United Kingdom

Introduction:
• Sarcopenia and frailty are common conditions affecting many older people living in the UK.
• A growing body of evidence supports resistance exercise training as a safe and effective intervention to improve muscle
strength in older people.
• Consensus guidelines released in 2018 strongly recommended the prescription of resistance-based physical exercise for
individuals with sarcopenia.
• However, a recent survey of current practice in the UK found that resistance exercise training was offered in only 9% of
departments delivering exercise interventions for sarcopenia and frailty with considerable variability demonstrated in the
content of the exercise interventions being offered across different sites
A Benchmarking and Feedback approach
• Debate continues as to the optimal duration,
frequency and intensity of exercise interventions
for sarcopenia and frailty in addition to how best
exercises should be progressed and the best
means of assessing outcomes for patients.
• A large-scale randomised control trial could
potentially address these questions; however this
would be a very lengthy and potentially costly
process.
• Alternatively, a benchmarking and feedback
model has the potential to drive service
improvement over a short timeframe through
cycles of assessment, feedback, and
improvement.
• The Benchmarking Exercise Programmes for
Older People project (BEPOP) draws upon the
experience of exercise professionals and
harnesses the variability seen in current practice
by gathering details of the content and outcomes
of exercise interventions currently offered to older
people from across multiple sites.
Proposed outcomes and future actions
• Data will be analysed to derive descriptive data on
each variable. Multiple regression analysis will be
performed to determine the relationship of
different exercise programme characteristics with
the greatest improvement in patient outcomes.
• Following review by an expert panel comprising
members of the British Geriatrics Society
Sarcopenia and Frailty Research Special Interest
Group, this data will inform the development of a
series of consensus guidelines for good practice
which shall be disseminated nationally to support
service development.
• Individual participants will receive tailored
feedback from our expert panel and signposting to
ongoing education and training resources.
• Participants will also be offered the opportunity to
benchmark their practice against a dashboard of
national practice.
• By undertaking multiple iterations of
benchmarking and feedback, those delivering
exercise training for older people with sarcopenia
or frailty will be able to share learning and evolve
practice towards the optimal duration, modality,
intensity, and frequency of interventions.
• Future cycles of benchmarking and feedback can
be adapted following the results of earlier
iterations as new questions for service
development arise.
Summary
• Recent work has shown that there is considerable variation in exercise interventions being offered to older
people living with sarcopenia and frailty and most are not in keeping with current best evidence.
• A benchmarking and feedback approach is an innovative, time-efficient, and cost-effective method of
engaging exercise professionals and promoting the development of exercise services for older people in
the UK. 

ISTRC 2021 - International Sarcopenia Translational Research Conference

Improving exercise interventions for older people living with sarcopenia and frailty through a new UK wide benchmarking and feedback project

service development

resistance training

sarcopenia

Welcome to the inaugural International Sarcopenia Translational Research Conference.  “Where Worlds Meet” – the event brings together a broad range of researchers and practitioners in a truly interdisciplinary forum, covering discovery science through to clinical practice.

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Access to this event requires a registration. Please email Eleanor Lockhart at sarcconf@ncl.ac.uk if you have any questions regarding your registration. 

poster

Introduction: The prevalence of PD and sarcopenia both increase with age. They share features of pathogenesis including IL6 driven neuroinflammation and mitochondrial dysfunction. However the degree to which they co-occur and if the presence of sarcopenia is influenced by Parkinson’s disease stage is unknown. Methods: Predefined literature search strategies were used on MEDLINE, EMBASE, Scopus and Web of Science. Studies conducted in people with PD or aPS reporting on the prevalence of sarcopenia or those providing sufficient data to compute this using validated sarcopenia definitions were included. Mean prevalence was calculated across studies. A pooled odds ratio was calculated across studies reporting on prevalence of sarcopenia in controls. Risk of bias was assessed using the AXIS tool. Results: 1683 studies (199 duplicates) were identified through the search; 67 assessed in full; 14 met inclusion criteria. Average study quality score was 14.5/20. The mean prevalence of sarcopenia in parkinsonian patients was 17.9% (range 2- 31.4%). The mean prevalence of probable sarcopenia (i.e. low muscle strength) was 49.1% (range 17.5-76.7%). In all studies with non-parkinsonian controls, sarcopenia was more prevalent in those with parkinsonian disorders. The combined odds ratio was 2.49 (p <0.0001) see fig. 1. UPDRS III score positively correlated with prevalence of sarcopenia but this was not consistently shown in individual studies, see fig 2. Only 3 studies commented on the prevalence of sarcopenia in aPS and there was little agreement as to whether sarcopenia is more prevalent in PD or aPS. Conclusions: Sarcopenia is a prevalent and important issue in parkinsonian disorders. Probable sarcopenia is especially common. Recognition of this should prompt clinical testing and provision of appropriate interventions to minimise negative clinical outcomes associated with movement disorders being compounded by muscle weakness.

