C-reactive protein, which is directly involved in the development of cardiovascular disease (38). This can also lead to the development of chronic inflammatory diseases, such as asthma and COPD (39).


Air pollution and COVID-19

In recent years, a large number of research groups have examined the interaction between airborne particles and viruses. For example, the risk of pneumonia caused by respiratory syncytial virus (RSV) in children is increased by the penetrate of particulate pollutants (PM2.5 and PM10) deep into the respiratory tract (40). Similar results have been reported for measles, the incidence of which was significantly amplified by an increase in PM2.5 of 10 μg/m3 (4). In Europe, the epidemiological data show that the regions known to be the most polluted by PM2.5, PM10, and NO2 (Lombardy and the Po valley in northern Italy) were also the most affected by the spread of SARS-CoV-2 (42, 43). In the United States, the results of an ecological study of 98% of the American population (currently under review) suggested a strong association between elevated particulate matter concentrations and mortality rates due to COVID-19 (44). A slight increase in long-term exposure to PM2.5 leads to a large increase in mortality associated with COVID 19. A study conducted in 120 Chinese cities determined a significant association between a 10 μg/m3 increase in PM2.5, PM10, NO2 and O3 and the number of new positive cases (2.24%, 1.76%, 6.94% and 4.76%, respectively) (45). Thus, several research groups have looked at whether or not the presence of SARS-COV-2 RNA on particulate matter in outdoor air samples is a potential early indicator of the spread of COVID-19 (43). Thus, an RT-qPCR analysis of RNA extracted from 34 PM10 samples showed the presence of the E gene (which is specific for SARS-like viruses) and RdRP genes (which are highly specific for SARS-CoV-2) (46). However, it is not known whether virus-carrying particles are contagious. There are several possible explanations for the impact of air pollution exposure on the severity of COVID-19. One of them would be that chronic exposure to air pollution has been implicated in many cardiopulmonary diseases. The oxidative stress due to exposure to pollutants leads to the production of free radicals, which damage the respiratory system and reduce resistance to viral and bacterial infections. Pollutants might both directly impair the lungs’ ability to eliminate pathogens and indirectly exacerbate any underlying cardiovascular or pulmonary diseases (47, 48). The presence of co-morbidities leads to inflammation, and pollutant-induced oxidative stress and cell damage may worsen the prognosis (49, 50). Chronic exposure to PM2.5 leads to the overexpression of alveolar ACE-2 receptors; this increase might amplify the viral load, deplete ACE-2 receptors, and weaken host defenses. Moreover, NO2 acts as a pro-oxidant by depleting the anti-oxidant pool and thus impairing tissue defenses (especially phagocytic activity) and increasing inflammation and cell damage. Exposure to NO2 causes a severe form of COVID-19 in ACE-2-depleted lungs and thus worsens the outcome (51).


Inflammation at the crossroads?

The most severe forms of COVID-19 increase in prevalence with age; as described above, the oldest people have the highest mortality rate and the greatest risk of cytokine shock. The analysis of patients with COVID-19 patients shows that younger individuals are less affected by the disease (52). This can be explained by the immature immune system in children, who are much less affected by this epidemic (53, 54). Moreover, it is now well known that the effects of air pollution are exacerbated among the elderly, with effects on the immune, respiratory and cardiovascular systems (55, 56). The cytokine storm sometimes seen in COVID-19 is particularly damaging for older adults (57); in particular, myocardial injury can be amplified by exposure to particulate pollutants. Indeed, PM2.5 exposure is known to increase the risk of heart diseases like as acute myocardial injury and infarction (58). One of SARS-CoV-2’s first targets is the respiratory tract, which is continuously exposed to external stressors. Activation of the immune system in the lungs during exposure to gaseous or particulate pollutants has already been demonstrated – especially in sensitive individuals like older adults (56). Moreover, the aggravation of chronic inflammatory respiratory diseases (e.g. asthma) by air pollution has been widely described (59, 60). Thus, COVID-19 may have more serious outcomes (e.g. cytokine shock) when the respiratory tract has already been sensitized by chronic exposure to air pollution.



In conclusion, one can legitimately hypothesize that COVID-19 is synergized by age and exposure to air pollution via an exacerbation of inflammation. Further research is needed to determine the infectious potential of SARS-CoV-2 on particulate matter and the latter’s potential role in spreading disease. Public health policies in populations such as older adults (e.g. reducing their exposure to atmospheric pollution) may now be especially important. Furthermore, disparities in socioeconomic factors and elevated prevalences of diabetes, heart disease, and chronic airway diseases (e.g. lung cancer and COPD) are likely to accentuate the mortality rate among older populations (47). The presence of common pathways (including inflammation and repeated exposure to air pollutants) may have contributed to the disproportionate impact of COVID-19 on older adults.

Conflict of interest: The authors report no conflict of interest.
Author contributions: All the authors participated in the preparation of the manuscript, the search for publications and their analysis. The authors would like to thank David Fraser (Biotech Communication SARL) for his careful correction of the English language of the manuscript.
Sponsor’s role: This research did not receive any specific grant from funding agencies in the public, commercial, or not.


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Y. Rolland1, M. Cesari2, R.A. Fielding3, J.Y. Reginster4,5, B. Vellas7, A.J. Cruz-Jentoft6 and the ICFSR Task Force


1. Service de Médecine Interne et Gérontologie Clinique, Gérontopôle, CHU Toulouse, INSERM 1027, France; 2. IRCCS Istituti Clinici Scientifici Maugeri, University of Milan, Milan, Italy; 3. Tufts University, Boston, MA, USA; 4. Division of Epidemiology, Public Health and Health Economics, University of Liege, Liege, Belgium; 5. Chair for Biomarkers of Chronic Diseases, Biochemistry Department, College of Science, King Saud University, Riyadh, Kingdom of Saudi Arabia; 6. Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain; 7. Gerontopole, INSERM U1027, Alzheimer’s Disease Research and Clinical Center, Toulouse University Hospital, Toulouse, France
Corresponding author: Yves Rolland, Service de Médecine Interne et Gérontologie Clinique, Gérontopôle, CHU Toulouse, INSERM 1027, France, rolland.y@chu-toulouse.fr


Task Force members: Samuel Agus (Paris); Sandrine Andrieu (Toulouse, France); Mylène Aubertin-Leheudre (Montréal, Canada); Amos Baruch (South San Francisco, USA); Shalender Bhasin (Boston, USA); Louis Casteilla (Toulouse, France); Peggy Cawthon (San Francisco, USA) ; Manu Chakravarthy (Cambridge, USA); Rafael De Cabo (Baltimore, USA); Carla Delannoy (Vevey, Switzerland); Philipe De Souto Barreto (Toulouse, France) ; Waly Dioh (Paris, France); Luigi Ferrucci (Baltimore, USA); Françoise Forette (Paris, USA); Sophie Guyonnet (Toulouse); Joshua Hare (Miami) ; Darren Hwee (South San Francisco); Kala Kaspar (Vevey); Nathan LeBrasseur (Rochester, USA); Valérie Legrand (Nanterre, France); Roland Liblau (Toulouse, France); Yvette Luiking (Utrecht, The Netherland) ; Bradley Morgan (South San Francisco, USA) ; Eric Morgen (Richmond, USA); John Morley (St Louis, USA) ; Angelo Parini (Toulouse, USA); Suzette Pereira (Columbus, USA); Alfredo Ramirez (Cologne, USA); Leocadio Rodriguez Manas (Getafe (Madrid), Spain); Ricardo Rueda (Columbus, USA); Jorge Ruiz (Miami, USA); Peter Schüler (Langen, Germany); Alan Sinclair (London, United Kingdom); Nicolas Thevenet (Nanterre, France); Janneke Van Wijngaarden (Utrecht, The Netherlands); Bruno Vellas (Toulouse, France) ; José Viña (Valencia, Spain); Jeremy Walston (Baltimore, USA); Debra Waters (Dunedin, New Zealand)

