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research-article2014
NCPXXX10.1177/0884533614536231Nutrition in Clinical PracticeLitchford
Invited Review
Counteracting the Trajectory of Frailty and Sarcopenia in Older Adults
Nutrition in Clinical Practice Volume 29 Number 4 August 2014 428–434 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536231 ncp.sagepub.com hosted at online.sagepub.com
Mary Demarest Litchford, PhD, RDN, LDN1
Abstract Food preservation technologies and medical advances in the past 50 years have contributed to safeguarding the health and prolonging the lives of individuals worldwide. However, living longer does not automatically equate with being healthy, living independently, making judicious decisions, or setting goals and achieving them. Most adults will experience 1 or more health problems with lingering consequences. It is the impact of the disease or injury that determines overall well-being and quality of life. Frailty, sarcopenia and malnutrition have been identified as common geriatric syndromes associated with functional decline, disability, hospitalization, institutionalization, and mortality. The evidence demonstrates that these geriatric syndromes could be prevented or the course of the syndrome altered through prevention strategies. Since these syndromes often present concurrently, it is prudent for healthcare professionals to recognize the interrelationships and clinical implications of these syndromes to employ tactics to promote desirable outcomes. (Nutr Clin Pract. 2014;29:428-434)
Keywords aged; frail elderly; nutritional status; vitamin D; geriatrics; malnutrition; nutrition; sarcopenia; frailty
The world’s population is aging. The subset older than 60 years is expected to triple by 2050. The fastest growing cohort in the developed countries is adults 80 years and older.1 Experts predict that by 2030, adults 65 years and older will account for about 20% of the U.S. population. More than 65% of adults in the United States are burdened with 1 or more chronic conditions that contribute to diminished quality of life, as well as affect the person’s ability to perform fundamental activities both inside the home and in the community.2 Many factors are propelling the trajectory of physical and functional decline that leads to impaired mobility and dependence. Changes in functional status and mobility hinder performance of nutrition-related activities of daily living (ADLs), which contribute to declining nutrition status, frailty, malnutrition, and sarcopenia. In an effort to mitigate progressive decline and subsequent healthcare care costs for older adults, the United States Preventive Health Services Task Force (USPST) commissioned the Agency for Health Research and Quality (AHRQ) to conduct a systematic review of the published evidence on modifiable geriatric syndromes. Common Syndromes in Older Adults Related to Primary and Secondary Prevention3 identified 8 modifiable syndromes in older adults that are associated with functional decline, disability, institutionalization, and mortality (Figure 1). The evidence demonstrates that these common geriatric syndromes could be prevented or the course of the syndrome altered through prevention strategies. Geriatric syndromes are not independent of one another and often overlap one another. Functional status is related to nutrition status in 2 ways. It is a major quality of life factor for older adults and a determinant of meeting nutrient requirements. This article focuses on the unique trajectory of 3 modifiable geriatric
syndromes—frailty, sarcopenia, and malnutrition—that contribute to functional decline in older adults.
Frailty Frailty is a multidimensional syndrome in which there is an increased state of vulnerability due to age-related decline in more than 1 physiological system that compromises an adult’s ability to cope with routine and acute stressors.4 It encompasses a progressive reduction in physical, psychological, social, and cognitive reserves. Moreover, frailty is associated with a reduced ability to regain physiological homeostasis. The progression of frailty is driven by the balance between strengths supporting independence and deficients of self-sufficiency.4,5 The prevalence of frailty increases with age; is associated with an increased risk for falls, disability, and hospitalization; and is a predictor of mortality. Characteristics of frailty include chronic undernutrition and malnutrition, unplanned weight loss, fatigue, exhaustion, weakness, reduced walking speed (slowness), low physical activity, and impaired mobility. Clinicians differentiate degrees of frailty by phenotype (ie, robust, prefrail, or frail) or by an accumulation of functional deficits.3-5 From 1CASE Software & Books, Greensboro, North Carolina. Financial disclosure: None declared. This article originally appeared online on June 9, 2014. Corresponding Author: Mary Demarest Litchford, PhD, RDN, LDN, CASE Software & Books, 5601 Forest Manor Dr, Greensboro, NC 27410, USA. Email: [email protected]; [email protected]
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Malnutrition
Figure 1. Eight syndromes in older adults, associated with functional decline, disability, institutionalization and mortality, that can be modified using primary and secondary preventions.3
Sarcopenia is 1 component of frailty. The functional limitations in older adults may be because they are weak, and they are weak in part because they have low muscle mass. Furthermore, frailty may reflect a shift in body composition favoring higher fat stores and reduced lean reserves.6,7 Frailty may be exacerbated by chronic undernutrition.3,4
Sarcopenia Sarcopenia is the progressive loss of muscle mass, muscle quality, and physical strength and function that may contribute to frailty and disability in older adults. It is not limited to individuals with low body weight. Changes in body composition are due in part to changes in the continuous cycle of skeletal muscle protein synthesis (MPS) and degradation or muscle protein breakdown (MPB). Net protein balance is the difference between MPS and MPB. To accrue skeletal muscle protein, there must be a significant rise in MPS or anabolic activity (ie, exercise, adequate diet) coupled with a reduction in MPB or catabolic activity.8-11 With aging, the balanced cycle of muscle synthesis/degradation shifts toward more breakdown than synthesis of muscle tissue.6,7 It is recognized that reduced anabolic stimulation from changes in anabolic hormones, insulin resistance, subclinical inflammation (catabolic stimuli), insufficient intakes of protein and energy, impaired utilization of nutrients, and inactivity play significant roles in the progression of sarcopenia.12 The diagnosis is usually based on the estimated lean body reserves relative to skeletal size and total body mass and loss of strength. The Foundation for the National Institutes of Health Sarcopenia
