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Sunghwan Ji,1,2,&ast; Ji Yeon Baek,1,&ast; Jin Go,3 Chang Ki Lee,4 Sang Soo Yu,5 Eunju Lee,1 Hee-Won Jung,1 Il-Young Jang1,6 1Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 2Department of Digital Health, SAIHST, Sungkyunkwan University, Seoul, Republic of Korea; 3Department of Vascular Surgery, Gohigh Vascular Center, Seoul, Republic of Korea; 4Department of Urology, Goldman Urology Clinic, Seoul, Republic of Korea; 5Department of Plastic Surgery, Hit Plastic Surgery Clinic, Seoul, Republic of Korea; 6PyeongChang Health Center and County Hospital, Pyeongchang-gun, Gangwon, Republic of Korea&ast;These authors contributed equally to this workCorrespondence: Hee-Won Jung; Il-Young Jang, Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea, Tel +82-2-3010-1852 ; +82-2-3010-1658, Email dr.ecsta@gmail.com; onezero2@gmail.comBackground: Functional sarcopenia is characterized by decreased physical performance and grip strength despite preserved muscle mass. The effectiveness of a program combining exercise and nutritional support—known interventions for individuals with low muscle mass—was evaluated for its impact on older adults with functional sarcopenia.Methods: An unblinded, parallel-group randomized controlled trial was conducted in a public medical center in a rural Korean community. Eligible older adults with functional sarcopenia were randomized into either the intervention group, receiving a 12-week program of group exercises and nutritional support, or the control group, receiving education on lifestyle management. Outcomes measured included changes in gait speed, grip strength, physical performance, and quality of life indices.Results: The study enrolled 42 participants, with 21 allocated to each group. Compared with the control group, the intervention group showed significant improvements in the primary outcome of gait speed (mean change (m/s) 0.24 vs 0.00, p< 0.001) and secondary outcomes, such as Short Physical Performance Battery scores, grip strength, and quality of life. No significant adverse events were reported.Conclusion: The 12-week exercise and nutritional intervention significantly enhanced physical performance, grip strength, and quality of life among community-dwelling older adults with functional sarcopenia. This suggests that strategies commonly recommended for sarcopenia, including exercise and nutritional support, are also beneficial for individuals with functional sarcopenia, indicating the potential for broader application of such interventions.Keywords: sarcopenia, frailty, exercise

Youngseok Yi,1 Yura Lee,2 Selin Kang,3 Young Hye Kwon,4 Yeon Mi Seo,4 Ji Yeon Baek,1 Il-Young Jang,1 Eunju Lee,1 Younsuck Koh,5 Hee-Won Jung,1,&ast; Chan Mi Park6,&ast; 1Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea; 2Department of Information Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 3Department of Economics, The Graduate School, Yonsei University, Seoul, South Korea; 4Department of Nursing, Asan Medical Center, Seoul, South Korea; 5Department of Pulmonary and Critical Care Medicine, Health Screening and Promotion Center, Asan Medical Center, Seoul, South Korea; 6Marcus Institute for Aging Research, Hebrew Senior Life, Harvard Medical School, Boston, MA, USA&ast;These authors contributed equally to this workCorrespondence: Chan Mi Park, Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, 1200 Centre Street, Boston, MA, 02131, USA, Tel +1-617-363-8000, Email chanmipark@hsl.harvard.edu Hee-Won Jung, Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea, Tel +82-2-3010-1852, Email dr.ecsta@gmail.comPurpose: This study aims to identify unmet needs and barriers for improving inpatient care for older adults at an academic hospital in Korea by using a qualitative focus group design and the Age-Friendly Health Systems (AFHS) framework.Patients and Methods: A total of 14 healthcare providers and employees participated in focus group interviews. Participants included medical doctors, registered nurses, a receptionist, a patient transporter, a pharmacist, a physical therapist, and a social worker. The data were analyzed qualitatively, as per the Consolidated Criteria for Reporting Qualitative Research guidelines. The analysis method encompassed a thematic framework analysis via the AFHS 4Ms framework, consisting of the four domains “What Matters”, “Medication”, “Mentation”, and “Mobility”.Results: Multiple barriers and unmet needs were identified using the AFHS 4Ms framework in the provision of inpatient care for older adults at the hospital. The main barriers identified in the “What matters” domain are a lack of shared decision-making and individualized care plans, as well as economic and safety-conscious preferences among some older patients. In the “Medications” domain, the main barriers to providing adequate and safe pharmacotherapy include patient and caregiver-related factors, increased complexity of medication use, and lack of institutional support systems. In the “Mentation” domain, the main issues identified are communication barriers related to patients, caregiver factors, and insufficient delirium management due to a lack of adequate processes/environments such as delirium identification. In the “Mobility” domain, the main challenges include reduced mobility and geriatric complications, unnecessary mobility restrictions, and the increased risk of falls due to lack of resources and environmental factors.Conclusion: The study highlighted the need for improvements in inpatient care for older adults at an academic hospital in Korea. Identified unmet needs and barriers can be used to guide a more patient-centered approaches for an age-friendly inpatient environment.Keywords: geriatrics, age-friendly health systems, 4M framework, patient-centered care, geriatric adverse outcomes

