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  1. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, et al.
    J Am Med Dir Assoc, 2014 Feb;15(2):95-101.
    PMID: 24461239 DOI: 10.1016/j.jamda.2013.11.025
    Sarcopenia, a newly recognized geriatric syndrome, is characterized by age-related decline of skeletal muscle plus low muscle strength and/or physical performance. Previous studies have confirmed the association of sarcopenia and adverse health outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people. Despite the clinical significance of sarcopenia, the operational definition of sarcopenia and standardized intervention programs are still lacking. It is generally agreed by the different working groups for sarcopenia in the world that sarcopenia should be defined through a combined approach of muscle mass and muscle quality, however, selecting appropriate diagnostic cutoff values for all the measurements in Asian populations is challenging. Asia is a rapidly aging region with a huge population, so the impact of sarcopenia to this region is estimated to be huge as well. Asian Working Group for Sarcopenia (AWGS) aimed to promote sarcopenia research in Asia, and we collected the best available evidences of sarcopenia researches from Asian countries to establish the consensus for sarcopenia diagnosis. AWGS has agreed with the previous reports that sarcopenia should be described as low muscle mass plus low muscle strength and/or low physical performance, and we also recommend outcome indicators for further researches, as well as the conditions that sarcopenia should be assessed. In addition to sarcopenia screening for community-dwelling older people, AWGS recommends sarcopenia assessment in certain clinical conditions and healthcare settings to facilitate implementing sarcopenia in clinical practice. Moreover, we also recommend cutoff values for muscle mass measurements (7.0 kg/m(2) for men and 5.4 kg/m(2) for women by using dual X-ray absorptiometry, and 7.0 kg/m(2) for men and 5.7 kg/m(2) for women by using bioimpedance analysis), handgrip strength (<26 kg for men and <18 kg for women), and usual gait speed (<0.8 m/s). However, a number of challenges remained to be solved in the future. Asia is made up of a great number of ethnicities. The majority of currently available studies have been published from eastern Asia, therefore, more studies of sarcopenia in south, southeastern, and western Asia should be promoted. On the other hand, most Asian studies have been conducted in a cross-sectional design and few longitudinal studies have not necessarily collected the commonly used outcome indicators as other reports from Western countries. Nevertheless, the AWGS consensus report is believed to promote more Asian sarcopenia research, and most important of all, to focus on sarcopenia intervention studies and the implementation of sarcopenia in clinical practice to improve health care outcomes of older people in the communities and the healthcare settings in Asia.
  2. Kua CH, Mak VSL, Huey Lee SW
    J Am Med Dir Assoc, 2019 03;20(3):362-372.e11.
    PMID: 30581126 DOI: 10.1016/j.jamda.2018.10.026
    OBJECTIVES: Deprescribing is effective in addressing concerns relating to polypharmacy in residents of nursing homes. However, the clinical outcomes of deprescribing interventions among residents in nursing homes are not well understood. We evaluated the impact of deprescribing interventions by health care professionals on clinical outcomes among the older residents in nursing homes.

    DESIGN: Systematic review and meta-analysis of randomized controlled trials. CINAHL, International Pharmaceutical Abstracts, MEDLINE, EMBASE, and Cochrane Library were searched from inception until September 2017; manual searches of reference lists of systematic reviews identified in the electronic search; and online trial registries for unpublished, ongoing, or planned trials. (PROSPERO CRD42016050028).

    SETTING AND PARTICIPANTS: Randomized controlled trials in a nursing home setting that included participants of at least 60 years of age.

    MEASURES: Falls, all-cause mortality, hospitalization, and potentially inappropriate medication were assessed in the meta-analysis.

    RESULTS: A total of 41 randomized clinical studies (18,408 residents) that examined deprescribing (defined as either medication discontinuation, substitution, or reduction) in nursing were identified. Deprescribing interventions significantly reduced the number of residents with potentially inappropriate medications by 59% (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.19-0.89). In subgroup analysis, medication review-directed deprescribing interventions reduced all-cause mortality by 26% (OR 0.74, 95% CI 0.65-0.84), as well as the number of fallers by 24% (OR 0.76, 95% CI 0.62-0.93).

    CONCLUSIONS: Compared to other deprescribing interventions, medication review-directed deprescribing had significant benefits on older residents in nursing homes. Further research is required to elicit other clinical benefits of medication review-directed deprescribing practice.

  3. Kua CH, Yeo CYY, Tan PC, Char CWT, Tan CWY, Mak V, et al.
    J Am Med Dir Assoc, 2021 01;22(1):82-89.e3.
    PMID: 32423694 DOI: 10.1016/j.jamda.2020.03.012
    OBJECTIVES: Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate.

    DESIGN: Pragmatic multicenter stepped-wedge cluster randomized controlled trial.

    SETTING AND PARTICIPANTS: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications.

    METHODS: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months.

    RESULTS: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P 

  4. Dent E, Lien C, Lim WS, Wong WC, Wong CH, Ng TP, et al.
    J Am Med Dir Assoc, 2017 Jul 01;18(7):564-575.
    PMID: 28648901 DOI: 10.1016/j.jamda.2017.04.018
    OBJECTIVE: To develop Clinical Practice Guidelines for the screening, assessment and management of the geriatric condition of frailty.

    METHODS: An adapted Grading of Recommendations, Assessment, Development, and Evaluation approach was used to develop the guidelines. This process involved detailed evaluation of the current scientific evidence paired with expert panel interpretation. Three categories of Clinical Practice Guidelines recommendations were developed: strong, conditional, and no recommendation.