Malnutrition may be concurrent with frailty and/or sarcopenia. The etiology of malnutrition is a reflection of its context. Starvation is the primary driver of malnutrition in the context of social or environmental circumstances, whereas inflammation is the primary initiator of rapid loss of lean mass and total body weight in acute illness or injury and comorbidity in chronic diseases.15,16 Changes in functional and nutrition status of older adults may be compounded by 1 or all of these situations. Older adults are the most likely segment of the population to get sick from a poor diet.17 The National Health and Nutrition Examination Survey (NHANES) data demonstrate a linear decrease in total energy, fat, and protein intake as men and women age.18,19 Almost 40% of adults 70 years and older do not consume the Recommended Dietary Allowance (RDA) for protein (0.8 g/kg/d). Moreover, muscle loss in community-living elders was found to be negatively related to protein intake in this population cohort.20 Individuals in negative-energy balance have higher physiological requirements for protein to maintain nitrogen balance because protein is used to meet energy requirements rather than for tissue accretion.21-23 More than 55% of hospitalized elders are undernourished and up to 85% of elderly residents living in institutions are undernourished.24,25 Older patients who are malnourished on admission are at markedly higher risk of life-threatening complications during hospitalization. Admission to an extended care facility is associated with unplanned weight loss and poor nutrition due to dementia, sensory loss, polypharmacy, and comorbidities.25-27 Elders who depend on feeding assistance at meals are much more likely to lose weight than those who are able to eat independently. Among institutionalized elders, eating dependency increases the risk of having a low body mass index (BMI) or weight loss by 1.5–2 times. Low energy intake, significant weight loss, and malnutrition are associated with increased mortality in elders.28
Concurrent Occurrence of Sarcopenia, Frailty, and Malnutrition Aging and functional decline are inescapable, yet the concurrent presentation of frailty, sarcopenia, and malnutrition in the older adult increases the velocity and progression toward loss of independence. The characteristics of frailty, sarcopenia, and malnutrition are summarized in Table 1, noting the similarities and differences of these syndromes. The concurrent occurrence of frailty, sarcopenia, and malnutrition may lead to a self-perpetuating cycle of naturally progressing event (Figure 2). For instance, the progressive loss of muscle mass and diminished function and strength manifest in sarcopenia are partly due to suboptimal intake of dietary protein compared
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Figure 2. Cycle of functional decline. ADL, activities of daily living; BMI, body mass index; HBV, high biologic value; IWL, involuntary weight loss.
with estimated physiological requirements. Similarly, starvation-related malnutrition results in loss of skeletal muscle mass and involuntary weight loss. Reduced muscle strength contributes to weakness, impaired functionality, and loss of nutritionrelated ADLs. One potential consequence of weakness and functional decline is that as community-dwelling elders become more sedentary and reclusive, grocery shopping and meal preparation become more difficult. The end result may include fewer trips to the grocery store, reduced food inventory, dependence on others to purchase food or provide meals, skipped meals, and increased consumption of low-nutrient ready-to-eat products.3 Food insecurity may arise when access to groceries is limited due to shopping or transportation disabilities, especially if the older adult has a physical or cognitive disability, is single, and has a limited income.37 Sustained protein and energy intakes below physiological needs, coupled with weakness and declining lean body reserves due to inactivity and age or disease-related inflammation, perpetuate a vicious cycle of impaired functionality and reduced ability to perform nutrition-related ADLs. The dire consequences are manifest when an acute episode of illness or injury requires hospitalization. For instance, a community-dwelling elder develops an acute illness such as an upper respiratory tract infection that progresses into pneumonia. During the episode of illness, the elder’s physical stamina and appetite are significantly reduced, resulting in a minimal nutrient intake.
Yet resting energy requirements are elevated due to inflammatory stress, and lean body reserves are being mobilized to meet protein requirements. The subsequent trajectory of decline is exacerbated by the effects of inflammation compounded by the iatrogenic effects of hospitalization or institutionalization and of extended bed rest that further promote the loss of muscle mass. What began as seemingly insignificant changes in lifestyle choices and dietary habits may lead to loss of muscle mass and increased risk for illness and injury. Other metabolic changes that may contribute to the concurrent onset of frailty, sarcopenia, and malnutrition include reduced skin synthesis of previtamin D, coupled with impaired renal and gut response to 1,25-dihydroxyvitamin D (1,25(OH)2D), increasing the likelihood of a vitamin D insufficiency or frank deficiency. The NHANES data (2001–2008)40 for intake of vitamin D demonstrate that more than 85% of adults 51 years and older do not consume the 2010 RDA for vitamin D from food or supplements. Is it estimated that more than 70% of the U.S. older adult population have serum 25-hydroxyvitamin D (25(OH)D) levels below the recommended values for preventing fractures and falls.41,42 Vitamin D insufficiency is associated with a 4-fold increase in the risk of frailty. Several polymorphisms of vitamin D receptor (VDR) isolated in skeletal muscle have been associated with differences in muscle strength.40 Low serum levels of vitamin D have been associated with an increase in
