Abstract
Background
Anorexia of aging is a common geriatric syndrome that includes loss of appetite and/or reduced food intake, with associated undernutrition, unintended weight loss, sarcopenia, functional decline, loss of independence and other adverse health outcomes. Anorexia of aging can have multiple and severe consequences and is often overlooked by healthcare professionals (HCPs). Even more concerningly, clinicians commonly accept anorexia of aging as an inevitable part of ‘normal’ aging. The aim of this assessment was to identify current gaps in professional knowledge and practice in identifying and managing older persons with anorexia. Results may guide educational programmes to fill the gaps identified and therefore improve patient outcomes.
Methods
This international assessment was conducted using a mixed‐methods approach, including focus group interviews with subject matter experts and an electronic survey of practicing HCPs. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in‐country collaborating organizations.
Results
A quantitative survey of 26 multiple‐choice questions was completed by physicians, dietitians and other HCPs (n = 1545). Most HCPs (56.8%) recognize a consistent definition of anorexia of aging as a loss of appetite and/or low food intake. Cognitive changes/dementia (91%) and dysphagia (87%) are seen as the biggest risk factors. Most respondents were confident to give nutritional (62%) and physical activity (59.4%) recommendations and engaged caregivers such as family members in supporting older adults with anorexia (80.6%). Most clinicians assessed appetite at each visit (66.7%), although weight is not measured at every visit (41.5%). Apart from the Mini‐Nutritional Assessment Short Form (39%), other tools to screen for appetite loss are not frequently used or no tools are used at all (29.4%). A high number of respondents (38.7%) believe that anorexia is a normal part of aging. Results show that treatment is focused on swallowing disorders (78%), dentition issues (76%) and increasing oral intake (fortified foods [75%] and oral nutritional supplements [74%]). Nevertheless, the lack of high‐quality evidence is perceived as a barrier to optimal treatment (49.2%).
Conclusions
Findings from this international assessment highlight the challenges in the care of older adults with or at risk for anorexia of aging. Identifying professional practice gaps between individual HCPs and team‐based gaps can provide a basis for healthcare education that is addressed at root causes, targeted to specific audiences and developed to improve individual and team practices that contribute to improving patient outcomes.
Keywords: anorexia of aging, geriatric anorexia, global assessment, professional practice gaps
Introduction
Anorexia of aging is a common geriatric syndrome that includes loss of appetite and/or reduced food intake, with associated undernutrition, unintended weight loss, reduced immune status, frailty, sarcopenia, functional decline, loss of independence, poor quality of life and other adverse health outcomes. 1 , 2 , 3 , 4 , 5 In older populations, the incidence of anorexia of aging ranges from 25% (community dwellers) to 85% (nursing homes) depending on individual circumstances, and given the advancing age of the world population, it is likely that the incidence of anorexia of aging will increase significantly over the next several decades. 5 , 6 There are several factors that may negatively affect appetite in older adults. Irrespective of primary or secondary anorexia, both central and peripheral signalling are observed, reflecting an exacerbation of physiological aging alterations related to appetite regulation control involving cholecystokinin, ghrelin, insulin, peptide YY, β‐endorphin and glucagon‐like peptide‐1, among others. 7 There are also chemosensory changes, gastrointestinal dysmotility and digestive dysfunction often implicated in some degree. For example, side effects of medications may alter the sense of taste or smell or induce oral dryness and constipation, all of which have been associated with appetite reduction. 8 A review by Maki et al. 9 cited causes of anorexia of aging in 81% of older adults such as infection (22%), benign gastrointestinal diseases (16%) and cardiovascular disease (8%). Prevention and recognition of anorexia of aging, therefore, are essential to reducing associated morbidity and mortality. 5
Despite the high prevalence of anorexia of aging, it is often overlooked by healthcare professionals (HCPs). 10 Assessment of anorexia of aging is rarely performed in clinical practice, and screening tools are inconsistently used in practice. 11 Even more concerningly, clinicians commonly accept anorexia of aging as an inevitable part of ‘normal’ aging. Early detection of anorexia of aging and swift implementation of management strategies may prevent its consequences on nutritional status, health, frailty and quality of life. 12 Clinicians must recognize that anorexia of aging assessment cannot be performed through body mass index (BMI) analysis but must specifically address appetite. 13
Different assessments have been used to evaluate appetite: Visual Analogue Scale (VAS), 2 , 5 the Appetite, Hunger and Sensory Perception Questionnaire (AHSPQ), 14 the Council on Nutrition Appetite Questionnaire (CNAQ) and its short derivative, the Simplified Nutritional Appetite Questionnaire (SNAQ), 15 the Functional Assessment of Anorexia and Cachexia Therapy (FAACT) 5 , 6 and the Rapid Geriatric Assessment (RGA) 16 ; however, it is not clear which method is optimal. Additionally, it is important that clinicians differentiate between anorexia of aging and similar diagnoses, such as frailty, which often ‘overlap in constructs, diagnosis, and treatment’. 17
Exercise can have a positive impact on appetite. Exercises that include resistance, balance and flexibility training can increase muscle mass, strength, physical function and mobility, helping to maintain independence and improve quality of life. 18 , 19 , 20 Resistance training can increase muscle strength and mass. 21 , 22 , 23 However, the application of generalized exercise benefits to older adults with anorexia of aging is less clear due to a lack of sufficient evidence. 6 , 24 Although commonly recommended to older adults with anorexia, the practice of physical exercises did not result in any benefit according to a systematic review. 24 Nutritional intervention has been evaluated in older adults. Diet supplementation with protein, leucine and creatine, and omega‐3 fatty acids has been found to improve malnutrition, although they have no specific effect on appetite. 6 , 25 , 26
Several pharmacotherapies are available for appetite stimulation in anorexia of aging, although side effects have limited their utility. The two commonly utilized appetite stimulants are megestrol acetate and dronabinol. In an early analysis of megestrol acetate in geriatric patients, patients reported greater improvements in appetite, enjoyment of life and well‐being. 27 However, appetite‐stimulating pharmacotherapies rarely have an impact on weight and other measures of nutritional status in older persons, and the risks of these agents in older adults can outweigh the benefits and therefore are not recommended for anorexia of aging. 28 New drugs may improve clinicians' ability to treat anorexia of aging while limiting side effects and adverse events. Many of these agents are being evaluated in cancer patients and include atypical antipsychotics (AAPs), 29 mirtazapine (antidepressant), 30 , 31 anamorelin hydrochloride (active ghrelin receptor agonist) 32 , 33 , 34 and PF‐06946860 (selective humanized monoclonal antibody). 35 Given the limitations of current pharmacotherapy for anorexia of aging, it is essential that healthcare providers are aware of and prepared to utilize novel agents when they become available.