J Frailty Aging 2021;in press
Published online February 7, 2021, http://dx.doi.org/10.14283/jfa.2021.4



Interactions among physiological pathways associated with osteoporosis and sarcopenia are thought to contribute to the onset of frailty. The International Conference on Frailty and Sarcopenia Research Task Force thus met in March 2020 to explore how emerging interventions to manage fracture and osteoporosis in older adults may reduce frailty, disability, morbidity, and mortality in the older population. Both pharmacological and non-pharmacological interventions (including nutritional intervention, exercise, and other lifestyle changes) were discussed, including nutritional intervention, exercise, and other lifestyle changes. Pharmacological treatments for osteoporosis include bone-forming and antiresorptive agents, which may optimally be used in sequential or combination regimens. Since similar mechanisms related to resorption underlie physiological changes in muscle and bone, these interventions may provide benefits beyond treating osteoporosis. Clinical trials to test these interventions, however, often exclude frail older persons because of comorbidities (such as mobility disability and cognitive impairment) or polypharmacy. The Task Force recommended that future clinical trials use harmonized protocols, including harmonized inclusion criteria and similar outcome measures; and that they test a range of multidomain therapies. They further advocated more high-quality research to develop interventions specifically for people who are frail and old. The ICOPE program recommended by WHO appears to be highly recommended to frail older adults with osteoporosis.

Key words: Frailty, osteoporosis, prevention, ICOPE.



All organisms show biologically driven declines in motor function as they age and these declines are closely linked to mortality (1, 2). In humans, these declines manifest as the frailty syndrome, which is defined by the overlapping characteristics of low physical activity, slowed motor performance, weakness, fatigue or exercise intolerance, and unintentional weight loss (3). Physiologically, frailty reflects a lowered resistance to stressors resulting from multi-systemic decline. Clinically, frailty is associated with diagnoses of sarcopenia, the age-related loss of muscle mass and strength, and osteoporosis, the loss of bone mass and the deterioration of bone tissue (4). When they occur together, the syndrome may be referred to as “osteosarcopenia” (5). Moreover, interactions between bone and muscle through multiple physiological pathways, including hormonal and inflammatory pathways, are thought to result in the frailty syndrome (6).
As it has done every year since 2014, the International Conference of Frailty and Sarcopenia Research (ICFSR) Task Force brought together researchers from academia and industry to discuss challenges and opportunities for managing frailty and sarcopenia. In 2020 the Task Force met in Toulouse, France, where it focused attention on emerging interventions to manage fracture and osteoporosis in frail older adults. This population group has often been excluded from recent osteoporosis drug trials due to comorbidities and polypharmacy, despite the fact that they may potentially benefit more from a treatment since they are more likely to have falls, fractures, disability and a poor prognosis.


Associations of frailty with osteoporosis, fragility fracture, and malnutrition

Bone fragility caused by osteoporosis occurs commonly in older adults and results in increased risk of fragility fracture (7). A systematic review of worldwide studies estimated that 9 million osteoporotic fractures occurred in 2000, resulting in substantial disability, morbidity, and mortality (8). However, osteoporosis may not be diagnosed until an individual has experienced multiple fragility fractures; and studies show that after diagnosis, treatment for osteoporosis is not routinely given in older adults and adherence to medical regimens is poor (9).
One of the most common and disabling fractures sustained by older persons is hip fracture, which may result in long-term mobility impairment, reduced ability to care for oneself or participate in everyday activities, pain, anxiety, and depression (10). Nutrition plays an important role in bone health and sarcopenia (11, 12), and malnutrition is common in individuals with hip fracture (13). Sarcopenia is also associated with an increased rate fractures in older adults (14, 15).
Most patients with hip fracture complain of pain and resulting functional limitations six months after the fracture (16), which can lead to a vicious cycle of self-medication and mistrust of clinicians (17). Recovery from hip fracture may be delayed in the presence of sarcopenia (18), and hip fracture may be particularly disabling in individuals with frailty (19). Nearly 30 years ago, Marottoli and colleagues showed that physical function before the fracture predicts functional recovery (20). Comorbidities, fear of falling, and other age-related conditions may further exacerbate hip fracture and its associated functional consequences (21, 22). Moreover, individuals over age 80 years, in addition to meeting the frailty phenotype proposed by Fried and colleagues (i.e., weight loss, fatigue, slow gait speed, weakness, sedentary lifestyle), often live alone, and often experience cognitive decline (23); thus they need special management for frailty. However, frail older persons are often excluded from clinical trials of fragility fracture interventions, in part because of comorbidities, sarcopenia, cognitive impairment, and polypharmacy (24).
The substantial impact of fragility fractures on functioning in frail older persons thus requires dedicated and multidisciplinary care pathways, which have been shown to improve quality of life and physical function and limit excessive costs (25,26). Intensive interventions including exercise and physical therapy immediately following hip fracture is essential. Preventive strategies also need to be widely implemented, including early identification of those at risk, increased prescribing of bone loss prevention treatments, and the introduction of care models based on the comprehensive geriatric assessment and personalization of interventions. Recently multidisciplinary, evidence-based guidelines for the management of osteoporosis and fragility fractures have been published (27–29).
Given the association of poor nutrition with sarcopenia and frailty (30, 31), assessment of the nutritional status of older adults provides a potential pathway to interventions that could delay or prevent these disabling conditions of aging (32). The Mini Nutritional Assessment (MNA) is a tool designed to rapidly assess nutritional status though a series of simple measurements and brief questions (33). The MNA has been validated in frail older persons (34) and in community-dwelling older adults, demonstrating that frailty and malnutrition are distinct but related conditions (35–37).
Using the MNA short form (MNA-SF), investigators showed that poor nutrition in combination with frailty was associated with an increased prevalence and incidence of poor functional outcomes in the Singapore Longitudinal Aging Study (32). In cancer patients, a low MNA score combined with a high Groningen Frailty Index (GFI) score was associated with an increased mortality risk (38). MNA score has also been used as a prognostic factor of adverse outcomes after hip fracture (39). Yet while there is mounting evidence about the importance of stratifying research populations for frailty, impaired nutritional status at baseline has been associated with greater benefits from the interventions (40, 41). The new ESPEN guidelines on the treatment of malnutrition in older people include a section on hip fracture, with the recommendation to incorporate nutrition intervention into a multidisciplinary approach (42).
As a screening tool in outpatients, the MNA-SF has been shown to have a sensitivity of 71.2% and specificity of 92.8% (AUC 0.906) for the detection of frailty, and a 45.7% sensitivity and 78.3% specificity (AUC 0.687) for the detection of pre-frailty (43). In hospitalized patients, the MNA-SF predicted frailty with good sensitivity but only marginal specificity (44). There is no evidence that the MNA can be used as an outcome measure in trials.