The Prevalence of Sarcopenia in Parkinson’s Disease and Related Disorders A systematic review

Adiposity and grip strength: a Mendelian Randomisation study

Background: Sarcopenia is associated with a low intake of energy and nutrients (e.g., protein and specific micronutrients as calcium, selenium, magnesium and vitamin D), which appears to influence muscle mass (muscle quantity and quality) and function (strength and walking speed). Material and methods: This research was part of a cross-sectional study called the Nutriage project (Ref. 0359_NUTRIAGE_1_E-5), which included a sample of permanent residents in fifteen nursing homes for older adults in Galicia (Northwest Spain). Food intake data were collected by the precise weighing method. Results were compared with Dietary Reference Intakes for >70-year-olds, alongside recommendations of the European Society for Clinical Nutrition and Metabolism and PROT-AGE group. The variables analyzed were energy, protein, selenium, calcium, magnesium and vitamin D in both sexes. Means for nutrient intake, were calculated, and differences by sex and age categories were tested using t-test or ANOVA. P values < 0.05 were considered statistically significant. Results: The sample selected for this study was 162 residents, where 65.4% were women and 34.6% were men. The average age of the participants was 85.6 years. Conclusions: The dietary intake of the institutionalized elderly in this study did not meet the recommended nutritional requirements in terms of calcium, magnesium and vitamin D. 5% of the residents did not meet their caloric needs and 22% of them were below the protein recommendations of ESPEN and PROT-AGE group. Despite finding no significant differences, in our sampl e we have seen that energy, protein and micronutrient consumption is higher in women than in men. Based on these findings, the nutritional intake of nursing homes is inadequate in terms of micronutrients, especially considering the published scientific evidence on the contribution of proteins and specific nutrients for the prevention of sarcopenia.

Protein and micronutrients intake in elderly living in nursing homes in northeast Spain: Are enough to prevent sarcopenia?

Background: • Dietary protein provides essential amino acids required for healthy aging. • Understanding how dietary protein sources vary for different population subgroups will allow for more targeted nutrition interventions. Methods: • Analysis of cross-sectional data from NHANES 2011–2016 • Adults (18+ years) with one 24-hour dietary recall (n = 15,697) • Population proportions were calculated based on protein intake (g/day) for food categories.  Discussion: • The top ten sources of protein accounted for over 40% of dietary protein for all groups. • Chicken (whole pieces) was the top-ranked source for all groups. • Only two plant-based proteins appeared in the top ten sources: beans, peas and legumes for Hispanics, and nuts and seeds for Other. • Public health strategies that encourage diversity in protein sources and incorporate legumes nuts, and poultry have the potential to shift the overall population protein intake distribution toward improving overall diet quality.

Age and Racial/Ethnicity Differences in Dietary Sources of Protein, NHANES, 2011-2016

Background: Beginning as early as the 4th decade of life, evidence suggests that skeletal muscle mass and skeletal muscle strength decline in a linear fashion, with up to 50% of mass being lost by the 8th decade of life[1] . Given that muscle mass accounts for up to 60% of body mass, pathological changes to this important metabolically active tissue can have profound consequences on the older adult. The consequences of sarcopenia are often severe in older adults, as the strength and functional declines associated with sarcopenia can in turn contribute to a number of adverse health outcomes, including loss of function, disability, and frailty. A greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. Material and methods: This longitudinal study included NHS healthcare professionals (n=50) who were asked to complete a questionnaire regarding awareness of sarcopenia, risks involved, diagnostic strategies and it’s management. Conclusion: Although concept of sarcopenia and frailty is familiar to most NHS healthcare professional’s practical application is limited due to lack of awareness regarding the diagnostic methodology, risks as well as time constrains.