The aim of this international assessment, which involved several regional societies and individuals from various countries, was to identify professional practice gaps regarding the knowledge and management of anorexia of aging. The results of this survey could add to the development of educational initiatives to healthcare providers across professions involved in recognizing, diagnosing and managing older adults with or at risk for anorexia of aging. This project was led by the Society on Sarcopenia, Cachexia and Wasting Disorder (SCWD) in collaboration with the American Society of Parenteral and Enteral Nutrition (ASPEN), the European Society for Clinical Nutrition and Metabolism (ESPEN), the European Geriatric Medicine Society (EuGMS), the Geriatrics and Gerontology Society of Chile, the St. Louis Geriatrics Work Force Enhancement Program (GWEP), the International Conference on Frailty and Sarcopenia Research (ICFSR), the Japanese Association on Sarcopenia and Frailty (JASF) and the Japanese Geriatric Society (JGS).
Methods
This international assessment was conducted using a mixed‐methods approach that included (1) a literature review of classic and recent articles on the definition, causes and management of anorexia of aging and (2) focus group interviews of clinical experts leading to the development of (3) a survey of practicing HCPs, who are members of the collaborating societies, to collect quantitative data. An International Advisory Board (IAB) was recruited to analyse the current status of care for older adults with anorexia and to identify professional practice gaps among HCPs in their respective countries. This information formed the basis of the development of the survey. To ensure in‐country relevance, the survey was reviewed, refined and validated by the IAB and the Regional Advisory Board (RAB) representing Europe, Japan, Latin America and the United States. In this paper, we report the quantitative findings of this international assessment.
Survey
The quantitative survey consisted of 26 multiple‐choice, Likert scale or free response items. The estimated online completion time was 20 min. The survey was organized into respondent demographics (four items), screening (five items), defining/diagnosing (five items), treating (four items) and referral (two items). The survey was available in English, Japanese, Italian, Spanish and Portuguese to increase in‐country clinician response rates. The survey was disseminated electronically using QuestionPro© from 25 May 2022 to 30 November 2022 for the English version and from 16 June 2022 to 5 October 2022 for the translated versions. Dissemination was supported by the collaborating organizations, IAB and the RAB members.
Following the close of the survey, data were downloaded from QuestionPro© and analysed. All data were collected confidentially and rendered anonymously with the removal of all IP addresses.
Respondents who did not pursue the survey (n = 866) after Item 10, ‘In the absence of an explicit cause such as acute illness, anorexia in older adults is most accurately defined as:’, were removed from the original file and not included in the analysis. Therefore, the aggregate analysis was conducted on the remaining 1545 respondents.
Data analysis
Analyses included descriptive statistics (mean, standard deviation, %) and summarizing free text responses. For the purposes of evaluating the percentage response, single response items were divided by the total number of respondents per item. For multiple response items (select all that apply), the percentage response was calculated by the number of respondents who proceeded after the definition item (N = 1545) regardless of the respondent drop‐off over time.
Results
Survey participation and respondent characteristics
Data were collected from 2416 survey responders. Of these, 871 were excluded from analysis as they did not pursue the survey following the item on definition, leaving a total of 1545 for analysis. Most respondents completed the survey in Japanese (61.4%) followed by English (14%). By country, most respondents were from Japan (60.9%), followed by Brazil (9.6%), the United States (8.9%) and Italy (6.7%). By profession, specialist physicians/medical doctors was the group with the highest response (32.1%), followed by primary care or general practice physicians (18.6%), dietitians/registered dietitians/nutritionists (15.6%), pharmacists (15.6%), ‘other’ (7.1%) and physical therapists (7%). Most respondents provided patient care in a private hospital (21.7%), public hospital (17.2%) or academic medical centre (14.9%). For those who listed specialty practice, geriatrics was reported most often (28.3%) across the professions (Table 1 ).
Table 1.
Respondent demographics (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| Health profession | |||
| Primary care or general practice physician/medical doctor | 288 | 18.6% | |
| Specialist physician/medical doctor | 496 | 32.1% | |
| Physician assistant | 9 | 0.6% | |
| Advanced practice nurse (e.g., nurse practitioner) | 28 | 1.8% | |
| Registered nurse/nurse | 54 | 3.5% | |
| Pharmacist | 115 | 7.4% | |
| Occupational therapist | 23 | 1.5% | |
| Physical therapist | 108 | 7.0% | |
| Dietitian/registered dietitian/nutritionist | 241 | 15.6% | |
| Social worker | 9 | 0.6% | |
| Psychologist | 10 | 0.6% | |
| Speech/language pathologist | 37 | 2.4% | |
| Other mental health provider/counsellor | 7 | 0.5% | |
| Education specialist | 10 | 0.6% | |
| Other (free text) | 109 | 7.1% | |
| Missing system | 1 | 0.1% | |
| Specialty (if applicable) | |||
| Allergy and immunology | 3 | 0.2% | |
| Cardiology | 59 | 3.8% | |
| Endocrinology | 46 | 3.0% | |
| Geriatrics | 438 | 28.3% | |
| Gastroenterology | 19 | 1.2% | |
| Internal medicine | 114 | 7.4% | |
| Neurology | 64 | 4.1% | |
| Oncology | 11 | 0.7% | |
| Otorhinolaryngology | 4 | 0.3% | |
| Physical medicine/rehabilitation | 168 | 10.9% | |
| Psychiatry | 29 | 1.9% | |
| Pulmonology | 18 | 1.2% | |
| Rheumatology | 6 | 0.4% | |
| General surgery | 22 | 1.4% | |
| Surgical specialty | 19 | 1.2% | |
| Other | 364 | 23.6% | |
| Missing system | 161 | 10.4% | |
| Primary practice location | |||
| Academic medical centre | 230 | 14.9% | |
| Private hospital | 335 | 21.7% | |
| Public hospital | 266 | 17.2% | |
| Multispecialty group practice | 28 | 1.8% | |
| Long‐term care/nursing home | 154 | 10.0% | |
| Solo practice | 125 | 10.0% | |
| Specialty group practice | 13 | 0.8% | |
| Community‐based health centre/clinic | 92 | 6.0% | |
| Home health centre | 106 | 6.9% | |
| Veterans administration medical centre/military facility | 7 | 0.5% | |
| National health service/government | 38 | 2.5% | |
| Other | 116 | 7.5% | |
| Missing system | 35 | 2.3% | |
Screening for anorexia of aging
Most respondents reported assessing appetite at each visit (66.7%), and more than half of the respondents reported that older adults should be screened for appetite loss at each appointment (54%) and when the older adult has lost a determined percentage of body weight (52%) (Table 2 ). One third (31%) reported a need to screen for appetite loss when the older adult or family member expresses concern. Less than a quarter of respondents (24%) reported a need to screen for appetite loss at least annually. Responses were not mutually exclusive.