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Table 1. Characteristics of Frailty, Sarcopenia, and Malnutrition. Category
Frailty
Etiology
•• Interplay of environmental and intraindividual challenges that lead to behavioral adaptation3,4
Common comorbidities
•• Mental health limitations4 •• Undernutrition and malnutrition3-5
Physical characteristics
Associated functional decline and disabilities
Physiologic and metabolic changes
•• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Weakness3,4 Decreased walking speed3,4 Decreased VO2 max4 Exhaustion3,4 Homeostenosis3,32 Reduced muscle strength3-5 Impaired mobility3-5 Unsteady gait5 Use of assistive devices4,5 Compensatory strategies or environmental supports4 Reduced quality of life3,4 Greater dependency3,4 Maladaptations to aging3,4 Selected vitamin and mineral deficiencies3,39 Impaired immunity4
Sarcopenia 29
•• •• •• ••
Inactivity Undernourished3,29,30 Inflammation related3,29-31 Marked inflammation → cachexia3,29-31 •• Suboptimal protein intake3,12,20,30 •• Exacerbated by inflammatoryrelated medical diagnoses3,33,34 •• Frailty3-5 •• Weight unchanged or loss3,29,30,33 •• Muscle wasting3,12,25,35,36 •• Fatigue12,29,34 •• •• •• ••
Reduced muscle strength3,29,35 Impaired mobility26,34,36 Reduced quality of life3 Greater dependency3,26
•• Reduced anabolic stimulation27,29,33 •• Increased insulin resistance29-31 •• Anorexia30 •• Selected vitamin and mineral deficiencies3 •• Shift in body composition from lean → fat28
Malnutrition •• Starvation related15,16 •• Inflammation related 15,16 •• Marked inflammation → severe malnutrition15,16,24,25,28 •• Suboptimal protein intake3,4,17-20,32 •• Exacerbated by inflammatoryrelated medical diagnoses3,15,24 •• Decline in cognitive skills3 •• Depression3 •• Unplanned weight loss unless masked by edema15,16,24,26 •• Impaired senses of taste and smell27,28 •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
the occurrence of sarcopenia.43,44 Selected observational studies have reported the association between low serum vitamin D levels and functional limitations (ie, muscle weakness, difficultly rising from a chair, difficulties in ascending stairs, balance problems, and increased risk for falls and fractures).40,43,44 More research is needed to clarify the interrelationships weakness, muscle function, and vitamin D status.
Role of Protein and Leucine The Health, Aging and Body Composition study assessed the association between dietary protein and changes in lean body
Reduced muscle strength3,15,16,24 Food preparation disability3 Shopping disability3 Food insecurity3,37 Impaired chewing and swallowing3,27,38 Reduced quality of life3 Greater dependency3,26 Changes in digestive processes21-23,28,36 Impaired micronutrient utilization21,22,25,26,36,37 Selected vitamin and mineral deficiencies3,25,28,36 Impaired immunity20 Anorexia22 Impaired protein utilization16,17,30,31 Shift in body composition from lean → fat27,28 Changes in basal metabolic rate19,20,27,28 Mobilization of nutrient reserves23,28
reserves over a 3-year period. Participants with the highest quintile of protein intake lost approximately 40% less lean body mass than those in the lowest quintile. The authors concluded that dietary protein may be a modifiable risk factor for sarcopenia in older adults.20 Researchers have demonstrated that the timing, distribution, and quality of dietary protein throughout the day are important factors in maximizing tissue accretion. The biological quality of dietary protein is determined by the distribution and quantity of indispensible amino acids required for tissue accretion.22 Moreover, the timing of meals and quantity of high-quality dietary protein consumed serve as a means to counteract the blunted protein-anabolic response to a small,
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mixed-macronutrient meal. One study in healthy older women found that providing 79% of the day’s protein at the noon meal improved protein retention compared with a more even distribution of dietary protein across all 3 meals.45 Other researchers found that consuming 30 g of high-quality dietary protein at each meal maximized protein synthesis in nonexercising adults. The key was consuming sufficient amounts of the indispensible amino acid (IAA) leucine required to activate mammalian target of rapamycin (mTOR) signaling pathway that regulates protein synthesis and muscle tissue accretion.29,46 Offering up to 90 g high-quality dietary protein in a single serving did not stimulate further protein synthesis.46 Not all sources of dietary protein are nutritionally equivalent.22 The benefit of enhancing a low-protein diet with a leucine supplement demonstrated an improved muscle synthetic response in a small nonrandom controlled cohort of community-dwelling elders at risk of muscle loss.47 More research is needed to clarify the long-term benefit of selected amino acid supplementation in modifying the trajectory of sarcopenia or as a secondary nutrition prevention to counteract the effects of sarcopenia. The Society for Sarcopenia, Cachexia and Wasting Disease recommendations for the prevention and management of sarcopenia serve as primary and secondary nutrition preventions to manage the concurrent occurrence of frailty, sarcopenia, and malnutrition. Selected recommendations include protein intakes 1.0–1.5 g/kg/d, leucine-enriched IAA supplements, and resistance exercise.48
Role of Vitamin D Studies demonstrate that vitamin D insufficiency and frank deficiencies are common in older adults. The clinical consequence of sustained vitamin D deficiency with suboptimal calcium intakes includes deteriorating bone health and increased risk for falls, fractures, and functional decline.48-52 The American Geriatrics Society (AGS)53 and the Society for Sarcopenia, Cachexia and Wasting Disease48 have published recommendations to counteract or decelerate the trajectory of functional decline and sarcopenia. The focus of the AGS consensus statement on vitamin D and calcium supplementation recommendations is on optimizing vitamin D status in adults 65 years and older and populations at risk for vitamin D deficiency (malabsorption syndromes,54,55 individuals who take medications that accelerate vitamin D metabolism,56 obesity,57-59 minimal sun exposure60) to reduce the risk of falls and fractures (ie, extraskeletal outcomes). The International Osteoporosis Foundation and the Endocrine Society concur with the AGS recommendation of a minimum of 1000 IU of vitamin D daily or intakes that achieve serum 25(OH)D levels of ≥75 nmol/L.61,62 The AGS consensus statement notes that optimal vitamin D intakes are 4000 IU/d, based on the equations of serum response to vitamin D intake.41 The AGS recommendations far exceed the RDA for vitamin D