Awareness regarding Frailty and Sarcopenia among healthcare professionals at a District General Hospital in South East United Kingdom

Background: The beneficial effect of resistance training (RT) for skeletal muscle health and physical functioning in older adults is well recognised. It may be further enhanced by ensuring adequate protein intake, preferably from sources with high biological value protein that are inexpensive, easy to prepare, and well tolerate. However, few intervention studies have used a whole food approach with RT, and there are challenges associated with older adults taking part in such interventions. Thirty community-dwelling older adults (18 men and 12 women) performed 6-weeks of RT, twice weekly, and were randomised into three intervention groups: "whole milk (3.6% fat) + RT” (Group 1), “skimmed milk (0.3% fat) + RT” (Group 2), and “control drink + RT” (Group 3). Control drink (cranberry juice) was supplemented with maltodextrin to match the caloric value of whole milk. Approximately 1 week following completion of the 6-week intervention delivered twice-weekly in a local gym, a homebased post intervention interview was conducted to understand participants’ experiences of taking part as well as the motivators and barriers to continuing the intervention after the study completion. Participants were asked a combination of structured multiple-response and standardised open-ended questions. Participants’ responses to 11 open-ended questions were recorded verbatim pertaining to (a) overall experience in the study (probing for what they liked/enjoyed or disliked/found difficult), three questions; (b) attitudes and barriers to consuming 2 X 500 mL milk/control drink intake postexercise (e.g. volume or liquid, taste), two questions; (c) changes in appetite and habitual diet because of milk/control drink intake, two questions; (d) opinions about the feasibility/acceptability of the intervention (milk+RT) for muscle health in older adults one question; (e) intentions to continue the intervention on their own after the study completion (probing for motivators and barriers), two questions and (f) any additional comments or thoughts about the study.  Conclusions: Overall participants responded positively to a nutritional and RT intervention. Opportunities for peer encouragement, social bonds and their retention, and affordability of exercising in a gym setting should be provided to older adults to promote and maintain positive health behaviours.

MIlk Intervention Muscle AgeiNg (MIlkMAN) pilot study: a content analysis of motivators and barriers to engagement

Background: Sarcopenia (muscle loss) is associated with chronic disease and lower quality of life in older adults. Increased protein intake is suggested as a strategy to slow or reverse this loss of muscle mass and strength. However, diverse study designs result in inconsistent findings on protein’s effects. Design: Meta-analysis used a random effects model (weighted mean difference (WMD)) and generic inverse variance methods to synthesize quantitative data, followed by a leave-one-out method for sensitivity analysis. Conclusions: In healthy older adults undergoing resistance exercise, increased protein intake leads to greater lean body mass, appendicular lean mass and knee extension strength, although no superior effect is seen with the use of additional protein alone.

Protein interventions augment the effect of resistance exercise on lean mass and strength in older adults: systematic review and meta-analysis of randomized controlled trials

Background: • Hip fracture is the most common reason for older people to require emergency surgery. • Sarcopenia, a condition of decreasing muscle mass, strength and physical performance with age, is common in older people. • Sarcopenia is associated with poor postoperative outcomes following hip fracture surgery; however, sarcopenia is not screened for on admission with hip fracture. • A simple, cheap and effective screening tool for sarcopenia is grip strength testing. Aims: 1. Design a protocol for grip strength testing in patients admitted with hip fracture. 2. Deliver a training programme in grip strength testing to physiotherapy staff. 3. Assess the feasibility of implementation through quantitative, qualitative and economic analysis. 4. Assess for association between grip strength and other risk scores in hip fracture. Conclusions: • Grip strength testing was simple, cheap and effective in screening for low muscle strength in hip fracture. • A protocol suited to the specific capabilities of hip fracture patients was produced. • A team of staff were trained over a relatively short number of sessions. • Testing was acceptable to both patients and staff and was conducted with fidelity to the protocol. • Testing was rapidly adopted into admission assessment for a high proportion of patients. • Many patients with low grip strength were identified who are at high risk of adverse postoperative outcomes following hip fracture.

Implementing grip strength assessment in hip fracture patients: a feasibility project