Table 2.
Domain (screening): Screening for anorexia of aging (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| Is appetite in older adults assessed at each visit? | |||
| Yes | 1031 | 66.7% | |
| No | 359 | 23.2% | |
| Unsure | 55 | 3.6% | |
| Not applicable for my practice setting | 91 | 5.9% | |
| Missing system | 9 | 0.6% | |
| Are older adults weighed at each visit using a weighing scale? | |||
| Yes | 641 | 41.5% | |
| No | 731 | 47.3% | |
| Unsure | 48 | 3.1% | |
| Not applicable for my practice setting | 114 | 7.4% | |
| Missing system | 11 | 0.7% | |
| How often should older adults be screened for appetite loss (select all that apply)? | |||
| At each appointment | 838 | 54% | |
| At least annually | 373 | 24% | |
| When the older adult has lost a determined percentage of body weight (example: >10% body weight in the last 3 months) | 807 | 52% | |
| When the older adult or family member expresses concern | 480 | 31% | |
| I do not know | 48 | 3% | |
| I do not screen older adults for appetite | 41 | 3% | |
| Who is responsible for screening older adults for appetite loss (choose all that apply)? | |||
| The primary treating physician | 1023 | 66% | |
| The nurse (nurse or advanced practice nurse) | 915 | 59% | |
| Physician assistant | 137 | 9% | |
| The dietitian/registered dietitian/nutritionist (non‐physician) | 778 | 50% | |
| Medical or nursing assistant | 125 | 8% | |
| Physical therapist | 168 | 11% | |
| Pharmacist | 108 | 7% | |
| Social worker | 80 | 5% | |
| I do not know | 58 | 4% | |
| No one | 70 | 5% | |
| Other (free text) | 0 | ||
| Not applicable for my practice setting | 41 | 3% | |
| The tools used in my practice setting to screen older adults for appetite loss include (select all that apply): | |||
| Appetite, Hunger and Sensory Perception Questionnaire (AHSPQ) | 24 | 2% | |
| Council on Nutrition Appetite Questionnaire (CNAQ) | 35 | 2% | |
| Functional Assessment of Anorexia and Cachexia Therapy (FAACT) | 19 | 1% | |
| Malnutrition Screening Tool (MST) | 64 | 4% | |
| Malnutrition Universal Screening Tool (MUST) | 92 | 6% | |
| Mini‐Nutritional Assessment Short Form (MNA‐SF) | 597 | 39% | |
| Nutritional Risk Screening (NRS) | 59 | 4% | |
| Rapid Geriatric Assessment (RGA) | 30 | 2% | |
| Simplified Nutritional Appetite Questionnaire (SNAQ) | 55 | 4% | |
| Visual Analogue Scale (VAS) | 30 | 2% | |
| Informal clinical interview | 325 | 21% | |
| Tool developed by my organization or association | 43 | 3% | |
| We do not use a tool to screen older patients for appetite loss | 464 | 30% | |
| I do not know | 146 | 9% | |
| I do not screen older adults for appetite loss | 699 | 29.4% | |
| Other (free text) | 0 | ||
When asked if older adults are weighed at each visit using a weighing scale, slightly more reported no (47.3%) than yes (41.5%). Often the primary treating physician is reported having the responsibility for screening older adults for appetite loss (66%), followed by the nurse or advanced practice nurse (59%) and dietitian/registered dietitian/nutritionist (50%). Responses were also not mutually exclusive.
The tool used most often to screen older adults for appetite loss was the Mini‐Nutritional Assessment Short Form (MNA‐SF) (39%), followed by an informal clinical interview (21%). Almost 30% (29.4%) did not use any tool to screen older adults for appetite loss. Responses were again not mutually exclusive.
Defining and diagnosing older adults with anorexia
In the absence of an explicit cause, most respondents selected ‘loss of appetite and/or low food intake in older adults’ as the most accurate definition of anorexia in older adults (56.8%) (Table 3 ). Approximately equal numbers of respondents reported ‘nutrition risk, malnutrition or undernutrition in older adults’ (14.7%) and ‘unintended weight loss in older adults’ (14.5%) as an accurate definition. The causes of anorexia mostly seen are poor dentition (84%), loss of motor skills/independence of activities of daily living (ADLs) (81%) and diminished smell and taste (78%). However, in terms of the risk factors for anorexia of aging, respondents selected cognitive changes/dementia as the biggest risk factor (91%), followed by dysphagia (87%) and social isolation (86%). When asked for the results of anorexia of aging, most identified malnutrition (93%), frailty (90%) and impaired muscle function/sarcopenia (89%).
Table 3.