Pharmacological treatment for osteoporosis, sarcopenia, and frailty

Better targeting of therapeutic interventions for the management of osteoporosis starts with diagnosis, identification of risk factors, and an assessment of fracture risk (45). The International Osteoporosis Foundation and European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis published guidance for the diagnosis and management of osteoporosis in 2013, and recently updated such guidance (46). Diagnostic criteria for sarcopenia have also been recommended by other different groups. The European Working Group on Sarcopenia in Older People (EWGSOP) published a definition in 2010 and updated it in 2019 based on a better understanding of the condition (47,48); and the ICFSR published guidelines on the management of sarcopenia in 2018 (49). In 2017, sarcopenia also was assigned a diagnostic code in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code book, indicating recognition of sarcopenia as a separately reportable disease condition for clinical practice and drug development (50).
A fracture may trigger a downward spiral of recurrent fractures known as the “fracture cascade” (51). A study in Iceland showed that the first fracture dramatically increases the risk of a subsequent fractures, particularly during the first year following the first event and regardless of the site of it. The authors concluded that treatment should be started immediately to prevent recurrence of the problem (52). Bone fragility, determined by assessing bone mineral density (BMD) at the hip or spine by DXA scan, is associated with high fracture risk (53), suggesting that restoring bone density may significantly reduce the risk of a second fracture. Low muscle strength and low physical function (sarcopenia) also increase the risk of injurious falls and fractures after a first hip fracture (54).
Several bone-forming drugs are clinically available, including anti-resorptive agents such as denosumab (55–57); romosozumab, a monoclonal antibody that both increases bone formation and inhibits bone resorption (58,59); anabolic agents such as teriparatide (60) and abaloparatide (61–63); biphosphonates such as alendronate and zoledronic acid (64); and myostatin inhibitors, which are also under research as potential drugs to treat sarcopenia (65, 66).
Optimal treatment of osteoporosis may require sequential or combination therapies, for example starting with a bone forming agent then add an antiresorptive agent for maintenance. For example, in the phase 2 FRActure study in postmenopausal woMen with ostEoporosis (FRAME), romosuzumab followed by denosumab reduced the risk of fracture in postmenopausal women (67). Other sequential regimens that have shown promise in lowering fracture risk and/or increasing bone density include romosozumab followed by alendronate (68), abaloparatide followed by alendronate (69,70), and combination denosumab/teriparatide followed by denosumab alone (71).


Preventing frailty and its consequences through nutrition and exercise

The concept of frailty facilitates a better understanding of heterogeneity in the older population and promotes study of the aging process. It provides a possible target for preventive measures aimed at reducing the functional decline and the occurrence of negative events such as falls and fractures (72, 73). Frail patients present with weakness, fatigue, a sedentary lifestyle and mobility impairment. They may have anorexia and recent weight loss. All of these clinical signs increase the risk of falls and fractures. They are also accessible to interventions such as nutritional management and/or physical exercise (focused on strength training and balance), which reduce the risk of falling (74, 75).
Several mechanisms responsible for both growth and decline of muscles and bones are shared. It has been hypothesized that pharmacological, nutritional, and/or exercise-based interventions may also overlap and provide mutual/dual benefits (76). For example, both skeletal muscle and bone respond to treatment with androgens, and exercise is an essential element of treatment regimens for osteoporosis, sarcopenia, and frailty. Malnutrition plays an important role in the development of both sarcopenia and frailty (31). Decreased dietary protein intake has been shown to result in decreased lean muscle mass in the Health Aging and Body Composition (ABC) Study (77). The Vitality, Independence and Vigor Study (VIVE2) showed that a high protein, high vitamin D nutritional supplement added to a physical activity intervention led to improvements in muscle density and a loss of intermuscular fat in mobility-limited older adults (78), although these benefits seemed insufficient to improve functional measures such as gait speed (79). Other studies have shown that a combination of resistance exercise and increased protein intake prevented muscle wasting in older adults (80, 81).
Obesity is known to contribute to functional declines and frailty in older adults. Sarcopenia in combination with obesity – a condition known as sarcopenic obesity – increases the risk of functional decline through multiple synergistic pathways. Intervention strategies to combat sarcopenic obesity include weight reduction, calorie restriction, and exercise. Pharmacological strategies may also prove useful (82). Weight reduction through calorie restriction has been shown to have positive effects on longevity, yet it also may result in a loss of fat and lean mass and bone density (83,84). In a study of older frail obese adults, an intervention that combined weight loss and aerobic plus resistance exercise, Villareal and colleagues showed that in comparison to either approach alone, the combination resulted in greater physical function and aerobic capacity and attenuated the loss of bone mineral density (85, 86).
The mechanisms by which dietary changes and exercise influence muscle and bone provide clues that may help design better and more targeted intervention strategies. For example, evidence implicates age-related declines in muscle insulin-like growth factor 1 (IGF-1) in sarcopenia; and both exercise and injury increase IGF-1, IGF-1 receptors, and IGF-1 activated signaling pathways. Aging muscle may have less ability to synthesize IGF-1 or may be resistant to IGF-1, and aging may also be associated with attenuation of the ability of exercise to induce IGF-1 (87).
A small study of healthy older women fed with a low-protein diet for 10 weeks showed a decline in both muscle mass and IGF-1 (88). More than 20 years ago, Rizzoli and colleagues showed that protein supplementation in frail individuals post hip fracture restored levels of IGF-1 in the plasma and attenuated loss in bone mineral density compared to placebo (89). Supplementation with selenium and coenzyme Q10 have also been shown to increase levels of IGF-1 in older adults (90).
Skeletal muscle cells express the vitamin D receptor (VDR), and low levels of vitamin D have been associated with lower muscle strength, mobility impairments, and disability (91). In mobility-impaired older women, vitamin D supplementation increased VDR expression and improved skeletal muscle fiber size (92). However, another study in older adults with low baseline levels of serum 25(OH)D showed that while supplementation increased serum levels to more normal levels, there was no effect on lean mass, lower-extremity power, or strength (93).
Nutritional supplements that target inflammation have also been proposed as a strategy for improving muscle function in older adults. For example, omega-3 fatty acids derived from fish oil have also been shown to slow decline in muscle mass and function in older adults (94). However, a recent clinical trial, the ENabling Reduction of low-Grade Inflammation in SEniors (ENRGISE) Pilot study, which tested the efficacy of fish oil and the angiotensin receptor blocker losartan in older, mobility-impaired adults, showed no improvement of walking speed or serum level of the inflammatory marker IL-6 (95).
Demonstrating the efficacy of nutritional interventions is challenging for many reasons, including the difficulty of determining whether the baseline level of dietary intake is inadequate and capturing subtle effects of change from baseline. These challenges are exacerbated when nutritional interventions are superimposed on other interventions.


Designing clinical trials to target bone fracture in frail older adults

The burden of fracture is expected to increase worldwide as the population ages, yet few trials have assessed the benefit of treatments in the oldest old and even less in the frail population (96, 97). Thus, fracture prevention and optimizing bone health represent important public health goals. Interventions that target the frail population offer the potential for the greatest benefit, as was demonstrated in a study by Rolland and colleagues, which tested the ability of strontium ranelate to reduce vertebral fractures in osteoporotic women, independently of frailty status (98). Beyond pharmacological interventions, nutrition and exercise have been shown to act synergistically to improve bone and muscle health and thus should be incorporated into randomized clinical trials (99).
To increase the efficiency and maximizing learnings from clinical studies, sponsors and researchers should use harmonized protocols with similar outcome measures. The ICFSR Task Force suggested the following:

Possible Study Design

The placebo-controlled, parallel-arm, double-blind trial is the gold standard for assessing efficacy and effectiveness. Other elements of an optimal trial design include:
• A long run-in phase before initiating treatment, during which activity diaries could be monitored and dietary inadequacies or anemia corrected to ensure a stable baseline.
• 2 x 2 designs for studies testing multimodal approaches such as resistance exercise and/or combination of resistance and aerobic exercise and nutrition.
• Using assessment time points that have been harmonized with other studies to enable data pooling and meta-analyses of data.
• Use the gold standard of collecting falls incidence using monthly calendars.
• At least one-year of follow up. If studies aim to target bone fracture or prevent the progression from pre-sarcopenia to sarcopenia, long follow-up will be necessary.

