Pharmacotherapy is a vital part of the multi-pronged strategy in dementia management. All dementia patients should be evaluated for suitability of pharmacological strategies to address the underlying disease, enhance cognitive symptomatology, and treat attendant behavioural complications. Once a definitive diagnosis of dementia has been made, the choice of symptomatic treatment hinges mainly on dementia etiology and stage of severity. While skillful use of symptomatic treatment can offer tangible but modest benefits in many cases, the decision to initiate such costly treatment should be individualised and always made in conjunction with the patient and caregiver. Disease-modifying treatment which goes beyond a primary symptomatic effect to target the underlying amyloid and tau pathways are currently undergoing clinical trials.

Sarcopenia refers to the age-associated progressive and generalized loss of skeletal muscle mass plus loss of muscle strength and/or reduced physical performance. Described as the biological substrate that antecedes physical frailty, sarcopenia is associated with adverse health outcomes in older adults. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code for sarcopenia represents a major step forward in translating sarcopenia to clinical practice. The Asian Working Group for Sarcopenia (AWGS) 2019 consensus provides an algorithm for identifying and diagnosing older adults with or at-risk for sarcopenia. “Possible sarcopenia” is defined by low muscle strength or reduced physical performance, and is applicable for primary health care and community settings. Accurate case finding and assessment requires proper administration using the correct instruments. Older adults with or at-risk for sarcopenia should be evaluated for reversible causes (using the ‘4D’ mnemonic). Currently, the mainstay of treatment is non-pharmacological, comprising resistance exercise and adequate protein intake.

Aged, 80 and over ; Evidence-Based Medicine ; Geriatrics ; Humans ; Male

INTRODUCTIONThis study aimed to determine the stratified normative data by age and education for a modified version of the Mini-Mental State Examination (MMSE) test from a large sample of community-dwelling Chinese older adults in Singapore, and to examine the MMSE's value in detecting early cognitive impairment.

METHODSWe studied 1,763 Chinese older adults with normal cognitive function and 121 Chinese older adults with early cognitive impairment (Clinical Dementia Rating global score 0.5). Normative MMSE values were derived for each of the 15 strata classified by age (three groups) and education level (five groups). Receiver operating characteristic curve analysis was conducted for the whole sample and each of the three education subgroups (no education, primary, secondary and above).

RESULTSEducation level and age significantly influenced the normative values of MMSE total scores in Chinese older adults with normal cognitive function. For the purpose of detecting early cognitive impairment, an optimal balance between sensitivity (Se) and specificity (Sp) was obtained at a cutoff score of 25, 27 and 29 for each of the three education groups, respectively. For the whole sample, the optimal cutoff point was 26 (Se 0.61, Sp 0.84, area under curve 0.78).

CONCLUSIONAge and education level must be taken into account in the interpretation of optimal cutoffs for the MMSE. Although widely used, the MMSE has limited value in detecting early cognitive impairment; tests with better performance should be considered in clinical practice.

Age Factors ; Aged ; Area Under Curve ; China ; Cognition Disorders ; diagnosis ; epidemiology ; ethnology ; Dementia ; diagnosis ; epidemiology ; ethnology ; Educational Status ; Female ; Humans ; Male ; Mental Status Schedule ; Middle Aged ; Neuropsychological Tests ; standards ; Psychometrics ; methods ; Reference Values ; Sensitivity and Specificity ; Singapore ; ethnology

INTRODUCTION: Sarcopenia is characterised by a progressive and generalised loss of skeletal muscle mass, strength and/or performance. It is associated with adverse health outcomes such as increased morbidity, functional decline and death. Early detection of sarcopenia in community-dwelling older adults is important to prevent these outcomes. Our scoping review evaluates validated screening tools that are used to identify community-dwelling older individuals at risk of sarcopenia and appraises their performance against international consensus definitions. MATERIALS AND METHODS: A systematic search on MEDLINE, PubMed and EMBASE was performed for articles that evaluated the predictive validity measures of screening tools and validated them against at least 1 internationally recognised diagnostic criterion for sarcopenia. RESULTS: Of the 17 articles identified in our search, 8 used questionnaires as screening tool, 2 utilised anthropometric measurements, 3 used a combination of questionnaire and anthropometric measures and 1 used a physical performance measure (chair stand test). The questionnaire Strength, Assistance with walking, Rising from chair, Climbing stairs and Falls (SARC-F) has the highest specificity (94.4-98.7%) but low sensitivity (4.2-9.9%), with the 5-item questionnaire outperforming the 3-item version. When SARC-F is combined with calf circumference, its sensitivity is enhanced with improvement in overall diagnostic performance. Although equation-based anthropometric screening tools performed well, they warrant external validation. CONCLUSION Our scoping review identified 6 candidate tools to screen for sarcopenia. Direct comparison studies in the community would help to provide insights into their comparative performance as screening tools. More studies are needed to reach a consensus on the best screening tool(s) to be used in clinical practice.