Domain (defining/diagnosing): Defining and diagnosing anorexia of aging (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| In the absence of an explicit cause such as acute illness, anorexia in older adults is most accurately defined as: | |||
| Loss of appetite and/or low food intake in older adults | 877 | 56.8% | |
| Unintended weight loss in older adults | 224 | 14.5% | |
| Sarcopenia or loss of muscle mass, strength and/or function | 120 | 7.8% | |
| Nutrition risk, malnutrition or undernutrition in older adults | 227 | 14.7% | |
| Frailty in geriatric patients | 91 | 5.9% | |
| Missing system | 6 | 0.4% | |
| Causes of anorexia in older adults include (select all that apply): | |||
| Diminished smell and taste in older adults | 1207 | 78% | |
| Changes in hormones that alter satiety control mechanisms | 799 | 52% | |
| Early satiety from slowed gastric emptying | 1000 | 65% | |
| Poor dentition | 1305 | 84% | |
| Chronic inflammation | 790 | 51% | |
| Constipation | 1068 | 69% | |
| Osteoarthritis | 257 | 17% | |
| Osteoporosis | 183 | 12% | |
| Loss of motor skills/independence of ADLs | 1254 | 81% | |
| Risk factors for anorexia in older adults include (select all that apply): | |||
| Social isolation | 1325 | 86% | |
| Inability to travel to access food | 1080 | 70% | |
| Lack of sufficient resources to buy food | 1016 | 66% | |
| Chronic medical conditions (e.g., congestive heart failure, chronic obstructive pulmonary disease and diabetes) | 1246 | 81% | |
| Cognitive changes/dementia | 1398 | 90% | |
| Depression | 1255 | 81% | |
| Infection | 853 | 55% | |
| Dysphagia | 1342 | 87% | |
| Polypharmacy/side effect of medications | 1225 | 79% | |
| Anorexia in older adults may directly or indirectly result in (select all that apply): | |||
| Malnutrition | 1437 | 93% | |
| Dehydration | 1306 | 85% | |
| Frailty | 1392 | 90% | |
| Impaired muscle function/sarcopenia | 1382 | 89% | |
| Anaemia | 1166 | 75% | |
| Pressure ulcers | 1113 | 72% | |
| Decreased energy | 1156 | 75% | |
| Depression | 929 | 60% | |
| Altered mental status | 1035 | 67% | |
| Confusion/impaired cognitive functioning | 977 | 63% | |
| Urinary tract infections | 745 | 48% | |
| Death | 1036 | 67% | |
| I use the definition and/or diagnostic criteria from professional organizations to support and confirm my identification of or diagnosis of anorexia in older adults (select all that apply): | |||
| American Society for Parenteral and Enteral Nutrition (ASPEN) | 158 | 10% | |
| European Society for Clinical Nutrition and Metabolism (ESPEN) | 196 | 13% | |
| SARC‐F | 224 | 14% | |
| Frailty scores | 389 | 25% | |
| Designated national/regional guidelines | 90 | 6% | |
| My institutional guidelines | 133 | 9% | |
| My own clinical judgement | 518 | 34% | |
| I do not know any tools to diagnose anorexia in older adults | 340 | 22% | |
| Other (free text) | 0 | ||
| I do not diagnose or screen for anorexia in older adults | 233 | 15% | |
Abbreviations: ADLs, activities of daily living; SARC‐F, Strength, Assistance with walking, Rising from a chair, Climbing stairs and Falls.
Respondents reported mostly using their own clinical judgement (34%) and/or frailty scores (25%) to identify/diagnose anorexia in older adults. However, 22% reported not knowing any tools that could be used to diagnose anorexia in older adults. Responses were also not mutually exclusive.
Treating older adults with anorexia
Of all respondents, almost 30% (29.9%) reported using tools and resources developed by experts most or all of the time to care for their older patients with anorexia (Table 4 ). Still, 19.1% preferred to use their own clinical judgement or rarely used a tool or resource developed by experts, whereas just over 16% (16.4%) of respondents were not aware of tools or resources developed by experts to care for their older patients with anorexia.
Table 4.
Domain (treating): Treating anorexia of aging (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| I use tools and resources such as evidence‐based guidelines developed by experts to care for my older patients with anorexia. | |||
| Yes, all of the time | 140 | 9.1% | |
| Yes, most of the time | 322 | 20.8% | |
| Rarely | 295 | 19.1% | |
| No, I prefer to use my own clinical judgement | 315 | 20.4% | |
| No, I am not aware of tools and resources to care for my geriatric patients with anorexia | 254 | 16.4% | |
| No, I do not use tools and resources because I do not have access to them | 43 | 2.8% | |
| Not applicable for my professional role/responsibility | 110 | 7.1% | |
| Missing system | 66 | 4.3% | |
| When a diagnosis of anorexia in older adults is made, evidence‐based or consensus developed interventions may include (select all that apply): | |||
| Incorporating energy‐ and protein‐fortified foods in the diet | 1163 | 75% | |
| Recommending oral nutritional supplements (e.g., Boost and Ensure) | 1147 | 74% | |
| Addressing dentition issues | 1179 | 76% | |
| Treating swallowing disorders (if present) | 1204 | 78% | |
| Prescribing appetite stimulants (e.g., megace and dronabinol) | 340 | 22% | |
| Prescribing antidepressants | 519 | 34% | |
| Prescribing physical exercise | 724 | 47% | |
| Prescribing nutritional counselling | 904 | 59% | |
| Revising current prescriptions that are causing side effects | 980 | 63% | |
| Treating constipation | 995 | 64% | |
| Reviewing already prescribed medications | 1003 | 65% | |
| Referring to specialist for psychosocial support | 526 | 34% | |
| Referring to support services (e.g., social worker, financial counsellor and transportation assistance) | 594 | 38% | |
| Screening for abuse and/or neglect | 496 | 32% | |
| Other (free text) | 0 | ||
| I do not know | 32 | 2% | |
| Not applicable for my professional role/responsibility | 33 | 2% | |
| I am confident in providing nutrition recommendations for older patients with anorexia. | |||
| Strongly agree | 336 | 21.7% | |
| Agree | 622 | 40.3% | |
| Neither agree nor disagree | 304 | 19.7% | |
| Disagree | 114 | 7.4% | |
| Strongly disagree | 26 | 1.7% | |
| Not applicable for my professional role/responsibility | 68 | 4.4% | |
| Missing system | 75 | 4.9% | |
| I am confident in providing physical activity recommendations for older patients with anorexia. | |||
| Strongly agree | 270 | 17.5% | |
| Agree | 647 | 41.9% | |
| Neither agree nor disagree | 313 | 20.3% | |
| Disagree | 133 | 8.6% | |
| Strongly disagree | 19 | 1.2% | |
| Not applicable for my professional role/responsibility | 81 | 5.2% | |
| Missing system | 82 | 5.3% | |
The most used interventions used to treat older adults diagnosed with anorexia were treating swallowing disorders if present (78%), addressing dentition issues (76%), incorporating energy‐ and protein‐fortified foods in the diet (75%) and recommending oral nutritional supplements (74%). The fewest respondents reported prescribing appetite stimulants (22%). Responses were not mutually exclusive. The majority agreed or strongly agreed that they were confident in providing nutritional (62%) recommendations for their older patients with anorexia. Although the prescription of physical exercise as an intervention was only selected as being used on average (47%), the majority of respondents did agree or strongly agreed being confident in providing activity recommendations (59.4%).
Referral of older adults with anorexia of aging
Referrals for further assessment and treatment of anorexia in older adults was most often initiated by registered nurses/nurses (41%), followed by dietitians/registered dietitians/nutritionists (37%), general practitioners/physicians (34%) and specialist physicians/medical doctors (28%). When asked if sufficient specialists were available for referral, 42.8% responded ‘yes’ most or all of the time. An equal number of respondents reported that there were insufficient numbers of specialists available to them for assessment or treatment (42.4%) (Table 5 ).