Sunghwan Ji,1 Ji Yeon Baek,2 Taeyang Jin,1 Eunju Lee,2 Il-Young Jang,2 Hee-Won Jung2 1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 2Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of KoreaCorrespondence: Ji Yeon Baek, Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea, Tel +82-2-3010-0020, Email complete_flow@naver.comPurpose: Although the association between a single assessment of frailty index (FI) and clinical outcomes has been revealed in prior studies, there is a lack of knowledge about the prognostic value of FI at different time points and the changes in repeated measurements of FI. Hence, we sought to determine the clinically meaningful changes in FI and reveal the association with the changes and a composite outcome of mortality and institutionalization.Participants and Methods: This study was based on a longitudinal study of the Pyeongchang Rural Area cohort that included people aged 65 years or older, ambulatory and living at home. Individuals were divided into the worsened group (changes in FI ≥ 0.03 during 2 years) and the stable group (changes in FI < 0.03 during 2 years). The incidence of a composite outcome was compared between the two groups and the relationship was adjusted for age, sex, baseline FI, and follow-up FI.Results: Of the 953 participants, 403 (42.3%) and 550 (57.7%) were included in the worsened group and the stable group, respectively. The worsened group had a significantly higher risk of the composite outcome than the stable group (HR, 2.37 [95% CI, 1.54– 3.67]; p < 0.001). Although the higher risk remained significant after adjusting for age, sex, and baseline FI, the statistical significance disappeared after adjusting for follow-up FI (p = 0.614). The aggravation of FI in the worsened group was predominantly due to aggravation of FI domains, such as activities in daily living, cognitive function and mood, and mobility rather than comorbidity burden.Conclusion: Aggravation of FI was associated with a composite outcome regardless of baseline FI, and the association was significantly reflected in the follow-up measurement of FI. The worsening FI was mainly attributable to functional geriatric domains.Keywords: frailty index, changes in frailty index, mortality, geriatric domains

Hee-Won Jung, 1 Taeyang Jin, 1 Ji Yeon Baek, 1 Seongjun Yoon, 2 Eunjoo Lee, 1 Jack M Guralnik, 3 Il-Young Jang 1 1Division of Geriatrics, Department of Internal Medicine, Asan Medical Center, Seoul, Republic of Korea; 2Dyphi Research Institute, Dyphi Inc., Daejeon, Republic of Korea; 3Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USACorrespondence: Il-Young JangDivision of Geriatrics, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of KoreaTel +82-2-3010-1658Email onezero2@gmail.comPurpose: The importance of evaluating frailty status of older adults in clinical practice has been gaining attention with cumulative evidence showing its relevance in clinical outcomes and decision-making. We aimed to develop and validate whether the functional age predicted by an electronic continuous short physical performance battery (eSPPB) could predict frailty status.Patients and Methods: We reviewed medical records of outpatients (N=834) of Asan Medical Center, aged 51– 95 years. We used the eSPPB data of 717 patients as a development cohort, and that of 117 patients, who also underwent comprehensive geriatric assessments, as a validation cohort. Frailty index was calculated by counting deficits of 45 geriatric items including comorbidities, daily functions, mobility, mood, and cognition. For functional age, we used balance score (0– 4), gait speed (m/s), and stand-up time (s) measured 5 times in the chair rise test.Results: From the development cohort, we established a functional age using the formula (83.61 − 1.98*[balance score] − 5.21*[gait speed] + 0.23*[stand-up time]), by multivariate linear regression analysis with chronological age as a dependent variable (R 2 = 0.233). In the validation cohort, the functional age positively correlated with frailty index (p < 0.001). C-statistics classifying frailty (defined as frailty index ≥ 0.25) was higher (p < 0.001) with functional age (0.912) than that with chronological age (0.637). A cut-off functional age of ≥ 77.2 years maximized Youden’s J when screening for frailty, with sensitivity of 94.4% and specificity of 80.8%.Conclusion: A newly developed functional age predictor using eSPPB parameters can predict the frailty status as defined by the deficit accumulation method and may serve as a physical biomarker of human aging.Keywords: frailty, biomarker, physical performance, diagnosis

