Sarcopenia

Background

Sarcopenia, defined as age-related loss of muscle function and strength, has a reported prevalence of up to 40.4% in the older adult. Despite its association with frailty, disability and mortality, it is underdiagnosed among hospitalized older patients. Exercise interventions have also been shown to improve fall risk scores for sarcopenic patients.

Objective

A QI initiative was started by a team comprising doctors and physiotherapists. Our aim was to enhance detection of possible sarcopenia and reduce time to delivery of targeted physiotherapy interventions to 1 working day from admission in patients aged 65 admitted to our ward. Interventions were grouped into three main categories – strength training, balance and gait stability training. A pilot study of 12 patients showed that no sarcopenia assessments were carried out and mean time to PT review was 2.16 days from admission, with an average of 1.08 interventions performed per patient.

Methodology

Fishbone analysis and Pareto chart were conducted to identify and prioritise factors behind low screening rates of sarcopenia, before driver diagram was performed to develop solutions. Our team established that education of junior doctors on sarcopenia and implementation of SARC-CAIF screening were the most appropriate interventions to achieve our objective.

Results

A total of 26 patients were identified, with an average age of 76.7 [6.7] years old. The mean SARC-F and SARC-CaIF scores were 4.51 [3.5] and 14.6 [2.4] respectively. 50% (13/26) of patients were admitted for falls. After implementation of SARC-CaIF screening, mean time to PT review was shortened to 1.38 days from admission, with an increase in PT interventions to 2.23 per patient.

Discussion and Conclusions

The prevalence of possible sarcopenia is high inpatient. More can be done to enhance its detection among frail hospitalized older patients, so as to deliver targeted physiotherapy interventions. Doctor education and SARC-CaIF screen are simple and practical tools that can be utilised.

Introduction

The SARC-F questionnaire can be rapidly implemented by clinicians to identify patients with probable sarcopenia. A score ≥4 is predictive of sarcopenia and poor outcome. We sought to identify the prevalence and demographic correlates of probable sarcopenia (SARC-F score ≥4) in community-dwelling older adults.

Methods

480 participants (219 men, 261 women) identified from Primary Care completed a questionnaire ascertaining demographic, lifestyle factors, comorbidities, nutrition risk score (DETERMINE) and SARC-F score. Participant characteristics in relation to probable sarcopenia were examined using sex-stratified logistic regression. Age was included as a covariate.

Results

The median (lower quartile, upper quartile) age was 79.8 (76.9, 83.5) years. 12.8% of men and 23% of women had probable sarcopenia. Self-reported walking speed strongly associated with probable sarcopenia (men: odds ratio (OR) 10.39 (95% CI: 4.55, 23.72), p<0.001; women: 11.42 (5.98, 21.80), p<0.001 per lower band). Older age was associated with probable sarcopenia in both sexes (p=0.01) as was higher DETERMINE score (men: 1.30 (1.12, 1.51), p=0.001; women: 1.32 (1.17, 1.50), p<0.001 per unit increase). Among men, being married or in a civil partnership or cohabiting was protective against probable sarcopenia (0.39 (0.17, 0.89), p=0.03) as was reporting drinking any alcohol (0.34 (0.13, 0.92), p=0.03) while in women generally similar relationships were seen though these were weaker. Higher BMI (1.14 (1.07, 1.22), p<0.001 per unit increase) and presence of comorbidities (1.61 (1.34, 1.94), p<0.001 per extra medical condition) were also associated with probable sarcopenia in women. All associations were robust after adjustment for age.

Conclusions

Probable sarcopenia (SARC-F score ≥4) was common in older adults living in their own homes. As expected, self-reported walking speed was highly predictive of probable sarcopenia. In addition to advancing age and malnutrition, socio-demographic factors were also important. Identifying these factors in clinical practice should trigger sarcopenia screening in older adults.

Introduction: Sarcopenia is common in hospitalised older people and is associated with unfavourable health consequences. Identification of sarcopenia risk with the offer of resistance exercise are key to improving outcomes and recommended in clinical practice guidelines.

Previously, there was no sarcopenia testing on Older People’s Medicine (OPM) wards highlighting a need for local improvement. This project seeks to translate and implement best practice to determine the possibility for physiotherapy staff working in OPM to offer a sarcopenia intervention as part of discharge planning. Improving sarcopenia care can help an ageing population maintain health and independence.

Project aim: Within 3 months, to achieve a 50% increase in the number of patients offered sarcopenia assessment.

Methods: Using the ‘Plan-Do-Study-Act’ approach, a sarcopenia assessment and therapy intervention was developed and introduced as part of the discharge process on an OPM ward. Measures: The weekly number of patients with a documented offer for sarcopenia assessment was collected over 13 weeks and evaluated on a run chart. Cohort data were also recorded and described using descriptive statistics.

Results: At baseline, 0 patients were offered sarcopenia assessment, this improved to 59/87 (68%). The mean age was 82 years (range 66-97) and 53 (90%) consented to be tested for sarcopenia; grip strength was measured in 51 (96%) and standardised 5*sit-to-stand in 5 (9%), with the latter typically not measured without upper limb support. There was a high prevalence of probable sarcopenia, (49 [92%]); 47 (96%) of those engaged with the exercise plan offered.

Conclusions: Physiotherapy staff can identify sarcopenia and offer therapy, as part of discharge planning of older people from hospital. Resources are necessary for sustainable and scalable application. Implementation could help older people to recondition after hospitalisation and improve clinical outcomes, benefiting patients and the healthcare system.

