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The population is ageing worldwide at a phenomenal pace from 900 million ≥ 60 years old in 2015 to 2 billion in 2050 (1). The longer lifespan is due to advancement in public health, medical, social and economic development. However, healthspan has been slow to improve in most countries where the last decade of life is spent in poor health (2). Aging is associated with declines in functional capacity, and preserving function including lengthening healthspan is an increasingly important challenge for countries with a fast aging population. The World Report on Ageing and Health by World Health Organisation (WHO) defines healthy ageing as the process of developing and maintaining functional ability that enables wellbeing (3). The interaction between individual’s intrinsic capacity and environmental characteristics are crucial to achieve the optimum trajectory which can be modified to maintain a person’s functional ability and intrinsic capacity throughout the life course. We assert that greater knowledge of the effects of the exercise interventions on age-related amelioration of intrinsic capacity domains (i.e locomotion, vitality, cognition, psychological, sensory) that is present in the frail will allow a more coherent and holistic approach to treatment of the frail. This Viewpoint emphasizes the idea that the physiological bases underlying the assertions that exercise treatment of frailty directed at increasing muscle mass by pharmaceuticals in order to treat symptoms of frailty is an example of current medical, scientific and pharmaceutical industrial lack of appreciation of the role of exercise as a therapeutic agent having a major role both in the treatment and prevention not only of disease but also in functional capacity (4, 5).

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults. These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR). To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefitharm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process. We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Frailty is now a well-recognized and common syndrome among older persons. Frailty is a syndrome which increases the risk of an older person to develop disability or to die when exposed either to physical or psychosocial stressors . Although frailty, disability and multimorbidity often coexist and interact, they are distinct and separate concepts. Growing evidence suggests that each of these interrelated conditions is preventable and their associated complications manageable. However, early identification is imperative as once disability and multimorbidity occur, frailty in less likely to be prevented or reversed. As such it should be distinguished from persons with disability in their activities of daily living. The conditions leading to the frailty syndrome should have some degree of reversibility, thus distinguishing it from multimorbidity. Recently, the International Conference of Frailty and Sarcopenia Research (ICFSR) formulated evidence-based guidelines for the identification and management of physical frailty. Physical frailty was originally defined and validated by Fried et al. This definition included measurements of low activity level, slowness of walking, muscle weakness, exhaustion and weight loss. This approach differs from that of Rockwood and Mitnitski which used the number of “deficits” (signs, symptoms, clinical conditions) to determine a frailty index. Primary care represents the entry point into the health care system for many older adults who may be pre-frail and frail. A shortage of geriatricians and the higher frequency of frailty in community settings call for primary care clinicians (general practitioners, generalists, family physicians) to increasingly assess and manage older adults at risk for frailty or who are already frail.The purpose of this paper is to suggest practical frailty screening and management strategies in primary care settings. We will also discuss the characteristics of these instruments and their applicability to primary care. For the sake of consistency hereafter, we will refer to clinicians delivering primary care as primary care providers.

The prevalence of anemia and its impact on frailty and physical function amongst the multiethnic older populations in the Southeast Asian (SEA) countries are often not well studied. Singapore, a nation comprised of multiethnic communities, is one of the most rapidly aging population globally. We aim to evaluate the prevalence of anemia and its impact on frailty, and physical function in Healthy Older People Everyday (HOPE)- an epidemiologic population-based study on community-dwelling older adults in Singapore. Cross-sectional study. Community. 480 adults ≥ 65 years old. Data were collected from interviewers-administered questionnaires on socio-demographics, FRAIL scale, Mini-Mental State Examination, EQ-5D, Barthel Index, and Lawton index. Hemoglobin concentration and physical assessments, including anthropometry, grip strength, timed up-and-go (TUG) were measured. The overall prevalence of anemia was 15.2% (73 out of 480). The Indian ethnic group had the highest prevalence of anemia (32%, OR=3.02; 95%CI= 1.23–7.41) with the lowest hemoglobin concentration compared to the overall population (13.0±1.3g/L and 13.5±1.4g/L, p=0.02). Hemoglobin levels and anemia were significantly associated with frailty (OR=2.28; 95% CI=1.02–5.10), low grip strength (OR=1.79; 95% CI=1.01–3.03), ≥ one IADL impairment (OR=2.35; 95% CI=1.39–3.97). Each 1 g/dL increase in hemoglobin was associated with a 6% decrease in frailty odds after adjusting for potential covariates (OR = 0.94, 95% CI: 0.90–0.99). There was a significant difference in the mean TUG between the non-anemic (11.0±3.4 seconds) and anemic (12.3±6.0 seconds, p=0.01) counterparts, but no difference in the number of falls. In our multiethnic Asian population, anemia was adversely associated with frailty, decreased muscle strength, and IADL impairment. Health policies on anemia screening should be employed to avoid or potentially delay or reverse these adverse outcomes associated with anemia. Recognition, evaluation, and treatment of anemia amongst this vulnerable population is warranted.

Since its inception more than 20 years ago, theJournal of Nutrition, Health & Aging (JNHA) hasconsistently published outstanding research in thefields of aging, population health, longevity and geriatrics.During its prestigious history, the JNHA has grown rapidly tobecome the outlet of choice for publication of research topicsrelated to prevention and interventions to enable healthy aging,and delay or prevent the onset of disability associated withaging (1–3). Under the eminent leadership of Professor JohnE. Morley (2018-2021), the Journal significantly increasedits number of published papers and citations, reaching anaverage of approximately 200 publications per year and over570,000 articles’ downloads and visits (data from 2021). Thepapers - included expert consensus and clinical guidelines(4–6) - represented major scholarly contributions to the fieldof aging. Under the capable direction of Professor Morley, thejournal has striven to gain a better understanding of the clinicalimplications of the COVID-19 pandemic for older adults. Over60 Journal’s publications, many featuring renowned geriatricsexperts, have proposed insightful perspectives and practicalsolutions to combat the burdens associated with the pandemic,such as social isolation and containment (7–12).