Il-Young Jang,1,2 Hee-Won Jung,3 Hyelim Park,1,2 Chang Ki Lee,4 Sang Soo Yu,2 Young Soo Lee,1 Eunju Lee,1 Robert J Glynn,5,6 Dae Hyun Kim6,7 1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 2PyeongChang Health Center & County Hospital, Pyeongchang, Gangwon-Do, Republic of Korea; 3Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea; 4Goldman Urology Clinic, Seoul, Republic of Korea; 5Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 6Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA; 7Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA Purpose: The primary aim of this study was to evaluate the effectiveness of a 6-month multicomponent intervention on physical function in socioeconomically vulnerable older adults in rural communities. As secondary aims, we evaluated the effectiveness of the intervention on frailty and other geriatric syndromes, sustained benefit at 12 months, and baseline characteristics associated with poor response. Patients and methods: This designed-delay study was conducted in 187 adults (mean age: 77 years; 75% women) who were living alone or on a low income in three rural regions of Korea. A 24-week multicomponent program that consisted of group exercise, nutritional supplementation, depression management, deprescribing medications, and home hazard reduction was implemented with a planned 6-month interval from August 2015 through January 2017. The primary outcome was physical function, measured using the Short Physical Performance Battery (SPPB) score (range: 0–12; minimum clinically important difference ≥1) at 6 months. Secondary outcomes included frailty phenotype, sarcopenia, Mini Nutritional Assessment-Short Form score (range: 0–14), Center for Epidemiologic Studies-Depression Scale score (range: 0–60), and falls. Results: At 6 months, the SPPB score increased by 3.18 points (95% CI: 2.89, 3.48) from baseline. The program improved frailty (odds ratio: 0.06; 95% CI: 0.02, 0.16), sarcopenia (odds ratio: 0.32; 95% CI: 0.15, 0.68), Mini Nutritional Assessment-Short Form score by 1.67 points (95% CI: 1.28, 2.06), and Center for Epidemiologic Studies-Depression Scale score by -3.83 points (95% CI: -5.26, -2.39), except for fall (rate ratio: 0.99; 95% CI: 0.69, 1.43). These beneficial effects were sustained at 12 months. Body mass index ≥27 kg/m2 and instrumental activities of daily living disability at baseline were associated with poor improvement in the SPPB score. Conclusion: This 24-week multicomponent program had sustained beneficial effects up to 1 year on physical function, frailty, sarcopenia, depressive symptoms, and nutritional status in socioeconomically vulnerable older adults in rural communities. (ClinicalTrials.gov, NCT 02554994) Keywords: clinical trial, exercise, frailty, geriatric assessment, malnutrition, public health practice

Hee-Won Jung,1,2,* Il-Young Jang,3,4,* Chang Ki Lee,5 Sang Soo Yu,4 Jae Kyoon Hwang,4 Chawoong Jeon,4 Young Soo Lee,3 Eunju Lee3 1Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Republic of Korea; 2Geriatric Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea; 3Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 4PyeongChang Health Center & County Hospital, PyeongChang-gun, Gangwon-Do, Republic of Korea; 5Goldman Urology Clinic, Seoul, Republic of Korea *These authors contributed equally to this work Purpose: We aimed to describe the age- and sex-specific distributions of gait speed and to evaluate associations with longitudinal outcomes in Korean rural community-dwelling older adults.Patients and methods: A total of 1,348 people (mean age: 76 years, 55% women) in the population-based, prospective cohort of Aging Study of Pyeongchang Rural Area (ASPRA) between October 2014 and June 2017. All participants underwent a comprehensive geriatric assessment, including 4-m usual gait speed, and were followed annually.Results: Among the 1,348 participants, women had a slower gait speed than men (mean 0.709 m/s vs 0.850 m/s, P < 0.001). Gait speed was inversely associated with age, frailty index; slow gait speed as classified by sex-specific quartile was associated with the prevalence of common geriatric syndromes. During the mean follow-up period of 21.5 months (SD 7.88), future survival without mortality or institutionalization was affected by sex-specific gait-speed quartile (log rank test P < 0.001): the 1st quartile of sex-specific gait speed was associated with increased risk of death or institutionalization.Conclusion: Gait speed was related to age, sex, frailty status, and geriatric health outcomes in Korean rural community-dwelling older adults. Since this gait-speed distribution in an older Korean population differs from previous data on other populations, we should consider a gait-speed cutoff value based on sex-specific quartiles to prevent misclassification in sarcopenia and frailty diagnosis. Keywords: cohort studies, frailty, gait speed, geriatric assessment, physical function