Proposed Outcomes

• Primary outcome: fragility fractures at 24 months (hip and spine).
• Secondary outcomes:
o Physical performance and disability as measures of functional decline
o Injurious falls
o Patient-reported outcomes, including mobility assessments and quality of life
o Nursing home admissions
o Bone turnover biomarkers
o BMD assessment (hip and spine)
• Exploratory outcomes
o Cognitive function
o Comorbidities
o Survival

Note that Fragility fractures or injurious falls as the primary outcome will require a very large sample size. Benefit of pharmacological treatment has also needed a large sample size.

Potential Target Population

• Patients with low BMD, high rate of falls (such as ≥2 self-reported falls/year), and frailty.
• Inclusion criteria: ≥ 75 years old with osteoporosis defined by low BMD, FRAX, and/or history of osteoporotic fracture, and with frailty defined by variable proven predictive of falls (100). Patients in nursing homes and those with dementia should be included where possible.
• Exclusions: Projected life expectancy < 2 years or estimated glomerular filtration rate < 30 mL/min/1.73 m2, individuals who are bedridden or who have contraindications related to the drug being tested

Design of Interventions

Frailty is a complex syndrome requiring multidimensional interventions. Interventions should target two or more risk factors for falls. For example, polypharmacy and some specific medications have been associated with increase fracture risk (101, 102). The European Geriatric Medicine Society (EuGMS) Task and Finish group on Fall-Risk-Increasing Drugs (FRIDs) recently proposed practical recommendation and strategies to reduce the use of FRIDs (103). The increase risk of falls related to the use of psychotropics drugs (104), cardiovascular drugs (105) and other medications (106) is now well-known. As the field of geroscience continues to emerge, it may become possible to target aging itself (107). For example, cellular senescence represents a promising therapeutic paradigm for potentially preventing or even reversing age-related osteoporosis and simultaneously treating multiple aging comorbidities (108).
Multidomain interventions for preventing falls in older people living in the community typically include physical activity (strength and balance classes with walking practice), and deprescribing. A systematic review and meta-analysis concluded that such multidomain interventions may reduce the rate of falls and recurrent falls, although the impact on fracture reduction has not been clearly demonstrated (109).
To test an osteoporosis drug in combination with a multidomain intervention, four parallel groups are recommended: 1) osteoporosis drug alone, 2) multidomain intervention alone, 3) osteoporosis drug plus multidomain intervention, 4) placebo or active comparator.
The Multidomain Alzheimer’s Prevention Trial (MAPT) study is an example of a multidomain trial in frail older adults (110). This three-year, multicenter, randomized, placebo-controlled superiority trial enrolled community-dwelling persons aged 70 or older with spontaneous memory complaints, absence of dementia, and limitations in one instrumental activity of daily living or slow gait speed. They were randomly assigned to one of four groups: 1) a multidomain intervention comprising cognitive training, physical activity, and nutritional counseling plus omega-3 polyunsaturated fatty acids with a total daily dose of 800 mg docosahexaenoic acid and 225 mg eicosapentaenoic acid, 2) the multidomain intervention plus placebo, 3)omega-3 polyunsaturated fatty acids alone, or 4) placebo alone. The trial was registered with ClinicalTrials. gov (NCT00672685).


Conclusions and next steps

The ICFSR Task Force reached several conclusions. First, it recognized that the traditional care system is inadequate for dealing with complex health disorders of aging such as frailty, where multidisciplinarity is required (111, 112). Cognitive impairment is often associated with frailty and must be taken into consideration (113, 114). The links between frailty and cognition are now well described (115–117) and integrated care like the ICOPE program have to be promoted to prevent and treat fractures in frail older persons (118–121).
Second, the Task Force suggested that reducing fracture risk among older adults requires first intervening with a powerful agent to restore the strength of bone, and then switching to an anti-resorptive agent to maintain bone health. The need for treatment is especially true after a first major hip fracture. The high cost of many of these drugs imposes a barrier to such an approach and payers will require studies that document efficacy; yet fractures themselves are costly and health economics studies show that bone forming agents are cost-effective even over short time periods. Combination therapies were also recommended, not just for treating the bone but for other factors as well, particularly in individuals who are frail. Benefits of these drugs in frail populations with high risk of fracture, short life expectancy, and high risk of adverse events such as nursing home residents should be investigated. One problem is that these frail older adults often take many drugs due to co-morbidities, including cognitive impairment, undernutrition, depression, and loneliness, raising questions about the value of further adding drugs to treat osteoporosis versus decreasing drug consumption in frail older adults. Advances in the field of geroscience may help in the future to answer these questions by introducing new biomarkers and better targeted therapies (122–124).
Third, the Task Force noted that while pathophysiology of bone fracture is the same in frail and non-frail adults, the mechanisms that lead to bone fracture – poor balance, sarcopenia, poor physical performance, sedentary lifestyle, and poor nutritional status – differ. Given these differences, specific recommendations may be needed for interventions in people who are frail, for example by more routinely adopting multidimensional and comprehensive interventions (125). To develop these interventions, more studies are needed in people who are frail and old. In addition, high-quality research is needed to confirm the role of nutrition in reversing or preventing frailty and adverse outcomes in frail persons (126, 127). Moreover the ICOPE program developed by WHO appears to be most useful for the frail older adults with osteoporosis to maintain Intrinsic capacities, monitor functions with ICOPE MONITOR (119) and prevent further disabilities (Table 1).

Table 1
Screening Tool for the “Integrated Care for Older Persons” (ICOPE)


Acknowledgements: The authors thank Lisa J. Bain for assistance in the preparation of this manuscript.
Conflicts of interest: ACJ reports grants or personal fees from Fresenius Kabi, Abbott Nutrition, Nestlé, Nutricia, Sanofi, and Pfizer, all unrelated to the submitted article. MC is member of Advisory Board for Nestlé.
Ethical Standards: None
Open Access: This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.



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S. Dupuis-Blanchard1, C. Bigonnesse1, M.K. Andrew2, O. Gould3, D. Maillet1

1. Université de Moncton, Moncton, Canada; 2. Dalhousie University, Halifax, Canada; 3. Mount Allison University, Sackville, Canada.
Corresponding author: Suzanne Dupuis-Blanchard, School of Nursing, Université de Moncton, 18 Antonine Maillet Ave., Moncton, NB E1A 3E9, Canada,
Email : suzanne.dupuis-blanchard@umoncton.ca, Telephone : (506)858-4673, Fax : (506)858-4017

J Frailty Aging 2021;in press
Published online January 18, 2021, http://dx.doi.org/10.14283/jfa.2021.3



Background: The relationship between frailty and variables such as housing are the least included in models of frailty and research on frailty or social frailty and relocation is negligible. The decision to relocate is complex and demanding for older adults with a loss of independence but little is known about what makes older adults relocate to congregated housing designated for older adults, let alone in combination with social frailty, and how they navigate this transition. Objectives: This mixed method descriptive study aims to understand the influence of social frailty for a population of French-speaking semi-independent older adults relocating to a housing continuum community. Design: Semi-structured individual interviews including sociodemographic data and the PRISMA-7 Frailty Scale were conducted with recently relocated older adults. Setting: A newly opened French-speaking housing continuum community in Eastern Canada that offers luxury apartments for independent older adults, two assisted living facilities for semi-independent older adults along with a long-term care facility. Participants: Twenty-nine older adults with a mean age of 85 years, mostly female, married or widowed and highly educated. Measurements: Content analysis of the transcribed recorded interviews and descriptive statistical analyses to examine relationships between the frailty PRISMA-7 scale, answers to additional questions and the sociodemographic data. Results: There was not a significant difference in the scores for socialization before and after relocation nor between prior help and current help; however, there was a significant negative correlation between help and socialization before and after relocation. Three main themes included: imposed influences, push and pull factors and post relocation. Conclusions: The results indicate that several social factors contributed to relocation and that participants were experiencing social frailty. Participants were at the crossover point of being vulnerable to experiencing additional deficits which would potentially have led to higher frailty had they not relocated.