Table 5.
Domain (referrals): Referring patients with anorexia of aging (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| In my practice setting, referrals for further assessment and treatment of anorexia in older adults are most often initiated by the following healthcare team member(s): | |||
| General practitioner/physician | 528 | 34% | |
| Specialist physician/medical doctor | 432 | 28% | |
| Physician assistant | 86 | 6% | |
| Advanced practice nurse (e.g., nurse practitioner) | 179 | 12% | |
| Registered nurse/nurse | 633 | 41% | |
| Pharmacist | 79 | 5% | |
| Dietitian/registered dietitian/nutritionist (non‐physician) | 567 | 37% | |
| Occupational therapist | 101 | 7% | |
| Physical therapist | 158 | 10% | |
| Social worker | 154 | 10% | |
| Psychologist | 48 | 3% | |
| Mental health counsellor | 19 | 1% | |
| Speech language pathologist/speech therapist | 192 | 12% | |
| Dentist/dental hygienist | 134 | 9% | |
| Other (free text) | 0 | ||
| Not applicable for my professional role/responsibility | 113 | 7% | |
| There are sufficient specialists available for me to refer my older adult patients with anorexia for additional assessment and/or treatment. | |||
| Yes, all of the time | 119 | 7.7% | |
| Yes, most of the time | 542 | 35.1% | |
| Rarely | 271 | 17.5% | |
| No | 384 | 24.9% | |
| Not applicable for my professional role/responsibility | 133 | 8.6% | |
| Missing system | 96 | 6.2% | |
Attitudes and perceptions in the care of older adults with anorexia of aging
Commonly held perceptions and attitudes can impact the care that is provided to older adults with anorexia (Table 6 ). Respondents (38.7%) believed that anorexia is unavoidable in older patients, whereas 32% disagreed or strongly disagreed.
Table 6.
Domain (attitudes and perceptions): Perceptions and attitudes in the care of older patients with anorexia of aging (N = 1545)
| N | Statistic | ||
|---|---|---|---|
| Anorexia is unavoidable in geriatric patients. | |||
| Strongly agree | 166 | 10.7% | |
| Agree | 432 | 28.0% | |
| Neither agree nor disagree | 339 | 21.9% | |
| Disagree | 394 | 25.5% | |
| Strongly disagree | 100 | 6.5% | |
| Missing system | 114 | 7.4% | |
| The regular use of standardized tools to evaluate older patients for weight loss is critical. | |||
| Strongly agree | 592 | 38.3% | |
| Agree | 684 | 44.3% | |
| Neither agree nor disagree | 122 | 7.9% | |
| Disagree | 24 | 1.6% | |
| Strongly disagree | 4 | 0.3% | |
| Missing system | 119 | 7.7% | |
| Lack of high‐quality evidence to guide the care and treatment of older patients with anorexia makes it challenging for me as a clinician to choose treatment. | |||
| Strongly agree | 167 | 10.8% | |
| Agree | 594 | 38.4% | |
| Neither agree nor disagree | 390 | 25.2% | |
| Disagree | 233 | 15.1% | |
| Strongly disagree | 40 | 2.6% | |
| Missing system | 121 | 7.8% | |
| I have access to an interprofessional team with experience in the care of older adults with anorexia. | |||
| Yes, all of the time | 118 | 7.6% | |
| Yes, most of the time | 414 | 26.8% | |
| Rarely | 320 | 20.7% | |
| No | 522 | 33.8% | |
| Not applicable for my professional role/responsibility | 54 | 3.5% | |
| Missing system | 117 | 7.6% | |
| I involve caregivers such as family members as collaborators in supporting the older adult with anorexia. | |||
| Strongly agree | 459 | 29.7% | |
| Agree | 787 | 50.9% | |
| Neither agree nor disagree | 155 | 10.0% | |
| Disagree | 22 | 1.4% | |
| Strongly disagree | 4 | 0.3% | |
| Missing data | 118 | 7.6% | |
| I participate in continuing education/continuing professional development on nutrition for (select all that apply): | |||
| All patients | 335 | 22% | |
| Older patients | 406 | 26% | |
| Older patients with anorexia | 218 | 14% | |
| I do not engage in continuing education/continuing professional development on nutrition | 640 | 41% | |
The majority of respondents (82.6%) agreed or strongly agreed that the regular use of standardized tools to evaluate older patients for weight loss is critical. Almost half of the respondents (49.2%) agreed or strongly agreed with the statement that ‘Lack of high‐quality evidence to guide the care and treatment of older patients with anorexia makes it challenging for me as a clinician to choose treatment’.
Over half (54.5%) reported that they rarely or never have access to an interprofessional team with experience in the care of older adults with anorexia, whereas 34.4% reported that they did have access to an interprofessional team most or all of the time.
The majority of respondents (80.6%) reported involving caregivers, such as family members as collaborators in supporting older adults with anorexia.
Although 41% reported not participating in any continuing education (CE) or continuing professional development (CPD) on nutrition, 26% reported participating in continuing education/continuing professional development (CE/CPD) on nutrition for older patients and 22% reported participating in CE/CPD on nutrition for all patients.
Comparison by profession
To assess potential differences across professions, responses to select survey items were compared across five professions that were represented in the greatest numbers (primary care/general practice physicians, specialist physicians, pharmacists, dieticians/registered dieticians/nutritionists and physical therapists). The majority of respondents across all five professions chose ‘loss of appetite and/or low food intake’ as the most accurate definition of anorexia in older adults. Nevertheless, dieticians/registered dieticians/nutritionists more often use tools and resources developed by experts to care for older patients with anorexia than other professions (51%). Physicians (primary care/general practice and specialists) were more likely to use their own clinical judgement (32% and 26%, respectively) as compared with the other professions. Across the five professions, there is consistency in agreeing or strongly agreeing that lack of high‐quality evidence to guide the care and treatment of older patients with anorexia made it challenging for them as clinicians (range 47–52% across the professions) (Table 7 ).
Table 7.