Background: 
A third of people aged 65+ years fall every year, leading to fragility fractures in 10 - 15%, most commonly upper limb fractures
which are frequently the first sign of osteoporosis.
1) NICE clinical guidelines recommend
identifying and managing the risk factors for falling to prevent subsequent hip
fractures. It is estimated that by identifying these patients systematically, 25%
hip fractures (approximately 20,000 a
year in the UK) can be prevented
2) Osteoporosis and sarcopenia often coexist (osteo-sarcopenia) and both are
associated with increased risk of falls
and fractures. Early identification and
treatment of sarcopenia among older people with fragility arm
fractures could prevent further fractures.
3) This study evaluated the feasibility of assessing sarcopenia
among people aged 65+ years, who attend fracture clinic with
an upper limb fracture.
Methods:
4) This was a feasibility study
5) Patients aged 65 + years, with a single arm fracture (wrist or
upper arm), and able to give informed consent were recruited
from 3 fracture clinics in one acute hospital. Patients with
pathological fractures, multiple or lower limb fractures, active
cancer diagnosis or care home residents were excluded.
6) Sarcopenia was assessed using gait speed, grip strength with
unfractured arm (hand dynamometer using appropriate cut off
adjusted for age and gender), skeletal
muscle mass index SMI
(Bioimpedance BIA), SARC-F questionnaire, the European Working Group
on Sarcopenia in Older People
(EWGSOP) I and II criteria.
7) The sensitivity and specificity of each
measure was calculated against the
EWGSOP II criteria as the standard
reference.
Results:
Participant characteristics
• 100 patients (mean age 75 years± 7.2; 80 female) were recruited. Wrist (55%) and
 humerus (25%) were the most common type of fractures.
• Patients had comorbidities (mean=5 ± 3.45 ) and polypharmacy (mean No medications
=5 ± 3.4) but good physical (Barthel ADL median score=100, IQR (97,100)) and cognitive function (AMT median score=10, IQR (9,10)).
Prevalence of sarcopenia
• Sarcopenia was identified among 4% (EWGSOP I), 5% (SMI), 13% (EWGSOP II),
16% (gait speed test), 18% (SARC-F) and 39% (grip strength) see Table 1.
• Sarcopenia was significantly more prevalent among men with all measures: grip
strength (60% M vs 34% F), gait speed and SARC-F (40% M vs 12% F), the EWGSOP
II criteria (36% M vs 9% F) and EWGSOP I criteria (29% M vs 0% F).
• SARC-F had the best sensitivity (100%) and specificity (96%) against the EWGSOP II
criteria.
Feasibility of sarcopenia assessment
• Time needed to complete the assessments was on average 1-2 minutes for gait
speed, grip strength and SARC-F; 5 minutes for SMI, and 8-9 minutes when EWGSOP I
and II criteria were applied.
• Data were complete for grip strength and SARC-F. Missing data was reported among
2% for gait speed, 8% for SMI, 8% for EWGSOP II and 10% for EWGSOP I.
• The EWGSOP I & II criteria required most resources including: Jamar hand dynamometer,
measuring tape, and bioimpedance (BIA) machine. While SARC-F required the least resources (paper).
Conclusion
Assessing sarcopenia among older people with wrist or arm fractures was feasible in a busy fracture clinic. The self-completed questionnaire SARC-F had high sensitivity and specificity and was a quick, simple and cheap tool that could be suitable for routine use.
Prevalence of sarcopenia was significantly higher among men than women but the sample size was small and further research is needed
to confirm these findings.

The feasibility of assessing sarcopenia among older people with arm fracture using different criteria

Background:
SarQoL is a disease-specific quality-of-life
tool for use by patients with sarcopenia. The
questionnaire consists of 55 items organised
into 22 questions across seven domains:
Physical and mental health, Locomotion,
Body composition, Functionality, Activities of
daily living, Leisure activities and Fears.
Comprehensive validation data for SarQoL in
a UK population with sarcopenia are lacking.
This study tests SarQol’s internal
consistency, reliability, responsiveness and
external validity in a UK sarcopenia cohort.
Methods:
The SarQoL questionnaire was administered
by the research nurse at baseline and at sixmonth follow-up (by telephone) to assess
quality of life. Baseline visits were conducted
face to face (in a research clinic or in the
participants own home). Due to limitations on
face-to-face research activity imposed in the
UK as part of the pandemic response to
COVID-19, all but 8 follow-up visits were
conducted by telephone.
Measures of physical performance and selfreported function were also collected. The
SARC-F score was collected by telephone at
pre-screening and at the six-month follow-up
encounter. At baseline, maximum hand grip
strength, 4-metre walk speed and the Short
Physical Performance Battery (SPPB) were
measured.
At follow-up, participants were asked two
questions to assess global change in a)
fitness, and b) quality of life on a 7-point Likert
scale (much worse to much better).
Statistical analysis
All statistical analyses were conducted using
SPSS v26.
• Internal consistency was calculated using
Cronbach’s alpha.
• Reliability was calculated by intraclass
correlation in participants with no change in
a) their reported global fitness or b) their
quality of life.
• Responsiveness (Cohen’s d) was calculated
for participants reporting slight improvement
or worsening in their global scores.
• External validity was assessed by
comparing baseline SarQoL scores with
measures of physical performance and
functional ability.
Conclusions:
SarQoL showed:
• Good overall internal consistency
• Moderate reliability
• Evidence of criterion validity in crosssectional comparison with related measures.
• Variable responsiveness to change
Our results support the use of SarQoL as an
outcome measure in clinical trials of sarcopenia,
but further experience is required of its use in
trials to better define responsiveness and the
minimum clinically important difference (MCID)

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Improving exercise interventions for older people living with sarcopenia and frailty through a new UK wide benchmarking and feedback project

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