of 800 IU/d and are equal to the upper tolerable limit of 4000 IU/d. It is important to note that the RDA for vitamin D was established with the goal of achieving a serum 25(OH)D level of ≥30 nmol/L.41
Perspectives for Clinical Practice As the population ages, the concurrent occurrence of frailty, sarcopenia, and malnutrition is likely to rise. The AHRQ identified frailty, malnutrition, and sarcopenia as modifiable syndromes in older adults. Clinicians must work collaboratively to address chronic disease management and to promote positive lifestyle choices (exercise, fall prevention) while incorporating nutrition preventions to optimize muscle accretion and retention of muscle tissue. The quality and quantity of dietary protein consumed throughout the day are pivotal in counteracting the trajectory of functional decline and deterioration of nutrition status. Elders who “graze” or nibble on carbohydrate-dense, low-protein snacks or mini meals are unlikely to consume sufficient quantities of protein to reach plasma leucine levels necessary to maximize muscle tissue synthesis or sufficient vitamin D to optimize nonskeletal outcomes. Moreover, the elder who habitually skip meals or prefers to eat only 1 meal a day further limits the opportunities for muscle accretion or vitamin D sufficiency. Effective primary nutrition preventions include increasing intakes of high-quality protein with sufficient levels of leucine, optimizing vitamin D status with dietary supplements, and increasing daily resistance exercise. Clinicians should encourage elders to set a goal to consume 30 g of dietary protein per meal from foods and protein fortifiers or supplements. Foods rich in leucine include milk and other dairy products, eggs, seafood, and lean muscle meats. Leucine-rich protein supplements include whey protein isolate and soy protein isolate. Refer to nutrient analysis of other protein supplements to determine levels of leucine. For elders consuming diets low in calcium and vitamin D, dietary supplements are the easiest way to ensure that recommended levels are met. Many dietary supplements combine vitamin D and calcium because of improved absorption of calcium. However, the nutrient composition of these products needs to be evaluated to ensure that the recommended balance of vitamin D and calcium is consumed. Individual vitamin D and calcium pills may be preferred if elders are nonadherent to a supplement regimen due to adverse effects of the calcium. Elders experiencing marked inflammatory stress resulting in severe malnutrition and progressive sarcopenia require supportive, individualized nutrition care to promote quality of life. While it is clear that high-dose nutrition supplementation alone is not sufficient to reverse the mobilization of nutrients and other cytokine-related changes in organ function, it does support the nutrient needs of the elder by reducing the rate of lean
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mass depletion. Reasonably powered clinical trials are needed to quantify the benefits of a wide range of adjunctive therapies to counteract the trajectories of frailty, malnutrition, and sarcopenia in older adults.
Definitions Frailty: increased state of vulnerability and functional decline with an impaired ability to cope with both routine and acute stressors High-quality protein: dietary protein that provides sufficient amounts of all indispensible amino acids required for tissue accretion Inflammation-related malnutrition: cytokine-driven loss of lean body mass and total body weight Sarcopenia: progressive loss of muscle mass, muscle quality, and reduced strength Starvation-related malnutrition: inadequate intake of protein and/or energy over prolonged periods of time, resulting in loss of fat stores and/or muscle wasting as defined in the clinical characteristics of adult malnutrition. Undernourished/undernutrition: suboptimal intakes of protein and energy compared with established reference standards or recommendations based on physiological needs of recent duration as defined in the clinical characteristics of adult malnutrition
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Aster JC, eds. Robbins and Cotran Pathologic Basis of Disease. 8th ed. Philadelphia, PA: Saunders Elsevier; 2009. 38. Sloane PD, Ivey J. Nutritional issues in long term care. J Am Med Dir Assoc. 2008;9:476-485. 39. Jette AM, Branch LG. Musculoskeletal impairments and physical disablement among the aged. J Gerontol. 1990;45(6):M203-M208. 40. Wilhelm-Leen ER, Hall YN, Deboer IH, Chertow GM. Vitamin D deficiency and frailty in older Americans. J Intern Med. 2010;268: 171-180. 41. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011. 42. Wallace TC, Reider C, Fulgoni VL III. Calcium and vitamin D disparities are related to gender, age, race, household income level, and weight classification but not vegetarian status in the United States: analysis of the NHANES 2001-2008 data set. J Am Coll Nutr. 2013;32(5):321-330. 43. Annweiler C, Schott AM, Berrut G, Fantino B, Beauchet O. Vitamin D–related changes in physical performance: a systematic review. J Nutr Health Aging. 2009;13:893-898. 44. Hamilton B. Vitamin D and human skeletal muscle. Scand J Med Sci Sports. 2010;20:182-190. 45. Arnal M-A, Mosoni L, Boirie Y, et al. Protein pulse feeding improves protein retention in elderly women. Am J Clin Nutr. 1999;69:1202-1208. 46. Symons T, Sheffield-Moore M. A moderate serving of high-quality protein maximally stimulates skeletal muscle protein synthesis in young and elderly subjects. J Am Diet Assoc. 2009;109(9):1582-1586. 47. Casperson S, Sheffield-Moore M. Leucine supplementation chronically improves muscle protein synthesis in older adults consuming the RDA for protein. Clin Nutr. 2012;31(4):512-519. 48. Morely J, Argiles J. Nutritional recommendations for the management of sarcopenia. J Am Med Dir Assoc. 2010;11(6):391-396. 49. Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials. BMJ. 2009;339:b3692. 50. Bischoff-Ferrari HA, Willett WC. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009;169:551-561.
51. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T, DawsonHughes B. Calcium intake and hip fracture risk in men and women: a meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr. 2007;86:1780-1790. 52. Cranney A, Horsley T, O’Donnell S, et al. Effectiveness and Safety of Vitamin D in Relation to Bone Health. Evidence Report/Technology Assessment No. 158. AHRQ Publication No. 07-E013. Rockville, MD: Agency for Healthcare Research and Quality; August 2007. 53. American Geriatric Society. Consensus statement: Vitamin D for prevention of falls and the consequences in older adults. 2014. www.geriatricscareonline.org. Accessed April 8, 2014. 54. Slater GH, Ren CJ, Seigel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48-55. 55. Newbury L, Dolan K, Hatzifotis M, Fielding G. Calcium and vitamin D depletion and elevated parathyroid hormone following bilio-pancreatic diversion. Obes Surg. 2003;13:893-895. 56. Valsamis HA, Arora SK, Labban B, McFarlane SI. Antiepileptic drugs and bone metabolism. Nutr Metabol. 2006;3:36. 57. Arunabh S, Pollack S. Body fat content and 25-hydroxyvitamin D levels in healthy women. J Clin Endocrinol Metab. 2003.88:157-161. 58. Blum M, Dallal GE, Dawson-Hughes B. Body size and serum 25 hydroxy vitamin D response to oral supplements in healthy older adults. J Am Coll Nutr. 2008;27(2):274-279. 59. Gemmel K, Santry HP. Vitamin D deficiency in preoperative bariatric surgery patients. Surg Obes Relat Dis. 2009;5:54-59. 60. American Academy of Dermatology. Position statement on Vitamin D. Amended December 22, 2010. http://www.aad.org/Forms/Policies/ Uploads/PS/PS-Vitamin%20D%20Postition%20Statement.pdf. Accessed February 15, 2012. 61. Dawson-Hughes B, Mithal A. IOF position statement: vitamin D recommendations for older adults. Osteoporosis Int. 2010;21(7):1151-1154. 62. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Clinical practice guideline: evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-1930.
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research-article2014
NCPXXX10.1177/0884533614536231Nutrition in Clinical PracticeLitchford
Invited Review
Counteracting the Trajectory of Frailty and Sarcopenia in Older Adults
Nutrition in Clinical Practice Volume 29 Number 4 August 2014 428–434 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614536231 ncp.sagepub.com hosted at online.sagepub.com
Mary Demarest Litchford, PhD, RDN, LDN1
Abstract Food preservation technologies and medical advances in the past 50 years have contributed to safeguarding the health and prolonging the lives of individuals worldwide. However, living longer does not automatically equate with being healthy, living independently, making judicious decisions, or setting goals and achieving them. Most adults will experience 1 or more health problems with lingering consequences. It is the impact of the disease or injury that determines overall well-being and quality of life. Frailty, sarcopenia and malnutrition have been identified as common geriatric syndromes associated with functional decline, disability, hospitalization, institutionalization, and mortality. The evidence demonstrates that these geriatric syndromes could be prevented or the course of the syndrome altered through prevention strategies. Since these syndromes often present concurrently, it is prudent for healthcare professionals to recognize the interrelationships and clinical implications of these syndromes to employ tactics to promote desirable outcomes. (Nutr Clin Pract. 2014;29:428-434)
Keywords aged; frail elderly; nutritional status; vitamin D; geriatrics; malnutrition; nutrition; sarcopenia; frailty
The world’s population is aging. The subset older than 60 years is expected to triple by 2050. The fastest growing cohort in the developed countries is adults 80 years and older.1 Experts predict that by 2030, adults 65 years and older will account for about 20% of the U.S. population. More than 65% of adults in the United States are burdened with 1 or more chronic conditions that contribute to diminished quality of life, as well as affect the person’s ability to perform fundamental activities both inside the home and in the community.2 Many factors are propelling the trajectory of physical and functional decline that leads to impaired mobility and dependence. Changes in functional status and mobility hinder performance of nutrition-related activities of daily living (ADLs), which contribute to declining nutrition status, frailty, malnutrition, and sarcopenia. In an effort to mitigate progressive decline and subsequent healthcare care costs for older adults, the United States Preventive Health Services Task Force (USPST) commissioned the Agency for Health Research and Quality (AHRQ) to conduct a systematic review of the published evidence on modifiable geriatric syndromes. Common Syndromes in Older Adults Related to Primary and Secondary Prevention3 identified 8 modifiable syndromes in older adults that are associated with functional decline, disability, institutionalization, and mortality (Figure 1). The evidence demonstrates that these common geriatric syndromes could be prevented or the course of the syndrome altered through prevention strategies. Geriatric syndromes are not independent of one another and often overlap one another. Functional status is related to nutrition status in 2 ways. It is a major quality of life factor for older adults and a determinant of meeting nutrient requirements. This article focuses on the unique trajectory of 3 modifiable geriatric
syndromes—frailty, sarcopenia, and malnutrition—that contribute to functional decline in older adults.