    RECOMMENDATIONS: Strong recommendations were (1) use a validated measurement tool to identify frailty; (2) prescribe physical activity with a resistance training component; and (3) address polypharmacy by reducing or deprescribing any inappropriate/superfluous medications. Conditional recommendations were (1) screen for, and address modifiable causes of fatigue; (2) for persons exhibiting unintentional weight loss, screen for reversible causes and consider food fortification and protein/caloric supplementation; and (3) prescribe vitamin D for individuals deficient in vitamin D. No recommendation was given regarding the provision of a patient support and education plan.

    CONCLUSIONS: The recommendations provided herein are intended for use by healthcare providers in their management of older adults with frailty in the Asia Pacific region. It is proposed that regional guideline support committees be formed to help provide regular updates to these evidence-based guidelines.

  5. Thiruchelvam K, Hasan SS, Wong PS, Kairuz T
    J Am Med Dir Assoc, 2017 01;18(1):87.e1-87.e14.
    PMID: 27890352 DOI: 10.1016/j.jamda.2016.10.004
    BACKGROUND: Aging is often associated with various underlying comorbidities that warrant the use of multiple medications. Various interventions, including medication reviews, to optimize pharmacotherapy in older people residing in aged care facilities have been described and evaluated. Previous systematic reviews support the positive impact of various medication-related interventions but are not conclusive because of several factors.

    OBJECTIVES: The current study aimed to assess the impact of medication reviews in aged care facilities, with additional focus on the types of medication reviews, using randomized controlled trials (RCTs) and observational studies.

    METHODS: A systematic searching of English articles that examined the medication reviews conducted in aged care facilities was performed using the following databases: PubMed, CINAHL, IPA, TRiP, and the Cochrane Library, with the last update in December 2015. Extraction of articles and quality assessment of included articles were performed independently by 2 authors. Data on interventions and outcomes were extracted from the included studies. The SIGN checklist for observational studies and the Cochrane Collaboration's tool for assessing risk of bias in RCTs were applied. Outcomes assessed were related to medications, reviews, and adverse events.

    RESULTS: Because of the heterogeneity of the measurements, it was deemed inappropriate to conduct a meta-analysis and thus a narrative approach was employed. Twenty-two studies (10 observational studies and 12 controlled trials) were included from 1141 evaluated references. Of the 12 trials, 8 studies reported findings of pharmacist-led medication reviews and 4 reported findings of multidisciplinary team-based reviews. The medication reviews performed in the included trials were prescription reviews (n = 8) and clinical medication reviews (n = 4). In the case of the observational studies, the majority of the studies (8/12 studies) reported findings of pharmacist-led medication reviews, and only 2 studies reported findings of multidisciplinary team-based reviews. Similarly, 6 studies employed prescription reviews, whereas 4 studies employed clinical medication reviews. The majority of the recommendations put forward by the pharmacist or a multidisciplinary team were accepted by physicians. The number of prescribed medications, inappropriate medications, and adverse outcomes (eg, number of deaths, frequency of hospitalizations) were reduced in the intervention group.

    CONCLUSION: Medication reviews conducted by pharmacists, either working independently or with other health care professionals, appear to improve the quality of medication use in aged care settings. However, robust conclusions cannot be drawn because of significant heterogeneity in measurements and potential risk for biases.

  6. Lim MK, Wong PS, Othman S, Mohd Mydin FH, Lim PS, Lai PSM
    J Am Med Dir Assoc, 2023 Dec;24(12):1831-1842.
    PMID: 37844872 DOI: 10.1016/j.jamda.2023.09.008
    OBJECTIVES: To systematically synthesize the views of community-dwelling Asians on Advance care planning and to summarize the factors and reasons affecting their uptake of ACP.

    DESIGN: Mixed-methods systematic review (PROSPERO: CRD42018091033).

    SETTING AND PARTICIPANTS: Asian adults (≥18 years old) living in the community globally.

    METHODS: Medline (Ovid), Web of Science, CINAHL (EBSCO), Open Grey, and Google Scholar were searched from inception to June 30, 2022. Qualitative, quantitative, or mixed-methods studies reporting on the views of non-seriously ill community-dwelling Asian adults on ACP or the factors influencing their ACP uptake were included. Secondary research, studies not published in English, or studies not available as full text were excluded. Two independent teams of researchers extracted data, assessed methodologic quality, and performed the data analysis. Data analysis was conducted using the multistep convergent integrated approach based on Joanna Briggs Institute methodology for mixed-methods systematic review.

    RESULTS: Fifty-eight studies were included. Non-seriously ill community-dwelling Asians were willing to engage in ACP (46.5%-84.4%) although their awareness (3.1%-42.9%) and uptake of ACP remained low (14.0%-53.4%). Background factors (sociodemographic factors, and health status, as well as experience and exposure to information) and underlying beliefs (attitude toward ACP, subjective norm, and perceived behavioral control) were found to affect their uptake of ACP. A conceptual framework was developed to facilitate a proper approach to ACP for this population.

    CONCLUSIONS AND IMPLICATIONS: A flexible approach toward ACP is needed for non-seriously ill community-dwelling Asians. There is also a need to raise end-of-life and ACP literacy, and to explore ways to narrow the gap in the expectations and implementation of ACP so that trust in its effective execution can be built.

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