Key words: Social frailty, relocation, social support, community, official language minority.



Although frailty phenotypes have mostly ignored the notion of social frailty (1), the concept is slowly gaining interest in the literature. Defined as the absence of social resources, limited social activity and the inability to accomplish basic social needs (2), social frailty is touted as the precursor to physical frailty (3) or prefrailty (4, 5). Others who have explored the concept of social frailty have identified protective factors such as social support, engagement, living situation, self-esteem, sense of control, relations with others and contextual socio-economic status (6). Additional factors such as not living alone, going out more frequently, visiting friends, feeling helpful and talking with someone every day also had a strong impact on future disability in older adults living in the community (2, 7). Furthermore, despite the relevance of both frailty and social context on decision-making regarding housing and re-location (e.g. moving from rural to more urban areas, down-sizing or moving to supported living settings), the relationship between frailty and variables such as housing are the least included in models of frailty (1) and research on frailty or social frailty and relocation is negligible (8). Therefore, the goal of this mixed method descriptive study was to understand the influence of social frailty on decisions to relocate for a population of mostly well-educated and financially secure French-speaking semi-independent older adults.
The decision to relocate is complex and demanding for older adults with a loss of independence. Factors such as transportation, access to home maintenance services (especially in the language of choice), adequate income and level of education, attitude and resolve, self-perceived health, and choice of home/community have been determined to influence older adults’ ability to stay in their home (9) but little is known about what makes older adults relocate to congregated housing designated for older adults, whether social frailty plays a role in this decision, and how this transition is experienced (8). Although relocation is a common transition, it affects older adults much differently than younger adults. Recognizing components of social frailty in relocating older adults is important to prevent or delay a frailty diagnosis, prevent or lessen disability (10), reduce mortality (3) and improve the lives of families and caregivers (11).
This mixed method descriptive study was conducted at a newly opened Francophone housing continuum community in Eastern Canada that offers luxury apartments for independent older adults, two assisted living facilities for semi-independent older adults along with a long-term care facility. Given the influence of higher levels of education (12) and good socioeconomic status (13, 14, 15) on reducing the risk of frailty and the impact of identifying as a French-speaking older adult living in an official linguistic minority community (OLMC) on health inequalities (16), this study provides insight into the role of language as well as favourable social positioning on social frailty and relocation.



After receiving ethics approval, semi-independent older adults speaking and understanding French, aged 65 years or older, and living in a luxury housing continuum community were recruited. Recruitment strategies included brief presentations to older adults, advertisements in the community’s newsletter and electronic billboards, staff endorsing the study and the assistance of the Citizen Advisory Committee (CAC) which consisted of older adults and employees from the housing community.
The purpose of the CAC was to include stakeholders in the study to provide different perspectives and understanding to the research project to maximize the relevance of the results. CAC members informed and advised the research team and members included five older adults living at the study site, a community representative of an older adult organization, three researchers, one student research assistant and two employees from the housing continuum community. A total of three meetings were held with CAC members throughout the 12 months’ study.
A purposive sample of 29 older adults participated in semi-structured individual interviews of an average 40 minutes in duration. Interviews were conducted at a date and time convenient to the participant and most participants chose to have the interview in their apartment unit (in their new home). Sociodemographic data were recorded at the beginning of the interview and the PRISMA-7 Frailty Scale (17) was administered at the end of the interview process. The PRISMA-7 Frailty Scale is meant for early detection and management of frailty and is composed of seven yes and no questions addressing risk factors for frailty. Three or more “yes” answers are used as the cut-off for being at risk. In addition, corresponding questions related to the scale were administered with the goal of better understanding frailty of study participants. These Likert scale questions explored such components as help needed prior to relocation and after relocation, social activities prior and post relocation as well as asking for help from family and friends. For these items, a 7-point scale was used, with higher scores indicating higher levels of vulnerability.
Qualitative data analysis consisted of conventional content analysis (18) of the transcribed recorded interviews using NVivo 11 software to develop initial codes derived from the data, categories and defining themes. Descriptive statistical analyses for small sample sizes (19, 20) were performed to examine relationships between the frailty PRISMA-7 scale, answers to the additional questions and the sociodemographic data. Study results were discussed with the CAC for context and clarification as well as with the research team.



Participant Characteristics

Most of the 29 participants were female (62.1%) with an average age of 85 years old. Most were either married (38%) or widowed (41%) and 35% had no children living in proximity (20 km radius). Participants had relocated to the study site from a single dwelling (52%), an apartment or condo (28%) or directly from the hospital (14%). At the time of interview, most had relocated within 1-12 months. Participants were highly educated with 62% having a university degree and 17% a college education. Participants self rated their health as very good (35%) and good (41%) although 48% reported health problems that limited their activities.

Frailty Scale

Of the 29 study participants, 17 participants scored 3 or below (58.6 %) on the PRISMA-7 Frailty Scale with a group average score of 3.1 out of 7. Table 1 presents participants scores.

Table 1
PRISMA-7 Scores


Given the PRISMA-7 Frailty Scale scores for questions 3 (related to activities) and 5 (related to health), two corresponding Likert scale questions were analyzed: finding someone to help prior and post relocation as well as socializing before and after relocation. A paired-samples t-test was conducted to compare socialization prior to relocation and post relocation. There was not a significant difference in the scores for socialization before relocation (M = 5.14, SD = 1.38) and after relocation (M = 4.48, SD = 1.70), t(28) = 2.03, p = .052; d = .43 although a larger sample may have yielded statistical significance. Moreover, there was not a significant difference in the scores of prior help (M = 1.79, SD = 1.29) and current help (M = 1.36, SD = .78), t(27) = 1.80, p = .08; d = .40. A Pearson correlation indicated a significant negative correlation between help obtained and socialization both before relocation (r(28) = -.41, p = .03) and after relocation (r(27) = -.42, p = .03).

Imposed Influences

Results from the qualitative analysis indicated that two main life events seem to have compelled participants to move: health deterioration and capacity to source reliable support.

Health deterioration

Declining health happened over time but when a chronic health problem became overly challenging or that a new health issue arose, either for the study participant or their spouse, this was often a trigger factor that made participants decide to relocate. One participant explained: “My concern was mainly falling and finding myself alone.” Another participant shared: “I could see my health failing in terms of mobility, so sooner or later, it was better for me to initiate the move myself.”

Formal social support

Most participants described challenges in receiving formal home support services but also questioned the quality of the services once these were received. Many inconsistencies were identified such as arriving late, employee not staying for the contracted time, and tasks not completed. Even for those participants using private services, it remained challenging to receive the appropriate assistance. One participant shared, “I could have paid someone, but there’s no one reliable. I don’t mind paying $30 an hour, but they have to do the work.”

Informal social support

The majority of participants voiced strong opinions of not wanting to ask for help from family members, especially their children, but also from friends and neighbours: “It’s always trouble because you have to find someone to do your housework and other things, there’s too many things.” One reality shared by many participants was the impact of the loss of a spouse or primary caregiver as a trigger to relocation: “I have no one, I have no one anymore, they’re all deceased.”