Comparisons by profession (GP/primary care, specialist, pharmacist, dietitian/nutritionist and physical therapist)
| GP/primary care physician | Specialist physician | Pharmacist | Dietitian/nutritionist | Physical therapist | |
|---|---|---|---|---|---|
| Definition of anorexia of aging. | |||||
| Loss of appetite and/or low food intake | 163 | 287 | 58 | 149 | 63 |
| Unintended weight loss | 51 | 82 | 11 | 37 | 14 |
| Sarcopenia or loss of muscle mass | 20 | 40 | 14 | 13 | 9 |
| Nutrition risk, malnutrition or undernutrition | 38 | 66 | 15 | 27 | 19 |
| Frailty | 14 | 19 | 17 | 14 | 3 |
| Missing | 2 | 2 | 1 | ||
| Total | 288 | 496 | 115 | 241 | 108 |
| I use tools and resources such as evidence‐based guidelines developed by experts to care for my older patients with anorexia. | |||||
| Yes, all of the time | 19 | 46 | 6 | 49 | 4 |
| Yes, most of the time | 38 | 136 | 14 | 73 | 21 |
| Rarely | 64 | 81 | 21 | 43 | 28 |
| No, I prefer to use my own clinical judgement | 93 | 131 | 19 | 25 | 14 |
| No, I am not aware of tools and resources to care for my geriatric patients with anorexia | 55 | 65 | 28 | 26 | 19 |
| No, I do not use tools and resources because I do not have access to them | 8 | 10 | 2 | 4 | 1 |
| Not applicable for my professional role/responsibility | 3 | 13 | 16 | 7 | 17 |
| Missing | 8 | 14 | 9 | 14 | 4 |
| Total | 288 | 496 | 115 | 241 | 108 |
| Lack of high‐quality evidence to guide the care and treatment of older patients with anorexia makes it challenging for me as a clinician to choose treatment. | |||||
| Strongly agree | 27 | 45 | 7 | 33 | 18 |
| Agree | 122 | 200 | 47 | 92 | 35 |
| Neither agree nor disagree | 73 | 117 | 32 | 46 | 26 |
| Disagree | 49 | 87 | 16 | 36 | 16 |
| Strongly disagree | 5 | 18 | 1 | 8 | 3 |
| Missing | 12 | 29 | 12 | 26 | 10 |
| Total | 288 | 496 | 115 | 241 | 108 |
| There are sufficient specialists available for me to refer my older adult patients with anorexia for additional assessment and/or treatment. | |||||
| Yes, all of the time | 23 | 41 | 7 | 21 | 8 |
| Yes, most of the time | 96 | 182 | 24 | 99 | 30 |
| Rarely | 62 | 94 | 13 | 37 | 20 |
| No | 86 | 129 | 41 | 43 | 27 |
| Not applicable for my professional role/responsibility | 9 | 26 | 20 | 22 | 14 |
| Missing | 12 | 24 | 10 | 19 | 9 |
| Total | 288 | 496 | 115 | 241 | 108 |
| I have access to an interprofessional team with experience in the care of older adults with anorexia. | |||||
| Yes, all of the time | 16 | 38 | 4 | 25 | 10 |
| Yes, most of the time | 75 | 137 | 27 | 72 | 26 |
| Rarely | 73 | 107 | 15 | 45 | 20 |
| No | 112 | 175 | 48 | 68 | 39 |
| Not applicable for my professional role/responsibility | 1 | 11 | 12 | 6 | 2 |
| Missing | 11 | 28 | 11 | 25 | 11 |
| Total | 288 | 496 | 115 | 241 | 108 |
| I involve caregivers such as family members as collaborators in supporting the older adult with anorexia. | |||||
| Strongly agree | 74 | 166 | 20 | 88 | 30 |
| Agree | 168 | 271 | 68 | 110 | 45 |
| Neither agree nor disagree | 32 | 29 | 14 | 14 | 21 |
| Disagree | 1 | 2 | 1 | 4 | 2 |
| Strongly disagree | 1 | ||||
| Missing | 13 | 28 | 11 | 25 | 10 |
| Total | 288 | 496 | 115 | 241 | 108 |
Abbreviation: GP, general practice.
Discussion
This international, educational needs assessment explored professional practice gaps across multiple HCPs who are involved in the care of older patients with anorexia. It found gaps in use of a definition of anorexia of aging and in diagnosing and treating older adults with anorexia (Box 1). There was general consistency in respondents selecting the most accurate definition of anorexia in older adults in the absence of an explicit cause. This definition was consistent across professions implying that generally HCPs agree on how to define geriatric anorexia. According to this international survey, anorexia of aging is best defined as a result of loss of appetite and/or low food intake in older adults.
Respondents were most likely to use their own clinical judgement or frailty scores when diagnosing older adults with anorexia. In the last decade, five systematic reviews synthesized data on several aspects of anorexia of aging. 5 , 8 , 36 , 37 , 38 From a diagnostic perspective, 18 instruments were identified, mainly using Likert scales or visual methods. 5 However, only one of these reviews investigated diagnostic instruments, 5 plus the lack of consensus from professional societies might have interfered in educational acquisition from HCPs. The use of frailty instruments might be related to the close relationship between weight loss and physical frailty. The use of own clinical judgement might reflect HCPs who have a good understanding of definitions and criteria and therefore have incorporated them into their own clinical judgement processes or could highlight an educational opportunity. Less than one third of respondents reported using a tool or resource developed by experts most or all of the time in their care for older adults with anorexia, with 16% of respondents unaware of a tool or resource to use. When comparing by the top five professions, dietitians/registered dietitians/nutritionists reported significantly higher use of tools and resources as compared with the other professions, which may indicate an opportunity to engage members of that profession in the interprofessional education of their healthcare colleagues.
Less than 50% of respondents reported that they weighed older adults on a weighing scale at each visit. For those who reported that they did not weigh older adults, it is unclear whether older adults were weighed on a weighing scale with a regular frequency but less than each visit. Because outcomes for older adults are improved if interventions are implemented before significant weight loss occurs, this is an area for further evaluation and education.
Appetite however is reported by most of the respondents to be assessed at every visit. It is unclear whether respondents who reported that they did not assess appetite at each visit did so on a less frequent basis. As screening for appetite is a crucial step to assessing risk for undernutrition, determining best practices for frequency of assessment is an area of further exploration. The MNA‐SF is the most frequently used tool; besides this, clinicians mostly conduct an informal interview. Other screening tools were not used to screen older adults for appetite loss at all or were used infrequently by respondents in this assessment; however, there was generalized agreement that consistent use of screening tools was valuable. This is a comprehensive situation due to the lack of a consensus on diagnosing anorexia of aging. Previously, there are several instruments that were used to identify anorexia. 5 The discrepancy between intent and actual use in practice is an area that should be further explored. It is unclear whether HCPs chose not to use a screening tool that might be readily available, whether HCPs were aware of screening tools at all or whether HCPs were aware but did not have access to screening tools at the point of care.