Jung HW, Jin T, Baek JY, et al. Clin Interv Aging. 2020;15:2175–2182. Page 2180, Acknowledgments, line 5, the text “2018IF0143” should read “2018IF0413”. The authors apologize for this error. Read the original article

Il-Young Jang,1,2 Chang Ki Lee,3 Hee-Won Jung,4,5 Sang Soo Yu,2 Young Soo Lee,1 Eunju Lee,1 Dae Hyun Kim6,7 1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea; 2PyeongChang Health Center & County Hospital, PyeongChang, Gangwon-Do, Republic of Korea; 3Goldman Urology Clinic, Seoul, Republic of Korea; 4Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea; 5Geriatric Center, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-Do, Republic of Korea; 6Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 7Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA Purpose: Frailty is an important consideration in the management of lower urinary tract symptoms and erectile dysfunction in older men; frailty increases vulnerability to treatment-related adverse outcomes, but its burden is not known. The authors aimed to examine the burden of frailty and associated geriatric conditions in community-dwelling older men.Patients and methods: A cross-sectional study was conducted with 492 community-dwelling older men (mean age, 74.2 years; standard deviation, 5.6 years). All the participants were administered the International Prostate Symptom Score (IPSS) (range: 0–35) and a five-item version of the International Index of Erectile Function (IIEF-5) (range: 5–25). Frailty phenotype was assessed based on exhaustion, inactivity, slowness, weakness, and weight loss. Prevalence of frailty phenotype and geriatric conditions were assessed by the IPSS severity category (mild, 0–7; moderate, 8–19; severe, 20–35 points) and the first IIEF-5 question, which assesses the confidence in erectile function (low, 1–2; moderate, 3; high, 4–5 points).Results: Older men with severe urologic symptoms had a high prevalence of frailty. According to the IPSS questionnaire, the prevalence of frailty was 7.3% (21/288) in the mild category, 16.3% (26/160) in the moderate category, and 43.2% (19/44) in the severe category. Participants in the severe IPSS category showed high prevalence of dismobility (45.5%), multimorbidity (43.2%), malnutrition risk (40.9%), sarcopenia (40.9%), and polypharmacy (31.8%). According to erectile confidence based on the first IIEF-5 question, the prevalence of frailty was 18.7% (56/300) for low confidence, 5.3% (6/114) for moderate confidence, and 5.1% (4/78) for high confidence. Participants with low confidence in erectile function showed high prevalence of sarcopenia (39.0%), multimorbidity (37.7%), dismobility (35.7%), malnutrition risk (33.3%), and polypharmacy (23.0%).Conclusion: The prevalence of frailty and geriatric conditions was higher in older men with severe urologic symptoms. A frailty screening should be routinely administered in urology practices to identify older men who are vulnerable to treatment-related adverse events. Keywords: erectile dysfunction, frailty, geriatric assessment, lower urinary tract symptoms, risk management

Il-Young Jang,1,2,* Hee-Won Jung,3,4,* Chang Ki Lee,5 Sang Soo Yu,2 Young Soo Lee,1 Eunju Lee1 1Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, 2PyeongChang Health Center & County Hospital, Gangwon-Do, 3Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, 4Geriatric Center, Seoul National University Bundang Hospital, Gyeonggi-Do, 5Goldman Urology Clinic, Seoul, Republic of Korea *These authors contributed equally to this work Purpose: It is important to define lean muscle mass when diagnosing sarcopenia, but there is still controversy on the clinical implication of sarcopenia derived by height, weight, and body mass index (BMI) adjusted muscle mass indices. We aimed to evaluate the longitudinal clinical relevance of 3 sarcopenia definitions in the Korean population. Patients and methods: We conducted comprehensive geriatric assessments for 1,379 community-dwelling older participants in the Aging Study of PyeongChang Rural Area (ASPRA) cohort and followed them up prospectively for death, institutionalization, and disability every 3 months. Sarcopenia was defined using the Asian Working Group consensus algorithm, combining grip strength, gait speed, and muscle mass.Results: Among 1,343 participants (mean age: 76 years, 741 women) analyzed, there were 29 deaths and 89 institutionalizations during 22.0 ± 8.3 months follow-up (mean ± SD). All three muscle indices correlated to age and sex. All sarcopenia criteria with muscle mass indices of height, weight, and body mass index (BMI) adjustment significantly predicted death or institutionalization. However, when adjusted for age and sex, only the sarcopenia criteria with muscle mass index of height adjustment were significantly associated with major adverse health outcomes.Conclusion: Adjusting age and gender, the sarcopenia definition from the quintile-based muscle index of height adjustment could predict death or institutionalization in Korean community-dwelling older adults. Keywords: cohort studies, frailty, geriatric assessment, muscle index, muscle mass, muscles, sarcopenia