Push and Pull Factors

Participants also identified other factors contributing to social frailty and pushing them out of their home: transportation and feelings of insecurity.
The loss of one’s ability to drive had an important impact on aging in place. Being able to drive was deemed an aspect of independence that is irreplaceable by public transit. One participant explained:
I didn’t feel vulnerable, but in a condo, without a car…you need milk, well you have to call a taxi or a friend who has…In that sense, it didn’t make sense anymore. [If] I had been able to keep my car, I would still be there you know.

Feeling of insecurity

Feelings of insecurity were mentioned by many participants and was described as: “I wasn’t feeling well, I didn’t feel safe where I was.” Others explained that they were aware that they were aging and that they needed to make changes to facilitate life: “We knew that sooner or later, we would have to move. We wouldn’t be able to keep up with our activities. Especially since it was a lot more work for me to, to maintain the house.”

Pull factors

There were also reasons for wanting to relocate to the study location that facilitated participants’ decision to relocate. Some of these factors include the location of the housing continuum, near the university and cultural centre, as well as the language spoken in the study location. Many shared: “We wanted to be somewhere Francophone; my English is not too good.” Despite wanting to stay where French was spoken, some expressed difficulties with the different accents and words used by other residents. Other pull factors included the quality of services, the continuity of care options and the ability to be close to family members. Additionally, participants could financially afford to relocate to this relatively expensive housing complex.

Post Relocation

Participants explained that once relocated, they had to adapt to their new home and that this process was different for everyone. In fact, adapting to the new home seemed more difficult for those who had relocated without having made the decision to relocate or were forced by circumstances (or triggers), and while most had made their own decision, attitude towards their relocation seemed to impact their ability to adapt. Like this participant, many shared:
I meet people who ask me how I like my new apartment. It’s too small, but I tell myself, I can’t change it, I have to adapt. There you go. My head speaks to me a lot, I need to have patience. It’s not tomorrow when everything will fall into place. It will take time.
Establishing a routine also seemed like an important step in developing feelings of belonging. This included socializing with others but not overstepping boundaries. One participant explained: “I noticed here that people don’t go from apartment to apartment, and I like that.” Another explained how easy it was to be with others: “At 7PM, if no one calls, I go downstairs, and there’s someone there to play cards. You know, I think we’re a group, it seems like we can talk to each other if we need to talk and we play cards.” For those with hearing or sight impairments, socialization can be challenging and still for others, they feel like they don’t belong. One important element is that the move was not just a move but much more. One participant explained: “I knew it would be a major upheaval. It’s not a move, it’s a life change. It’s not really a move, I can’t count how many times I’ve moved in my life, but this is a major upheaval. I know when I leave here it’s probably going to be feet first.” This followed with a discussion about adapting to an aging self and the realities of aging as part of their relocation. Table 2 presents additional illustrative quotes from study participants.

Table 2
Additional Participant Quotes



Even though 79% of participants had a post-secondary education and all had an adequate income to access private supports before relocating, results indicate that social frailty may have been present before relocation and may have played a role in deciding to relocate. Even for this relatively advantaged group, access to services for aging in place remained challenging and inadequate which resulted in relocation. The post relocation administration of the PRISMA-7 Frailty Scale with a mean group score result of 3.1 suggests that prior to relocation, participants were at the crossover point of being vulnerable to experiencing additional deficits which would potentially have led to higher frailty had they not relocated, as a score of 3 or higher indicates a need for further assessment (17). By addressing social frailty through relocation, participants potentially alleviated multiple factors leading to the social frailty experienced prior to relocation (21). Two important factors that participants identified as forcing them to relocate were loss of social support networks, described as difficulties accessing services and death of a partner/primary caregiver, as well as a sudden change in health status in the self or partner. Other factors mentioned included transportation issues (loss of a driver’s licence) and feelings of insecurity, both previously recognized as components of aging in place (9).
Most of the participants in this study made the choice to relocate, and their new home offered services in their preferred language, a location close to friends and family, and the availability of a continuum of housing and care. Although the transition to this more supportive environment seemed to alleviate social frailty it remained that participants were required to adapt to a new environment, and establish new routines, new relationships and new patterns of socialization. Participants’ ongoing appraisal of their own resiliency, such as strong communication skills, affiliative personalities and favourable health status, combined with the unpredictability of the residential environment could influence their coping mechanism (22). This could potentially explain why participants failed to socialize more since relocation despite previous findings stating that one pull factor in relocation is increased socialization (23). Of particular interest is the finding that both before and after relocating to a supportive environment, those who require more help with daily activities tend to socialize less. If replicated, this finding may suggest that even in supportive environments, enhanced social support and opportunities for socializing may need to be provided when care needs increase, even with relatively independent older adults.
The results of this study provide a better understanding of the concept of social frailty. Specifically, social support networks, formal support services, transportation, and feeling safe were identified as determining factors of social frailty leading to relocation to a housing continuum community. Moreover, the use of a highly educated and financially comfortable sample of older adults allowed us to explore how decisions to relocate are made when options are relatively unconstrained by socioeconomic concerns. Study participants would have had the financial resources to pay for increased supports in their prior home as well as the education and social privilege to advocate for themselves. While recognizing these contributions, limitations of the study include a non-representative sample, limited statistical power due to the small sample size, and the use of limited and self-reported measures. Further research on social frailty is needed to better understand the relationship between social frailty and physical pre-frailty/frailty. In addition, a longitudinal study of older adults with data collections beginning before a relocation transition and continuing to a few years post relocation in congregated housing would provide additional understanding of both social frailty and the transition process, and how these two constructs interact. Clearly, the role that social frailty plays in older adults’ ability to age in place and the decision to relocate is worthy of future study.


Ethical standards: REB approval from Université de Moncton #1920-011.
Conflcit of interest: No conflict of interest.
Funding: This research was supported by funding from the Canadian Frailty Network (CAT2018-42) and the New Brunswick Health Research Foundation (2018-CFN-1775).



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C. Udina1, J. Ars1, A. Morandi1, J. Vilaró2, C. Cáceres1, M. Inzitari1

1. REFiT Barcelona research group, Parc Sanitari Pere Virgili and Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain; 2. Blanquerna School of Health Sciences, Global Research on Wellbeing (GRoW), Universitat Ramon Llull. Barcelona, Spain.
Corresponding author: Cristina Udina, MD, Parc Sanitari Pere Virgili, C/ Esteve Terradas, 30, 08023 Barcelona, Spain, cudina@perevirgili.cat, ORCID ID: 0000-0002-0140-669X

J Frailty Aging 2021;in press
Published online February 7, 2021, http://dx.doi.org/10.14283/jfa.2021.1



COVID-19 patients may experience disability related to Intensive Care Unit (ICU) admission or due to immobilization. We assessed pre-post impact on physical performance of multi-component therapeutic exercise for post-COVID-19 rehabilitation in a post-acute care facility. A 30-minute daily multicomponent therapeutic exercise intervention combined resistance, endurance and balance training. Outcomes: Short Physical Performance Battery; Barthel Index, ability to walk unassisted and single leg stance. Clinical, functional and cognitive variables were collected. We included 33 patients (66.2±12.8 years). All outcomes improved significantly in the global sample (p<0.01). Post-ICU patients, who were younger than No ICU ones, experienced greater improvement in SPPB (4.4±2.1 vs 2.5±1.7, p<0.01) and gait speed (0.4±0.2 vs 0.2±0.1 m/sec, p<0.01). In conclusion, adults surviving COVID-19 improved their functional status, including those who required ICU stay. Our results emphasize the need to establish innovative rehabilitative strategies to reduce the negative functional outcomes of COVID-19.

Key words: COVID-19, older adults, therapeutic exercise, rehabilitation, post-ICU rehabilitation.