Frailty Frailty is a multidimensional syndrome in which there is an increased state of vulnerability due to age-related decline in more than 1 physiological system that compromises an adult’s ability to cope with routine and acute stressors.4 It encompasses a progressive reduction in physical, psychological, social, and cognitive reserves. Moreover, frailty is associated with a reduced ability to regain physiological homeostasis. The progression of frailty is driven by the balance between strengths supporting independence and deficients of self-sufficiency.4,5 The prevalence of frailty increases with age; is associated with an increased risk for falls, disability, and hospitalization; and is a predictor of mortality. Characteristics of frailty include chronic undernutrition and malnutrition, unplanned weight loss, fatigue, exhaustion, weakness, reduced walking speed (slowness), low physical activity, and impaired mobility. Clinicians differentiate degrees of frailty by phenotype (ie, robust, prefrail, or frail) or by an accumulation of functional deficits.3-5 From 1CASE Software & Books, Greensboro, North Carolina. Financial disclosure: None declared. This article originally appeared online on June 9, 2014. Corresponding Author: Mary Demarest Litchford, PhD, RDN, LDN, CASE Software & Books, 5601 Forest Manor Dr, Greensboro, NC 27410, USA. Email: [email protected]; [email protected]
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Malnutrition
Figure 1. Eight syndromes in older adults, associated with functional decline, disability, institutionalization and mortality, that can be modified using primary and secondary preventions.3
Sarcopenia is 1 component of frailty. The functional limitations in older adults may be because they are weak, and they are weak in part because they have low muscle mass. Furthermore, frailty may reflect a shift in body composition favoring higher fat stores and reduced lean reserves.6,7 Frailty may be exacerbated by chronic undernutrition.3,4
Sarcopenia Sarcopenia is the progressive loss of muscle mass, muscle quality, and physical strength and function that may contribute to frailty and disability in older adults. It is not limited to individuals with low body weight. Changes in body composition are due in part to changes in the continuous cycle of skeletal muscle protein synthesis (MPS) and degradation or muscle protein breakdown (MPB). Net protein balance is the difference between MPS and MPB. To accrue skeletal muscle protein, there must be a significant rise in MPS or anabolic activity (ie, exercise, adequate diet) coupled with a reduction in MPB or catabolic activity.8-11 With aging, the balanced cycle of muscle synthesis/degradation shifts toward more breakdown than synthesis of muscle tissue.6,7 It is recognized that reduced anabolic stimulation from changes in anabolic hormones, insulin resistance, subclinical inflammation (catabolic stimuli), insufficient intakes of protein and energy, impaired utilization of nutrients, and inactivity play significant roles in the progression of sarcopenia.12 The diagnosis is usually based on the estimated lean body reserves relative to skeletal size and total body mass and loss of strength. The Foundation for the National Institutes of Health Sarcopenia
Malnutrition may be concurrent with frailty and/or sarcopenia. The etiology of malnutrition is a reflection of its context. Starvation is the primary driver of malnutrition in the context of social or environmental circumstances, whereas inflammation is the primary initiator of rapid loss of lean mass and total body weight in acute illness or injury and comorbidity in chronic diseases.15,16 Changes in functional and nutrition status of older adults may be compounded by 1 or all of these situations. Older adults are the most likely segment of the population to get sick from a poor diet.17 The National Health and Nutrition Examination Survey (NHANES) data demonstrate a linear decrease in total energy, fat, and protein intake as men and women age.18,19 Almost 40% of adults 70 years and older do not consume the Recommended Dietary Allowance (RDA) for protein (0.8 g/kg/d). Moreover, muscle loss in community-living elders was found to be negatively related to protein intake in this population cohort.20 Individuals in negative-energy balance have higher physiological requirements for protein to maintain nitrogen balance because protein is used to meet energy requirements rather than for tissue accretion.21-23 More than 55% of hospitalized elders are undernourished and up to 85% of elderly residents living in institutions are undernourished.24,25 Older patients who are malnourished on admission are at markedly higher risk of life-threatening complications during hospitalization. Admission to an extended care facility is associated with unplanned weight loss and poor nutrition due to dementia, sensory loss, polypharmacy, and comorbidities.25-27 Elders who depend on feeding assistance at meals are much more likely to lose weight than those who are able to eat independently. Among institutionalized elders, eating dependency increases the risk of having a low body mass index (BMI) or weight loss by 1.5–2 times. Low energy intake, significant weight loss, and malnutrition are associated with increased mortality in elders.28
Concurrent Occurrence of Sarcopenia, Frailty, and Malnutrition Aging and functional decline are inescapable, yet the concurrent presentation of frailty, sarcopenia, and malnutrition in the older adult increases the velocity and progression toward loss of independence. The characteristics of frailty, sarcopenia, and malnutrition are summarized in Table 1, noting the similarities and differences of these syndromes. The concurrent occurrence of frailty, sarcopenia, and malnutrition may lead to a self-perpetuating cycle of naturally progressing event (Figure 2). For instance, the progressive loss of muscle mass and diminished function and strength manifest in sarcopenia are partly due to suboptimal intake of dietary protein compared
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Figure 2. Cycle of functional decline. ADL, activities of daily living; BMI, body mass index; HBV, high biologic value; IWL, involuntary weight loss.
with estimated physiological requirements. Similarly, starvation-related malnutrition results in loss of skeletal muscle mass and involuntary weight loss. Reduced muscle strength contributes to weakness, impaired functionality, and loss of nutritionrelated ADLs. One potential consequence of weakness and functional decline is that as community-dwelling elders become more sedentary and reclusive, grocery shopping and meal preparation become more difficult. The end result may include fewer trips to the grocery store, reduced food inventory, dependence on others to purchase food or provide meals, skipped meals, and increased consumption of low-nutrient ready-to-eat products.3 Food insecurity may arise when access to groceries is limited due to shopping or transportation disabilities, especially if the older adult has a physical or cognitive disability, is single, and has a limited income.37 Sustained protein and energy intakes below physiological needs, coupled with weakness and declining lean body reserves due to inactivity and age or disease-related inflammation, perpetuate a vicious cycle of impaired functionality and reduced ability to perform nutrition-related ADLs. The dire consequences are manifest when an acute episode of illness or injury requires hospitalization. For instance, a community-dwelling elder develops an acute illness such as an upper respiratory tract infection that progresses into pneumonia. During the episode of illness, the elder’s physical stamina and appetite are significantly reduced, resulting in a minimal nutrient intake.