There was also a lack of consistency in how often respondents believed that older adults should be screened for appetite loss, which could contribute to HCPs' failing to regularly assess and identify older adults with or at risk for anorexia. In fact, longitudinal studies evaluating appetite trajectories among older adults are lacking. 8 , 36 In the absence of high‐quality evidence, guidelines or consensus from specialist in the field could mitigate this problem. Dissemination of guidelines with recommendations on the frequency of appetite assessment with an education that reinforces the guidelines could likely improve awareness of the need for consistent assessment.
Primary treating physicians, nurses and dietitians/registered dietitians/nutritionists were identified as the professions most responsible for screening older adults for appetite loss and, therefore, may be the professions that should be the target audience for education. This was somehow surprising as approximately 30% of medical specialists were geriatricians.
Respondents described treating swallowing/dentition issues most frequently for older patients with or at risk for anorexia, followed by strategies to increase nutritional intake, evaluating and treating medication‐related side effects and prescribing nutritional counselling, exercise and psychological support. Prescribing antidepressants or appetite stimulants was reported less frequently as was screening for abuse or neglect. Evidence for all those strategies is really limited based on three systematic reviews of anorexia management. 5 , 36 , 37 The strongest evidence for treatment relies on oral nutritional supplementation. 5 , 37
Overall confidence in providing nutritional and exercise activity recommendations was high across the respondents in this assessment; however, unsurprisingly, dietitians/registered dietitians/nutritionists were most confident of the professions in providing nutrition recommendations whereas physical therapists were most confident in providing activity recommendations. In fact, the evidence of physical exercise on anorexia is low, involving one study. 38
Referrals for further assessment and treatment of older adults with anorexia fell primarily to nurses/registered nurses. Dietitians/registered dietitians/nutritionists and physicians were also identified as professions that initiated referrals. As these professions appear to bear the most responsibility for referral, education focused on these professions in areas of promptness in referring, specialists for referral and follow up of referrals may be warranted. Respondents were equally split when asked if sufficient specialists were available for referrals. By profession, dietitians/registered dietitians/nutritionists may report greater availability of referral resources as they could be considered specialists as a profession.
Perhaps once an older adult has been referred to a profession that functions in a specialty practice area, there are more resources that become available, as compared with a primary care or general practitioner who may find that access to resources is more challenging.
More respondents believed that anorexia is unavoidable in older adults as compared with those who disagreed or strongly disagreed with the statement, implying that a significant portion of the HCP workforce may view anorexia as a normal part of aging. The belief that anorexia is unavoidable is not the same as a conviction that it cannot be treated. A similar perspective could be laid upon cancer cachexia or sarcopenia/muscle loss, which most people find normal or part of the disease, but still important to treat/prevent. Addressing attitudes and perceptions associated with aging for HCPs, as well as with older adults and their families, is an important area for education. HCPs must be able to describe what normal, healthy aging looks like and support older adults to achieve healthy aging. Assuming that anorexia is ‘normal’ reduces the chance that HCPs will screen, identify and treat older adults who are at risk for or experiencing anorexia.
While the majority of respondents reported that the regular use of standardized tools to evaluate older patients for weight loss is critical, descriptions of their behaviour in practice demonstrate otherwise. This discrepancy will require further analysis to identify root causes.
Lack of high‐quality evidence to guide the care and treatment of older adults with anorexia is a significant concern for respondents in this assessment. 5 , 7 , 8 , 36 , 37 Providing regular, up‐to‐date information and accessible education for HCPs is critical to improve the care of older adults.
Aggregate survey responses reflect that more than 50% of respondents rarely or never have access to an interprofessional team with experience in the care of older adults with anorexia. This might reflect global differences in healthcare systems and healthcare delivery, and understanding those differences and adapting educational interventions to regional context will be important for success.
There were relatively low rates of engagement in CE/CPD among respondents in this assessment despite the likelihood that those who chose to engage in and complete this assessment are more vested in the clinical topic area and patient population as compared with those who did not participate. There is opportunity to establish the relevance of CE/CPD for a wide range of HCPs who may not be aware of the significance for their practice setting and/or patient populations.
Box 1. Anorexia of aging education: Insights and gaps.
The majority of respondents agreed or strongly agreed to be confident in providing nutritional and/or exercise recommendations for their older patients with anorexia.
In the absence of an explicit cause, most respondents selected loss of appetite and/or low food intake as the most accurate definition for anorexia in older adults.
To diagnose anorexia in older adults, most of the respondents used their own clinical judgement and/or frailty scores. Concerningly, over a fifth of the respondents was not aware of any tools that could be used in the care for anorexia of aging.
Most of the respondents assessed appetite at each visit, although not all older adults are always weighed at each visit. Apart from the MNA‐SF, other tools to screen for appetite loss are not frequently used; most of the time, the reporting clinicians conduct an informal interview.
Registered nurses/nurses, dietitians/registered dietitians/nutritionists, general practitioners/physicians and, to a lesser extent, specialist physicians/medical doctors are responsible for referral for further assessment and treatment of anorexia in older adults.
Treatment of anorexia of aging is focused on treating swallowing disorders if present, addressing dental issues and increasing the patient's nutritional intake, via energy‐ and protein‐fortified foods and/or oral nutritional supplements. To a lesser extent, appetite stimulants are being prescribed.
While over one third of the respondents considered anorexia as unavoidable in older patients, almost half of them believed that there is a lack of high‐quality evidence to guide the care and treatment of older patients with anorexia, which makes it challenging to choose treatment.
Strengths and limitations
The strengths of this study included the international and interdisciplinary approach and its large number of respondents (n = 1545). The respondents had clinical expertise in the management and care of anorexia in older adults. Specialist physicians and primary care physicians had the highest level of response. This response correlates with their roles in the management and care of anorexia in older adults. The outcomes of the survey are highly relevant to develop effective educational programmes for practicing clinicians and for the training of new practitioners.
Participation to the survey was voluntary; therefore, findings may be biased towards those who are most actively involved in the care of older adults and those most interested in anorexia or nutritional disorders. Results primarily reflect the experiences of physicians/medical doctors, pharmacists, dietitians/registered dietitians/nutritionists and physical therapists. There were few respondents who identified as faculty, students/trainees or non‐clinical. The results therefore most likely reflect the opinions of those HCPs who were the most confident in treating older adults with anorexia.