COVID-19’s impact increases with age (1). Besides mortality, patients may experience relevant disability, related to serious complications requiring Intensive Care Unit (ICU) admission, which has been linked to physical impairments (2). Less severe cases might experience functional decline due to immobilization due to the disease and isolation measures to prevent transmission. Early and effective rehabilitation interventions are urgent, despite healthcare systems may be overwhelmed and rehabilitation may be disrupted. Therapeutic exercise (TE) is a physical therapy technique used to improve or maintain a person’s physical condition through resistance, endurance, flexibility and balance training. The intensity, volume, progression and type of exercise must be individualized based on the physical condition and tolerance during the execution of TE. Previous research shows the benefits of supervised TE in acutely ill patients to improve their physical condition and autonomy through exercise (3). During the early weeks of the pandemic our post-acute care facility had to adapt in order to provide care for COVID-19 patients (4). In addition to maintaining the usual physical therapy interventions for more impaired patients, we created an intensive rehabilitation pathway through TE to facilitate a quick recovery and faster discharge at home. Our aim is to describe the pre-post impact on physical performance of multi-component therapeutic exercise for post-COVID-19 rehabilitation.



We performed a cohort study of post-acute care patients that overcame COVID-19 and were included in a rehabilitation protocol based on multi-component therapeutic exercise. The inclusion criteria were: 1) ability to walk unassisted pre-COVID-19 (use of cane or walker was allowed); 2) able to stand after the resolution of acute COVID-19; 3) social situation allowed discharge in 10 days. We collected demographics, COVID-19 related variables, comorbidities (sum of hypertension, diabetes, arrhythmia, myocardial infarction, Chronic Obstructive Pulmonary Disease/Asthma, mild cognitive impairment, dementia, other neurodegenerative diseases, stroke, depression, osteoarthritis and low back pain) and prevalence of polypharmacy (5 or more drugs) at admission. Our comprehensive assessment included: pre-COVID functional status with the Barthel Index and Lawton Index and frailty status with the Clinical Frailty Scale (CFS); cognitive function at post-acute admission with the Montreal Cognitive Assessment (MoCA) for global cognition and the Symbol Digit Modalities Test (SDMT) for attention and processing speed. SDMT scores are age-adjusted (5), considering a score of 7 or higher as normal range. The Confusion Assessment Method (CAM) was used to screen for Delirium. These covariates were collected based on clinical and functional aspects that might impact physical function as well as the response to physical exercise. We assessed physical function at day 1 and 10 of the intervention. Those patients who were discharged before day 10 were evaluated at discharge. We performed the Short Physical Performance Battery (SPPB) as a measure of gait performance (time to walk 4 meters), balance (stand for 10 seconds with feet side-by-side and in semi-tandem and tandem positions) and lower limb strength (time required to stand up and sit down 5 times from a chair without using the arms). Furthermore, we assessed independence for the basic activities of daily living with the Barthel Index, need of assistance to walk with the Functional Ambulation Category (FAC) (6) and the single leg stance test (7). We evaluated exercise capacity with the 6-minute walk test (6MWT) in a sub-sample (for logistical reasons).
The 30-minute 7 days/week multi-component therapeutic exercise intervention (summarized in Figure 1) was led by an expert physical therapist and combined: a) resistance training [1-2 sets with 8-10 repetitions each (intensity between 30-80% of the Repetition Maximum (8) )]; b) endurance training (up to 15-minutes aerobic training with a cycle ergometer, steps or walking) and c) balance training (walking with obstacles, changing directions or on unstable surfaces). Additionally, recommendations were provided to decrease daily sedentary behavior. Each session was individualized to each patient’s physical condition.
Outcome measures included: SPPB global score, gait speed (m/s), balance score and chair-stand time (seconds), Barthel Index score, ability to walk unassisted (FAC score 4 or higher) and maintain single leg stance for 10 seconds and distance walked during the 6MWT (meters). We used descriptive statistics with mean and Standard Deviation (SD) or frequencies as required. We assessed differences between the initial and final values in the outcome variables with Wilcoxon signed rank test and McNemar test for continuous and categorical variables, respectively. We calculated the mean pre-post change for each continuous outcome variable: Variable POST – VARIABLE PRE. We used Mann-Whitney U test to compare the mean change in the outcomes between patients treated or not in the ICU as well as to compare baseline characteristics in both groups. All statistical analysis was performed with statistical software: IBM SPSS Statistics for Windows, Version 21.0. (Armonk, NY: IBM Corp).



We included 33 patients (66.2±12.8 years, 57.6% women), of whom 90.9% (n=30) presented with pneumonia and 60.6% (n=20) were admitted to the ICU, all (n=20) requiring mechanical ventilation, with a mean ICU stay of 10.3±9.9 days. The sample consisted of pre-COVID-19 well-functioning adults (Barthel Index 98.5±5.8 and Lawton Index 6.7±2.1) with low frailty (CFS score 2.5±1.3) and comorbidity (sum of comorbidities 1.5±1.6) but high polypharmacy at admission (72.7% (n=24)). Post-ICU patients were younger, with lower comorbidity, better pre-COVID-19 functional status and lower frailty, compared to non-ICU patients (Table 1). Although none of the patients had delirium according to CAM scores at admission, post-COVID-19 cognitive function was mildly impaired in the whole cohort and within both groups. After the intervention (mean duration=8.2±1.7 days), all physical performance measures showed a statistically significant improvement when comparing the initial and final values in the global sample and among post-ICU patients, while non-ICU patients did not improve in balance-related variables. Furthermore, post-ICU patients experienced a greater improvement in SPPB and gait speed mean change compared to non-ICU (4.4±2.1 vs 2.5±1.7, p<0.01 and 0.4±0.2 vs 0.2±0.1, p<0.01, respectively). None of the patients died during the intervention and all were discharged home. In a subsample of 22 participants (61.9±12.1 years, 63.6% women, 81.8% admitted to the ICU and 95.5% with pneumonia), mean 6MWT walked distance improved from 158.7±154.1 to 346.3±111.5 m (p<0.001).

Table 1
Baseline characteristics and functional outcomes, in the total sample and stratified by previous ICU admission

Abbreviations: ICU: Intensive Care Unit. MoCA: Montreal Cognitive Assessment. CFS: Clinical Frailty Scale. SDMT: Symbol Digit Modalities Test. SPPB: Short Physical Performance Battery. FAC: Functional Ambulation Category. SDMT normal range ≥ 7. Legend: (*) Pre-post comparison within group with Wilcoxon rank test and McNemar test (significance at a p-level < 0.05 marked with †). (‡) Comparison of the mean change between the ICU and the non-ICU groups with Mann-Whitney U Test (significance at a p-level < 0.05 marked with †)

Figure 1
Scheme of the individualized multi-component therapeutic exercise intervention, combining 3 or more modalities daily