Yet resting energy requirements are elevated due to inflammatory stress, and lean body reserves are being mobilized to meet protein requirements. The subsequent trajectory of decline is exacerbated by the effects of inflammation compounded by the iatrogenic effects of hospitalization or institutionalization and of extended bed rest that further promote the loss of muscle mass. What began as seemingly insignificant changes in lifestyle choices and dietary habits may lead to loss of muscle mass and increased risk for illness and injury. Other metabolic changes that may contribute to the concurrent onset of frailty, sarcopenia, and malnutrition include reduced skin synthesis of previtamin D, coupled with impaired renal and gut response to 1,25-dihydroxyvitamin D (1,25(OH)2D), increasing the likelihood of a vitamin D insufficiency or frank deficiency. The NHANES data (2001–2008)40 for intake of vitamin D demonstrate that more than 85% of adults 51 years and older do not consume the 2010 RDA for vitamin D from food or supplements. Is it estimated that more than 70% of the U.S. older adult population have serum 25-hydroxyvitamin D (25(OH)D) levels below the recommended values for preventing fractures and falls.41,42 Vitamin D insufficiency is associated with a 4-fold increase in the risk of frailty. Several polymorphisms of vitamin D receptor (VDR) isolated in skeletal muscle have been associated with differences in muscle strength.40 Low serum levels of vitamin D have been associated with an increase in
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Table 1. Characteristics of Frailty, Sarcopenia, and Malnutrition. Category
Frailty
Etiology
•• Interplay of environmental and intraindividual challenges that lead to behavioral adaptation3,4
Common comorbidities
•• Mental health limitations4 •• Undernutrition and malnutrition3-5
Physical characteristics
Associated functional decline and disabilities
Physiologic and metabolic changes
•• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
Weakness3,4 Decreased walking speed3,4 Decreased VO2 max4 Exhaustion3,4 Homeostenosis3,32 Reduced muscle strength3-5 Impaired mobility3-5 Unsteady gait5 Use of assistive devices4,5 Compensatory strategies or environmental supports4 Reduced quality of life3,4 Greater dependency3,4 Maladaptations to aging3,4 Selected vitamin and mineral deficiencies3,39 Impaired immunity4
Sarcopenia 29
•• •• •• ••
Inactivity Undernourished3,29,30 Inflammation related3,29-31 Marked inflammation → cachexia3,29-31 •• Suboptimal protein intake3,12,20,30 •• Exacerbated by inflammatoryrelated medical diagnoses3,33,34 •• Frailty3-5 •• Weight unchanged or loss3,29,30,33 •• Muscle wasting3,12,25,35,36 •• Fatigue12,29,34 •• •• •• ••
Reduced muscle strength3,29,35 Impaired mobility26,34,36 Reduced quality of life3 Greater dependency3,26
•• Reduced anabolic stimulation27,29,33 •• Increased insulin resistance29-31 •• Anorexia30 •• Selected vitamin and mineral deficiencies3 •• Shift in body composition from lean → fat28
Malnutrition •• Starvation related15,16 •• Inflammation related 15,16 •• Marked inflammation → severe malnutrition15,16,24,25,28 •• Suboptimal protein intake3,4,17-20,32 •• Exacerbated by inflammatoryrelated medical diagnoses3,15,24 •• Decline in cognitive skills3 •• Depression3 •• Unplanned weight loss unless masked by edema15,16,24,26 •• Impaired senses of taste and smell27,28 •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••
the occurrence of sarcopenia.43,44 Selected observational studies have reported the association between low serum vitamin D levels and functional limitations (ie, muscle weakness, difficultly rising from a chair, difficulties in ascending stairs, balance problems, and increased risk for falls and fractures).40,43,44 More research is needed to clarify the interrelationships weakness, muscle function, and vitamin D status.