INTRODUCTION: We developed a Clinical Frailty Scale algorithm (CFS-A) to minimise inter-rater variability and to facilitate wider application across clinical settings. We compared the agreement, diagnostic performance and predictive utility of CFS-A against standard CFS. MATERIALS AND METHODS: We retrospectively analysed data of 210 hospitalised older adults (mean age, 89.4 years). Two independent raters assessed frailty using CFS-A. Agreement between CFS-A raters and with previously completed CFS was determined using Cohen's Kappa. Area under receiver operator characteristic curves (AUC) for both measures were compared against the Frailty Index (FI). Independent associations between these measures and adverse outcomes were examined using logistic regression. RESULTS: Frailty prevalence were 81% in CFS and 96% in CFS-A. Inter-rater agreement between CFS-A raters was excellent (kappa 0.90, <0.001) and there was moderate agreement between CFS-A and standard CFS (kappa 0.42, <0.001). We found no difference in AUC against FI between CFS (0.91; 95% CI, 0.86-0.95) and CFS-A (0.89; 95% CI, 0.84-0.95; <0.001). Both CFS (OR, 3.59; 95% CI, 2.28-5.67; <0.001) and CFS-A (OR, 4.31; 95% CI, 2.41-7.69; <0.001) were good predictors of mortality at 12 months. Similarly, CFS (OR, 2.59; 95% CI, 1.81-3.69; <0.001) and CFS-A (OR, 3.58; 95% CI, 2.13-6.02; <0.001) were also good predictors of institutionalisation and/or mortality after adjusting for age, sex and illness severity. CONCLUSION Our study corroborated the results on inter-rater reliability, diagnostic performance and predictive validity of CFS-A which has the potential for consistent and efficient administration of CFS in acute care settings.

Biomedical Research ; Frailty ; Geriatrics ; Health Policy ; Health Services ; Humans ; Practice Guidelines as Topic ; Singapore

INTRODUCTIONA knowledge-attitude dissociation often exists in geriatrics where knowledge but not attitudes towards elderly patients improve with education. This study aims to determine whether a holistic education programme incorporating multiple educational strategies such as early exposure, ageing simulation and small group teaching results in improving geriatrics knowledge and attitudes among medical students.

MATERIALS AND METHODSWe administered the 18-item University of California Los Angeles (UCLA) Geriatric Knowledge Test (GKT) and the Singapore-modified 16-item UCLA Geriatric Attitudes Test (GAT) to 2nd year students of the old curriculum in 2009 (baseline reference cohort, n = 254), and before and after the new module to students of the new curriculum in 2010 (intervention cohort, n = 261), both at the same time of the year.

RESULTSAt baseline, between the baseline reference and intervention cohort, there was no difference in knowledge (UCLA-GKT Score: 31.6 vs 33.5, P = 0.207) but attitudes of the intervention group were worse than the baseline reference group (UCLA-GAT Score: 3.53 vs 3.43, P = 0.003). The new module improved both the geriatric knowledge (UCLA-GKT Score: 34.0 vs 46.0, P <0.001) and attitudes (UCLA-GAT Score: 3.43 vs 3.50, P <0.001) of the intervention cohort.

CONCLUSIONA geriatric education module incorporating sound educational strategies improved both geriatric knowledge and attitudes among medical students.

Curriculum ; Education, Medical, Undergraduate ; Educational Measurement ; Educational Status ; Geriatrics ; education ; Health Knowledge, Attitudes, Practice ; Humans ; Psychometrics ; Singapore ; epidemiology ; Statistics as Topic ; Students, Medical

This review introduces a qualitative methodology called institutional ethnography (IE) to healthcare professionals interested in studying complex social healthcare systems. We provide the historical context in which IE was developed, and explain the principles and terminology in IE for the novice researcher. Through the use of worked examples, the reader will be able to appreciate how IE can be used to approach research questions in the healthcare system that other methods would be unable to answer. We show how IE and qualitative research methods maintain quality and rigour in research findings. We hope to demonstrate to healthcare professionals and researchers that healthcare systems can be analysed as social organisations, and IE may be used to identify and understand how higher-level processes and policies affect day-to-day clinical work. This understanding may allow the formulation and implementation of actionable improvements to solve problems on the ground.