Abbreviation: RM: repetition maximum



In summary, in our sample of post-COVID-19 adults and older adults, physical function improved after a relatively short therapeutic exercise intervention. This improvement seems clinically meaningful, according to previous studies (9). Compared to the non-ICU group, post-ICU patients showed higher improvements, possibly due to their younger age and better functional, clinical and frailty status pre-COVID-19. Noteworthy, our sample showed mild cognitive impairment post-COVID-19 according to a brief cognitive assessment, which we might speculate as non-preexisting, especially in the ICU group, due to their relatively young age and preserved functional status. This cognitive dysfunction could be related to delirium during COVID-19’s acute phase or even be a neurological feature of COVID-19’s infection (10). Further research is needed to support these findings and to study long-term effects of COVID-19 on cognition.
Evidence about post-COVID-19 rehabilitation is still scarce, although there is a growing body of literature highlighting the need of rehabilitation strategies. To our knowledge, this is the first study on the effects of intensive rehabilitation through a structured therapeutic exercise intervention of post-COVID-19 patients in post-acute care, a setting able to combine the acute management of these patients with rehabilitative interventions (4). Improving physical function in post-ICU patients is crucial as previous research has shown long-term negative outcomes (11). However, the type of exercise intervention previously reported in post-ICU rehabilitation so far seems not comparable to our intensive and multimodal protocol (12). Previous research shows the efficacy of similar therapeutic exercise strategies tested in acute geriatric units, demonstrating functional benefits of short-term supervised exercise during acute medical illnesses: the reported magnitude of change of 2.4 points in the total SPPB (13) is similar to the change in our non-ICU group, which is indeed older and with a slightly pre-COVID-19 worse clinical and functional profile, compared to the ICU group. According to studies performed with Acute Respiratory Distress Syndrome survivors, the improvement in exercise capacity experienced in the small subsample seems also clinically relevant (14). The cognitive impairment detected among the post-ICU patients is also in line with the findings reported in Acute Respiratory Distress Syndrome survivors (15), however in our opinion the impairment detected in non-ICU patients, deserves further research to shed some light into the potential neurological manifestations of COVID-19.
Main limitations of the study are the small sample size and the absence of a control group to assess the effect of the intervention. Among the strengths, we enrolled adults and older adults post-COVID-19 with different acute care pathways during the acute phase, with a comprehensive assessment of clinical and functional variables.
In conclusion, adults and older adults surviving COVID-19 seem to improve their functional status, despite previous admission to ICU, through a short, individualized, multi-component therapeutic exercise intervention. Further research with controlled, larger samples and longer treatment periods might help elucidate the role of rehabilitation interventions in the reduction of negative functional outcomes of COVID-19, hence mitigating the potential increase in COVID-19-related disability and health care costs.


Funding: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interests: The authors (CU, JA, AM, JV, CC) state that they have no financial nor non-financial conflict of interests. MI received from Nestlé a fee for scientific advice, not related to the work or the topic of the current manuscript.
Ethics approval: The study procedures were approved by the institutional ethics committee. The authors declare that all study’s procedures are according to the 1964 Helsinki Declaration and that personal participant’s information was treated to ensure complete privacy. Furthermore, all procedures performed during the study were in the context of usual care of patients admitted to post-acute care.



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R. McGrath1, P.J. Carson2, D.A. Jurivich3

1. Department of Health, Nutrition, and Exercise Sciences, North Dakota State University, Fargo, ND, USA;
2. Department of Public Health, North Dakota State University, Fargo, ND, USA; 3. Department of Geriatrics, University of North Dakota, Grand Forks, ND, USA

Corresponding Author: Ryan McGrath, Department of Health, Nutrition, and Exercise Sciences, North Dakota State University, NDSU Dept. 2620, PO Box 6050, Fargo, ND 58108-6050, Phone: 701-231-7474, Fax: 701-231-8872, Email: ryan.mcgrath@ndsu.edu

J Frailty Aging 2020;
Published online January 6, 2020, http://dx.doi.org/10.14283/jfa.2020.73


Dear Editor,
SARS-CoV-2, the cause of COVID-19, remains a novel infectious virus that has led to millions of cases globally. While COVID-19 infection and death prevention remain a top public health priority, post-hospitalization COVID-19 recovery is also important and emerging in adults surviving infection. For example, persons that survived a COVID-19 hospitalization have persisting mobility impairments and morbidities several months post-hospitalization (1). Given that the initial months after a critical illness hospitalization are crucial for functional recovery, monitoring physical functioning and related biomarkers after discharge from a COVID-19 hospitalization could be vital for functional recovery, and the proper deployment of relevant interventions.
The pathophysiology related to functional recovery after a COVID-19 hospitalization may provide insights into improving the recovery process. For example, respiratory virus infections, such as COVID-19, trigger inflammatory responses at both the site of the infection and systemically (2). “Cytokine storms” have been observed in those with COVID-19 infections, which is linked to the same tissue damage and organ system failures that contributes to poor physical functioning (3). The hyperinflammatory states seen in COVID-19 patients are related to the inflammaging that leads to functional declines during aging, even in younger individuals (4). Interleukin-6 is a prognosticator in patients with COVID-19 (5), and is likewise an important contributor to declines in muscle function (6). Thus, the inflammatory responses observed in middle-aged and older adults with COVID-19, especially after hospitalization, could predict functional trajectories.
Clinical assessments of physical functioning help to identify the onset and progression of the disabling cascade (7). Although physical performance assessments such as gait speed may provide useful information regarding functional recovery from COVID-19 after hospitalization, these assessments have limitations because they require full body movements. Alternatively, muscle function assessments present organ level insights for the initial stages of physical function deficits. Muscle dysfunction precedes the physical performance limitations that lead to mobility impairments and morbidities such as sarcopenia (8).
Handgrip strength is a convenient assessment of strength capacity and reliable measure of muscle function that requires patients to squeeze a relatively inexpensive isometric dynamometer with maximal effort for a short duration (e.g., 3-5 seconds). As such, handgrip strength measurements are commonly used in clinical and research settings to examine muscle function. However, protocols for handgrip strength focus exclusively on maximal strength, and other muscle function characteristics that may better elucidate muscle dysfunction remain overlooked.
Utilizing digital handgrip dynamometers and attaching a triaxial accelerometer on the top of a dynamometer may help in evaluating the additional aspects of muscle function that are not otherwise ascertained with traditional handgrip dynamometers (9). For example, digital handgrip dynamometry and accelerometry have the ability to not only measure maximal strength, but also strength asymmetry, explosiveness, coordination, force steadiness, fatigability, and muscle contraction induced tremoring. Some of these aspects, such as fatigability, could similarly extend into the use of handgrip dynamometers for the concept of resilience, which may be important for COVID-19 survival and recovery. Utilizing digital handgrip dynamometry and accelerometry also maintains procedural ease and overall test inclusiveness for persons recovering from a COVID-19 hospitalization.

Figure 1
Conceptual Model for Monitoring Inflammatory Responses and Muscle Function for Predicting Functional Recovery After COVID-19 Hospitalization


Figure 1 presents a conceptual model for observing inflammatory responses and muscle function to predict functional recovery in persons recovering from a COVID-19 hospitalization. Overall, inflammation is an important biomarker for muscle function (10), and inflammatory responses occurring during COVID-19 infections could be linked to diminished physical functioning after COVID-19 recovery. Very little is known about how serum biomarkers and the several attributes of muscle function could be impacted after a COVID-19 hospitalization. Inflammatory responses occurring during COVID-19 critical illness hospitalizations that influence functional recovery could be worse than non-COVID-19 illness hospitalizations. Monitoring inflammatory responses and physical functioning in patients that are recovering from COVID-19 at discharge and intermittently thereafter may help to predict their functional trajectories and allow for timely interventions that foster recovery. Therefore, healthcare providers should strongly consider measuring inflammatory responses and physical functioning in COVID-19 patients sustaining a hospitalization if they are not already, and research efforts may likewise provide additional insights. Similar work may also have generalizability to other relevant hospitalizations.
Given the ongoing novelty of COVID-19, examining inflammatory responses and physical functioning is important for patients recovering from COVID-19 not only regain independent living, but also provide new information into the recovery process. While COVID-19 prevention and treatment are still of the utmost importance, surveilling the health of the growing number of persons recovering from a COVID-19 hospitalization will also emerge as a necessary implication.

Conflict of interest: No conflicts of interest.


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