Conclusions
Findings from this mixed‐methods educational needs assessment demonstrate areas of consistency across world regions and professions, while also identifying opportunities for additional exploration and/or intervention that may improve the care and outcomes of older adults at risk for or who have been diagnosed with anorexia.
HCPs in this assessment recognized a consistent definition of anorexia in older adults, the risk factors and potential impact of anorexia of aging, and the best interventional strategies to treat this. HCPs are also generally confident in their nutritional and activity recommendations and engage caregivers such as family members in supporting older adults with anorexia at high rates.
There was significant variation in areas such as how often appetite should be assessed in older adults, how often older adults should be weighed and which tools and resources should be used to screen and to diagnose older adults with anorexia. An alarmingly high number of HCPs seemed to believe that anorexia is a normal part of aging, and therefore, there is significant risk that they will not take steps to identify or treat older adults. Future research should explore whether anorexia and weight loss investigation and management in older adults are part of the formal educational curriculum of HCPs.
Finally, access to referral resources and interprofessional care teams were identified as system‐level barriers that may need to be addressed by more comprehensive strategies.
Conflict of interest statement
IA has received consultancy fees from Pfizer. AC has received honoraria and/or lecture fees from AstraZeneca, Boehringer Ingelheim, Menarini, Novartis, Servier, Vifor, Abbott, Actimed, Arena, Cardiac Dimensions, Corvia, CVRx, Enopace, ESN Cleer, Faraday, Impulse Dynamics, Respicardia and Viatris. SDA has received grants and personal fees from Vifor and Abbott Vascular and personal fees for consultancies, trial committee work and/or lectures from Actimed, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, BioVentrix, Brahms, Cardiac Dimensions, Cardior, Cordio, CVRx, Cytokinetics, Edwards, Farraday Pharmaceuticals, GSK, HeartKinetics, Impulse Dynamics, Novartis, Occlutech, Pfizer, Repairon, Sensible Medical, Servier, Vectorious and V‐Wave. He has been named co‐inventor of two patent applications regarding MR‐proANP (DE 102007010834 and DE 102007022367), but he does not benefit personally from the related issued patents. Other authors have no conflict of interest.
Acknowledgements
The authors certify that they comply with the ethical guidelines for authorship and publishing of the Journal of Cachexia, Sarcopenia and Muscle. 39
Members of the International Advisory Board are as follows: John E. Morley, MD, Saint Louis University, USA; Ivan Aprahamian, MD, MS, PhD, FACP, FISAD, FSCWD, Division of Geriatrics, Jundiaí Medical School, Jundiaí, Brazil; Hidenori Arai, MD, National Center for Geriatrics and Gerontology, Japan; Jürgen Bauer, MD, Department of Geriatrics, Heidelberg University, Heidelberg, Germany; RoseAnn DiMaria‐Ghalili, PhD, RN, FASPEN, FAAN, FGSA, College of Nursing and Health Professions, Drexel University, USA; Bill Evans, MD, Department of Medicine, Duke University, USA; Luigi Ferruci, MD, National Institutes of Health, USA; Christine Jacobs, MD, Saint Louis School of Medicine, USA; Sandra Maria Lima Ribeiro, PhD, MSc, University of São Paulo, Brazil; and Bruno Vellas, MD, Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
Members of the Regional Advisory Board for the United States are as follows: John E. Morley, MD, Saint Louis University; William Banks, MD, Division of Gerontology and Geriatric Medicine, University of Washington; Marla Berg‐Weger, PhD, MSW, Saint Louis University School of Social Work; Yulia Brockdorf, RD, LD, CDCES, CST, NCC, LPC, BC‐ADM, BC‐TMH, LMHC, FAIHM, LN, CD, Nutrition For Success, LLC, Hillsboro, Oregon; RoseAnn DiMaria‐Ghalili, PhD, RN, FASPEN, FAAN, FGSA, College of Nursing and Health Professions, Drexel University; Marianne Galang, RD, CSO, LD, API, Center for Human Nutrition, Digestive Disease Institute, Cleveland Clinic; Christine Jacobs, MD, Saint Louis School of Medicine; Hosam Kamel, MD, College of Medicine, University of Arizona, Tucson; Jorge Ruiz, MD, Miller School of Medicine, University of Miami; and Michael Wasserman, MD, LA Jewish Home for the Aged.
Members of the Regional Advisory Board for Europe are as follows: Jürgen Bauer, MD, Department of Geriatrics, Heidelberg University, Heidelberg, Germany; Tommy Cederholm, MD, Department of Clinical Nutrition, Uppsala University, Sweden; Alfonso Cruz‐Jentoft, MD, Geriatric Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Ligia J. Dominguez, MD, School of Medicine, University Kore of Enna, Italy; Mikel Izquierdo, PhD, Navarrabiomed, Complejo Hospitalario de Navarra (CHN)‐Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain, and CIBER of Frailty and Healthy Ageing (CIBERFES) Instituto de Salud Carlos III Madrid, Spain; Francesco Landi, MD, Department of Internal Medicine, Catholic University of Sacred Heart, Rome, Italy; and Bruno Vellas, MD, Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.
Members of the Regional Advisory Board for Japan are as follows: Hidenori Arai, MD, National Center for Geriatrics and Gerontology; Masahiro Akishita, MD, University of Tokyo; Masafumi Kuzuya, MD, Meitetsu Hospital, Nagoya; Shosuke Satake, MD, National Center for Geriatrics and Gerontology; Ken Sugimoto, MD, Kawasaki Medical University; and Hidetaka Wakabayashi, MD, Tokyo Women's Medical University.
Members of the Regional Advisory Board for South America are as follows: Ivan Aprahamian, MD, MS, PhD, FACP, FISAD, FSCWD, Division of Geriatrics, Jundiaí Medical School, Jundiaí, Brazil; José Ricardo Jauregui, MD, President IAGG, Argentina; Luis Miguel Gutierrez Robledo, MD, Geriatric Institute, Mexico; Mauricio Lorca, PhD, MSc, Austral University, Chile; and Sandra Maria Lima Ribeiro, PhD, MSc, University of São Paulo, Brazil.
Funding for this project was provided by Pfizer Inc. as an independent educational grant.
Aprahamian I, Coats AJ, Morley JE, Klompenhouwer T, Anker SD, on behalf of the International Advisory Board, and Regional Advisory Boards for North America, Latin America, Europe and Japan . 2023; Anorexia of aging: An international assessment of healthcare providers' knowledge and practice gaps. Journal of Cachexia, Sarcopenia and Muscle, 14, 2779–2792, 10.1002/jcsm.13355
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