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      Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

      1 , 2 , , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 37 , 3 , 10 , 11 , 1 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36
      The Journal of Nutrition, Health & Aging
      Springer Paris
      Aged, 80 and over, Practice guideline, Frailty/diagnosis, Frailty/therapy*, Patient Care Planning/standards

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          The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.


          These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care.

          Recommendations for Screening and Assessment

          The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation).

          Recommendations for Management

          A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

          Electronic Supplementary Material

          Supplementary material is available for this article at 10.1007/s12603-019-1273-z and is accessible for authorized users.

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          Most cited references115

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          STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

          Purpose: screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.
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            Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial.

            Improving vitamin D status may be an important modifiable risk factor to reduce falls and fractures; however, adherence to daily supplementation is typically poor. To determine whether a single annual dose of 500,000 IU of cholecalciferol administered orally to older women in autumn or winter would improve adherence and reduce the risk of falls and fracture. A double-blind, placebo-controlled trial of 2256 community-dwelling women, aged 70 years or older, considered to be at high risk of fracture were recruited from June 2003 to June 2005 and were randomly assigned to receive cholecalciferol or placebo each autumn to winter for 3 to 5 years. The study concluded in 2008. 500,000 IU of cholecalciferol or placebo. Falls and fractures were ascertained using monthly calendars; details were confirmed by telephone interview. Fractures were radiologically confirmed. In a substudy, 137 randomly selected participants underwent serial blood sampling for 25-hydroxycholecalciferol and parathyroid hormone levels. Women in the cholecalciferol (vitamin D) group had 171 fractures vs 135 in the placebo group; 837 women in the vitamin D group fell 2892 times (rate, 83.4 per 100 person-years) while 769 women in the placebo group fell 2512 times (rate, 72.7 per 100 person-years; incidence rate ratio [RR], 1.15; 95% confidence interval [CI], 1.02-1.30; P = .03). The incidence RR for fracture in the vitamin D group was 1.26 (95% CI, 1.00-1.59; P = .047) vs the placebo group (rates per 100 person-years, 4.9 vitamin D vs 3.9 placebo). A temporal pattern was observed in a post hoc analysis of falls. The incidence RR of falling in the vitamin D group vs the placebo group was 1.31 in the first 3 months after dosing and 1.13 during the following 9 months (test for homogeneity; P = .02). In the substudy, the median baseline serum 25-hydroxycholecalciferol was 49 nmol/L. Less than 3% of the substudy participants had 25-hydroxycholecalciferol levels lower than 25 nmol/L. In the vitamin D group, 25-hydroxycholecalciferol levels increased at 1 month after dosing to approximately 120 nmol/L, were approximately 90 nmol/L at 3 months, and remained higher than the placebo group 12 months after dosing. Among older community-dwelling women, annual oral administration of high-dose cholecalciferol resulted in an increased risk of falls and fractures. anzctr.org.au Identifier: ACTRN12605000658617; isrctn.org Identifier: ISRCTN83409867.
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              Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care.

              Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronic conditions, frailty, and disability. However, in geriatric medicine, there is a growing consensus that these are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions, including their clinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analyses in selected areas where no current published data exists. Overall, the goal of this article is to provide a basis for distinguishing between these three important clinical conditions in older adults and showing how use of separate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.