Role of Protein and Leucine The Health, Aging and Body Composition study assessed the association between dietary protein and changes in lean body
Reduced muscle strength3,15,16,24 Food preparation disability3 Shopping disability3 Food insecurity3,37 Impaired chewing and swallowing3,27,38 Reduced quality of life3 Greater dependency3,26 Changes in digestive processes21-23,28,36 Impaired micronutrient utilization21,22,25,26,36,37 Selected vitamin and mineral deficiencies3,25,28,36 Impaired immunity20 Anorexia22 Impaired protein utilization16,17,30,31 Shift in body composition from lean → fat27,28 Changes in basal metabolic rate19,20,27,28 Mobilization of nutrient reserves23,28
reserves over a 3-year period. Participants with the highest quintile of protein intake lost approximately 40% less lean body mass than those in the lowest quintile. The authors concluded that dietary protein may be a modifiable risk factor for sarcopenia in older adults.20 Researchers have demonstrated that the timing, distribution, and quality of dietary protein throughout the day are important factors in maximizing tissue accretion. The biological quality of dietary protein is determined by the distribution and quantity of indispensible amino acids required for tissue accretion.22 Moreover, the timing of meals and quantity of high-quality dietary protein consumed serve as a means to counteract the blunted protein-anabolic response to a small,
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mixed-macronutrient meal. One study in healthy older women found that providing 79% of the day’s protein at the noon meal improved protein retention compared with a more even distribution of dietary protein across all 3 meals.45 Other researchers found that consuming 30 g of high-quality dietary protein at each meal maximized protein synthesis in nonexercising adults. The key was consuming sufficient amounts of the indispensible amino acid (IAA) leucine required to activate mammalian target of rapamycin (mTOR) signaling pathway that regulates protein synthesis and muscle tissue accretion.29,46 Offering up to 90 g high-quality dietary protein in a single serving did not stimulate further protein synthesis.46 Not all sources of dietary protein are nutritionally equivalent.22 The benefit of enhancing a low-protein diet with a leucine supplement demonstrated an improved muscle synthetic response in a small nonrandom controlled cohort of community-dwelling elders at risk of muscle loss.47 More research is needed to clarify the long-term benefit of selected amino acid supplementation in modifying the trajectory of sarcopenia or as a secondary nutrition prevention to counteract the effects of sarcopenia. The Society for Sarcopenia, Cachexia and Wasting Disease recommendations for the prevention and management of sarcopenia serve as primary and secondary nutrition preventions to manage the concurrent occurrence of frailty, sarcopenia, and malnutrition. Selected recommendations include protein intakes 1.0–1.5 g/kg/d, leucine-enriched IAA supplements, and resistance exercise.48
Role of Vitamin D Studies demonstrate that vitamin D insufficiency and frank deficiencies are common in older adults. The clinical consequence of sustained vitamin D deficiency with suboptimal calcium intakes includes deteriorating bone health and increased risk for falls, fractures, and functional decline.48-52 The American Geriatrics Society (AGS)53 and the Society for Sarcopenia, Cachexia and Wasting Disease48 have published recommendations to counteract or decelerate the trajectory of functional decline and sarcopenia. The focus of the AGS consensus statement on vitamin D and calcium supplementation recommendations is on optimizing vitamin D status in adults 65 years and older and populations at risk for vitamin D deficiency (malabsorption syndromes,54,55 individuals who take medications that accelerate vitamin D metabolism,56 obesity,57-59 minimal sun exposure60) to reduce the risk of falls and fractures (ie, extraskeletal outcomes). The International Osteoporosis Foundation and the Endocrine Society concur with the AGS recommendation of a minimum of 1000 IU of vitamin D daily or intakes that achieve serum 25(OH)D levels of ≥75 nmol/L.61,62 The AGS consensus statement notes that optimal vitamin D intakes are 4000 IU/d, based on the equations of serum response to vitamin D intake.41 The AGS recommendations far exceed the RDA for vitamin D
of 800 IU/d and are equal to the upper tolerable limit of 4000 IU/d. It is important to note that the RDA for vitamin D was established with the goal of achieving a serum 25(OH)D level of ≥30 nmol/L.41
Perspectives for Clinical Practice As the population ages, the concurrent occurrence of frailty, sarcopenia, and malnutrition is likely to rise. The AHRQ identified frailty, malnutrition, and sarcopenia as modifiable syndromes in older adults. Clinicians must work collaboratively to address chronic disease management and to promote positive lifestyle choices (exercise, fall prevention) while incorporating nutrition preventions to optimize muscle accretion and retention of muscle tissue. The quality and quantity of dietary protein consumed throughout the day are pivotal in counteracting the trajectory of functional decline and deterioration of nutrition status. Elders who “graze” or nibble on carbohydrate-dense, low-protein snacks or mini meals are unlikely to consume sufficient quantities of protein to reach plasma leucine levels necessary to maximize muscle tissue synthesis or sufficient vitamin D to optimize nonskeletal outcomes. Moreover, the elder who habitually skip meals or prefers to eat only 1 meal a day further limits the opportunities for muscle accretion or vitamin D sufficiency. Effective primary nutrition preventions include increasing intakes of high-quality protein with sufficient levels of leucine, optimizing vitamin D status with dietary supplements, and increasing daily resistance exercise. Clinicians should encourage elders to set a goal to consume 30 g of dietary protein per meal from foods and protein fortifiers or supplements. Foods rich in leucine include milk and other dairy products, eggs, seafood, and lean muscle meats. Leucine-rich protein supplements include whey protein isolate and soy protein isolate. Refer to nutrient analysis of other protein supplements to determine levels of leucine. For elders consuming diets low in calcium and vitamin D, dietary supplements are the easiest way to ensure that recommended levels are met. Many dietary supplements combine vitamin D and calcium because of improved absorption of calcium. However, the nutrient composition of these products needs to be evaluated to ensure that the recommended balance of vitamin D and calcium is consumed. Individual vitamin D and calcium pills may be preferred if elders are nonadherent to a supplement regimen due to adverse effects of the calcium. Elders experiencing marked inflammatory stress resulting in severe malnutrition and progressive sarcopenia require supportive, individualized nutrition care to promote quality of life. While it is clear that high-dose nutrition supplementation alone is not sufficient to reverse the mobilization of nutrients and other cytokine-related changes in organ function, it does support the nutrient needs of the elder by reducing the rate of lean
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mass depletion. Reasonably powered clinical trials are needed to quantify the benefits of a wide range of adjunctive therapies to counteract the trajectories of frailty, malnutrition, and sarcopenia in older adults.
Definitions Frailty: increased state of vulnerability and functional decline with an impaired ability to cope with both routine and acute stressors High-quality protein: dietary protein that provides sufficient amounts of all indispensible amino acids required for tissue accretion Inflammation-related malnutrition: cytokine-driven loss of lean body mass and total body weight Sarcopenia: progressive loss of muscle mass, muscle quality, and reduced strength Starvation-related malnutrition: inadequate intake of protein and/or energy over prolonged periods of time, resulting in loss of fat stores and/or muscle wasting as defined in the clinical characteristics of adult malnutrition. Undernourished/undernutrition: suboptimal intakes of protein and energy compared with established reference standards or recommendations based on physiological needs of recent duration as defined in the clinical characteristics of adult malnutrition
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