United Kingdom

Introduction: 
1) Frailty – a risk factor of mortality and morbidity post-surgery
2) Currently available frailty scores – only assess one or selected few of
frailty’s components
3) Aims – to assess the feasibility of comprehensively measuring frailty of
elective cardiac surgery patients
Methods:
Study period – 01/12/2018 to 30/09/2020, follow-up until 31/12/2020
1) Patients – all cardiac surgery patients older than 70 years
2) Comprehensive frailty assessment in the pre-assessment clinic
3) NEFS – 1 point each, 11 in total, 4 points = frail
Results:
201 consecutively recruited – 36 excluded (incomplete assessment)
165 patients – 63 (38.2%) frail, 102 (61.8%) non-frail
Conclusion:
1) Feasible to comprehensively evaluate cardiac surgery patients’ frailty
using the North East frailty score
2) NEFS independently predicts post-cardiac surgery outcomes
3) Further validation is required
4) NEFS has the potential to facilitate the heart team to better risk
stratify patients and help patients make informed decision


ISTRC 2021 - International Sarcopenia Translational Research Conference

The North East Frailty Score (NEFS) A New Comprehensive Frailty Tool for Elective Cardiac Surgery Patients – Results of the Pilot Study

pre-operative assessment

risk stratification

cardiac surgery

frailty

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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)

Validity of the SarQoL quality of life tool in a UK population of older people with impaired physical function: findings from SarcNet

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. 

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

Background:
Resistance exercise can improve muscle strength and physical performance in older adults and is
recommended as a first-line treatment for sarcopenia. There is a growing interest surrounding the
exercise recovery process in older adults, and many studies are now seeking to characterise the
acute physiological side-effects of exercise1, and identify interventions to expedite recovery in
ageing populations.
However, we are unaware of any literature that has sought to define the perspectives of older
adults, or determine their knowledge of, exercise induced muscle damage and recovery.
To inform the direction of future research, it is important that researchers and practitioners alike
understand what exercise recovery means to older adults regarding barriers and motivators to
participation, willingness to train, and the acceptability of exercise recovery interventions.
Aims:
• To understand the knowledge and
attitudes to recovery from
resistance exercise in older adults at
risk of sarcopenia
• To explore how muscle soreness
may affect participation in
subsequent exercise bouts
Results:
1. 93 % of respondents said they would expect muscle soreness in
the days following intense exercise. However, this was often
associated with doing ‘too much’, and was viewed negatively.
2. A general misunderstanding of muscle damage and muscle
soreness was identified in our participants.
3. 152/291 (52 %) of respondents said that they would be discouraged
to at least some extent from completing their usual daily activities if
they were experiencing muscle soreness
4. 195/281 (67 %) of respondents said they would be discouraged
from completing further exercise until their muscle soreness had
subsided.
Conclusion:
• The ageing population may have poor knowledge of the exercise
recovery process. There is a need to educate older adults on the
expected short-term effects of resistance exercise.
• Reassurance that muscle damage and soreness are not due to
incorrect exercise practices, but a normal component of the training
process, may help to support ongoing engagement in resistance
exercise programmes.

Knowledge and Attitudes to Recovery from Resistance Exercise in Older Adults at Risk of Sarcopenia

Background: 
The Muscle Ageing and Sarcopenia Studies Lifecourse (MASS_Lifecourse)
project aims to establish a life course cohort a cohort of adults aged 45-85 to
investigate age-related changes in skeletal muscle.
Study participation consists of a home-based health and lifestyle assessment and
a clinic visit involving a range of physical measures and muscle biopsy.
In 2020, restrictions imposed in response to the coronavirus pandemic meant that
home-based assessments were impractical or a barrier to participation and
alternative data collection approaches were needed. As such, the
MASS_Lifecourse study began to explore the feasibility of completing health and
lifestyle assessments with participants virtually.
Method: 
Participants
After responding to a written invitation from their GP,
prospective participants (aged 45-85) were contacted to
confirm their eligibility for the study. Following this,
participants were asked if they were willing to
complete the home-based assessment virtually using Zoom
or Microsoft Teams.
A convenient time was arranged with participants who were emailed a link to the
virtual meeting in advance. Participants were briefed via telephone about how to
join the virtual meeting and advised to find a quiet, comfortable space. Prompts for
multiple choice questions were shown on the screen using Microsoft PowerPoint
via screen sharing.
Health and Lifestyle assessment
After providing informed consent, participants completed a detailed health and
lifestyle profile which included demographic and clinical history, medications, comorbidities, brief questionnaire assessments of sarcopenia, frailty, functional
impairment, quality of life, disability, lifestyle (physical activity, diet, smoking,
alcohol), social support and use of health care.
Assessment of feasibility and acceptability
Upon completion of the virtual assessment participants were asked “How did you
find this assessment?” and were prompted to provide any further thoughts and
feedback on using a video-conferencing system for research data collection.
Approval for the MASS_Lifecourse study was received from the North East - Tyne
& Wear South Research Ethics Committee.
Results:
Feasibility and acceptability
All participants (n = 6; age 53-75 years) who were asked to complete a virtual
assessment agreed (5 x Zoom; 1 x Microsoft Teams). Assessment duration
ranged from 39-62 minutes which was similar to previous home-based
assessments in the study.
Virtual assessments were acceptable to participants who were positive about their
experiences.
“Happy to do via Zoom” PID84
“Haven’t used Zoom before but has worked well” PID82
“Has worked fine via Zoom” PID81
Participant feedback
Participants found the video-conferencing system easy to use and indicated that
they felt comfortable engaging in the study from home.
“It was fine; it's been nice to do it from home; in front of
the fire, nice and comfortable” PID83
Some participants suggested that this approach was more convenient for them
compared with a traditional home visit.
“I like the convenience [of data collection via zoom], happy to have the link
emailed and felt that this worked well, felt comfortable being at home and doing
the data collection” PID87
Cognitive assessment
A sub-sample of participants (n = 2) also completed virtual assessments of global
cognition (MoCA and MMSE). This was a feasible and acceptable approach for
conducting this type of assessment in this group.
Conclusion:
Performing virtual assessments was feasible and acceptable to participants in the
MASS_Lifecourse study. These findings should encourage researchers to explore
the potential of virtual data collection.
However, this approach needs to be explored in a wider range of participants,
particularly in those less familiar with relevant technology to fully quantify the
potential of this approach.
It may be possible to achieve time savings (reduced travel to home visits) by
performing data collection virtually where feasible.

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