                Author and article information

                J Nutr Health Aging
                J Nutr Health Aging
                The Journal of Nutrition, Health & Aging
                Springer Paris (Paris )
                3 October 2019
                3 October 2019
                : 23
                : 9
                : 771-787
                [1 ]GRID grid.449625.8, ISNI 0000 0004 4654 2104, Torrens University Australia, ; Adelaide, Australia
                [2 ]GRID grid.1051.5, ISNI 0000 0000 9760 5620, Baker Heart and Diabetes Institute, ; Melbourne, Australia
                [3 ]GRID grid.262962.b, ISNI 0000 0004 1936 9342, Division of Geriatric Medicine, , Saint Louis University School of Medicine, ; St. Louis, Missouri USA
                [4 ]GRID grid.411347.4, ISNI 0000 0000 9248 5770, Servicio de Geriatria, , Hospital Universitario Ramón y Cajal (IRYCIS), ; Madrid, Spain
                [5 ]GRID grid.17089.37, Department of Physical Therapy, Rehabilitation Medicine, , University of Alberta, ; Edmonton, Alberta Canada
                [6 ]GRID grid.411244.6, ISNI 0000 0000 9691 6072, Servicio de Geriatria, , Hospital Universitario de Getafe, ; Madrid, Spain
                [7 ]GRID grid.239585.0, ISNI 0000 0001 2285 2675, Mailman School of Public Health, , Columbia University Medical Center, ; New York, NY USA
                [8 ]GRID grid.10784.3a, ISNI 0000 0004 1937 0482, Department of Medicine, , The Chinese University of Hong Kong, ; Hong Kong, China
                [9 ]Geriatrics Division, Internal Medicine, Department, Faculty of Medicine of Jundiaí, Group of Investigation on Multimorbidity and Mental Health in Aging (GIMMA), Jundiaí, Brazil
                [37 ]Medical School, University City of São Paulo, São Paulo, Brazil
                [10 ]Perry County Memorial Hospital, Perryville, Missouri USA
                [11 ]GRID grid.411075.6, ISNI 0000 0004 1760 4193, Fondazione Policlinico A. Gemelli, ; Roma, Italy
                [12 ]GRID grid.13097.3c, ISNI 0000 0001 2322 6764, Population Health Sciences, , King’s College, ; London, UK
                [13 ]GRID grid.427812.a, Center for Geriatric Medicine, , Heidelberg University Agaplesion Bethanien Krankenhaus, ; Heidelberg, Germany
                [14 ]GRID grid.419475.a, ISNI 0000 0000 9372 4913, Intramural Research Program of the National Institute on Aging, ; Bethesda, USA
                [15 ]GRID grid.410759.e, ISNI 0000 0004 0451 6143, Division of Geriatric Medicine, Department of Medicine, National University Hospital, , National University Health System, ; Singapore, Singapore
                [16 ]GRID grid.412901.f, ISNI 0000 0004 1770 1022, Department of Geriatrics and National Clinical Research Center for Geriatrics, , West China Hospital of Sichuan University, ; Chengdu, China
                [17 ]GRID grid.419257.c, ISNI 0000 0004 1791 9005, National Center for Geriatrics and Gerontology, ; Obu, Japan
                [18 ]GRID grid.16872.3a, ISNI 0000 0004 0435 165X, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research institute, , Amsterdam UMC — location VU University Medical Center, ; Amsterdam, the Netherlands
                [19 ]GRID grid.289247.2, ISNI 0000 0001 2171 7818, Elderly Frailty Research Center, Department of Family Medicine, College of Medicine, , Kyung Hee University, ; Seoul, Korea
                [20 ]Alzheimer’s Disease Clinic Department, Azienda Sanitaria Locale (ASL) di Frosinone, Frosinone, Italy
                [21 ]GRID grid.24381.3c, ISNI 0000 0000 9241 5705, Clinical Nutrition and Metabolism, Department of Public Health and Caring Sciences, Uppsala University and Theme Aging, , Karolinska University Hospital, ; Stockholm, Sweden
                [22 ]GRID grid.10858.34, ISNI 0000 0001 0941 4873, Center for Life Course Health Research, , University of Oulu, ; Oulu, Finland
                [23 ]GRID grid.7737.4, ISNI 0000 0004 0410 2071, University of Helsinki and Helsinki University Hospital, ; Helsinki, Finland
                [24 ]National Institute of Geriatrics, Mexico City, Mexico
                [25 ]GRID grid.1012.2, ISNI 0000 0004 1936 7910, Western Australian Centre for Health and Ageing, Medical School, , University of Western Australia, ; Perth, Australia
                [26 ]GRID grid.38142.3c, ISNI 000000041936754X, Research Program in Mean’s Health: Aging and Metabolism, Boston Claude D. Pepper Older American Independence Center, Brigham and Women’s Hospital, , Harvard Medical School, ; Boston, Massachusetts USA
                [27 ]GRID grid.38678.32, ISNI 0000 0001 2181 0211, Dept des Sciences de l’activité physique, Université du Quebec à Montréal, , CRIUGM, ; Montreal, Québec Canada
                [28 ]GRID grid.7400.3, ISNI 0000 0004 1937 0650, Dept of Geriatrics and Aging Research, , University Hospital and University of Zurich, ; Zurich, Switzerland
                [29 ]GRID grid.411024.2, ISNI 0000 0001 2175 4264, Dept of Epidemiology and Public Health, Division of Gerontology, , University of Maryland School of Medicine, ; Baltimore, Maryland USA
                [30 ]GRID grid.410356.5, ISNI 0000 0004 1936 8331, Dept of Critical Care Medicine, , Queen’s University, ; Kingston, Ontario Canada
                [31 ]GRID grid.15276.37, ISNI 0000 0004 1936 8091, Dept of Aging and Geriatric Research, , University of Florida, ; Gainesville, Florida USA
                [32 ]GRID grid.26790.3a, ISNI 0000 0004 1936 8606, Miami VA Healthcare System GRECC and Division of Geriatrics & Palliative Medicine, , University of Miami Miller School of Medicine, ; Miami, Florida USA
                [33 ]GRID grid.25073.33, ISNI 0000 0004 1936 8227, School of Rehabilitation Sciences, Faculty of Health Sciences, , McMaster University, ; Hamilton, Ontario Canada
                [34 ]GRID grid.56302.32, ISNI 0000 0004 1773 5396, WHO Collaborating Center for Public Health Aspects of Musculoskeletal Health and Aging, Liège, Belgium and Chair for Biomarkers of Chronic Diseases, Department of Biochemistry, College of Science, , King Saud University, ; Riyadh, Kingdom of Saudi Arabia
                [35 ]GRID grid.29980.3a, ISNI 0000 0004 1936 7830, Dept of Medicine/School of Physiotherapy, , University of Otago, ; Dunedin, New Zealand
                [36 ]GRID grid.411175.7, ISNI 0000 0001 1457 2980, Gérontopôle UMR Inserm 1027, Université Paul Sabatier, , CHU Toulouse, ; Toulouse, France
                © The Author(s) 2019

                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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                © Serdi and Springer-Verlag France SAS, part of Springer Nature 2019

                aged,80 and over,practice guideline,frailty/diagnosis,frailty/therapy*,patient care planning/standards


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