Introduction:  Preoperative frailty is a key determinant of post-surgical outcomes and often co-exists with sarcopenia and malnutrition. Older patients account for a significant proportion of patients undergoing surgery for colorectal cancer and are therefore more likely to be affected by these risk factors.      

Methods:  Patients aged 65 and over undergoing planned surgery for colorectal cancer were recruited across five sites. Participants were screened preoperatively using the Clinical Frailty Scale (CFS) and Groningen Frailty Indicator (GFI). Nutritional status was assessed using the short form mini nutritional assessment (MNA-SF) and participant collection of spot urine samples to objectively measure habitual dietary intake. Sarcopenia was assessed through grip strength, gait speed and psoas muscle measurement using preoperative CT imaging. The non-radiological screening measures were repeated eight-weeks postoperatively, with additional urine samples collected in the first and fourth weeks.      

Results:  Forty-three participants (mean age 76 years, 60 % male) were recruited, of which 32% were frail. Using the mini-nutritional assessment 42 % of participants were identified as at risk of malnutrition and 9 % as malnourished. Urine assessment of habitual dietary intake is ongoing. There was a high prevalence of sarcopenia - 67 % determined by hand grip strength and 42% by CT analysis. Mean length of stay following surgery was 6.9 days. 28 % of participants were unable to complete the in-person post-operative follow up due to ill health, poor appetite and exhaustion.      

Conclusions:  This ongoing study has demonstrated the feasibility of incorporating frailty, nutritional status and sarcopenia screening alongside routine clinical care, in older adults undergoing surgery. However, retaining participants in observational studies during postoperative periods of convalescence, or whilst undergoing adjuvant treatment, is challenging. This study has also highlighted the potential of home urine sampling as a viable method of dietary assessment within community settings to aid malnutrition screening.     

Background

Patients living with Parkinson's disease (PD) who are sarcopenic are at significantly higher risk of falling (Cai et al., Frontiers in Neurology,2021,12,598035). Handgrip strength is a useful tool to assess for sarcopenia but is not commonly measured in clinical practice, despite the consequences that sarcopenia poses. This study aims to incorporate handgrip strength into the assessment of outpatients living with PD. Secondary objectives are to increase the understanding of whether exercise is associated with increased handgrip strength and to implement interventions for patients who are identified as sarcopenic; to improve their health outcomes.

Methods

Questionnaires were designed to gather quantitative data about patients' demographics, how frequently they fall, disease severity and their weekly exercise. These were given to patients attending the movement disorders clinic at Crawley hospital, between February and October 2023. Patients without a diagnosis of PD were excluded. Their grip strength was measured using a standardised technique with a calibrated manometer. Data was input to Microsoft Excel and analysed using Spearman's rank and Kruskal-Wallis test.

Results

Handgrip strength was obtained for 125 of 271 patients (46%) attending clinic over this period. Initially healthcare workers took 9.2 minutes to complete the questionnaire but this improved to 4.3 minutes after updating the form. Sixteen patients were excluded, leaving 51 females and 58 males; both with a mean age of 80. Grip strength reduced with PD severity when adjusted for gender; this was significant in males (H=51.9, p=0.00) but not females (H=4.8,p=0.31). Grip strength was weakly correlated with exercise, although not significant (r2=0.15,p=0.15) but did not appear to be related to frequency of falls (r2=0.01,p=0.92).

Conclusions

Handgrip measurement can be successfully implemented into outpatient assessment. Handgrip strength could be used to monitor the effect of lifestyle change in individuals. Limitations include self-reporting bias; which activities each individual classifies as exercise.

Introduction

Weight loss is common during acute hospital admissions, and can be devastating to the older patient where weight loss is associated with an increase in mortality over a 12 month period. Patients who lack the ability to communicate their food preferences are at risk of receiving food they do not like, especially as food orders are often taken when family/carers are not present.

Methods

While working on a Department of Medicine for Older People and Stroke (DMOPS) ward, we worked with the Multidisciplinary team (MDT) with the aim of reducing weight loss. We implemented two interventions. The first being ‘MUST Mondays’, where patients were weighed and had a Malnutrition universal screening tool (MUST) completed on admission to the ward, and then weekly. We also implemented A3 Laminated menus - where patients and their families/carers were given food choices for the week in advance, and could use a marker to identify foods they did/did not like. These were then displayed above the bedspace. All patients were over the age of 65. We excluded patients who were actively dying, patients who were aiming for weight loss (Such as in fluid overload) and patients who were admitted for fewer than 8 days.

Results

Prior to putting the interventions in place, we audited 23 patients admitted over a 3 month period. 70% of patients lost weight over the course of their admission, and 48% had MUST assessments completed weekly. We re-audited 5 months after the interventions were implemented, we audited 20 patients over a 5 month period and found 55% lost weight over the course of their admission, and 80% had weekly MUST assessments.

Conclusion

Working as an MDT to put in place small interventions can have a meaningful impact on reducing weight loss in older patients during acute hospital admission.

Background

Dietary nitrate (inorganic nitrate) supplementation has been proposed as an intervention to improve muscle function via increased nitric oxide (NO) availability. Although some studies show benefit in younger adults, the effectsin older people are unclear. This systematic review evaluated the effects of dietary nitrate supplementation on physical performance and muscle strength measures in older people.

Method

The review was conducted according to a prespecified protocol by two reviewers. We included interventional studies using dietary nitrate supplementation, mean participant age 60 and over, with or without sarcopenia or impaired physical performance. Outcomes of interest were physical performance and measures of muscle strength and mass. Risk of bias was assessed using a structured tool. Results were grouped by intervention and outcome measures and were described by narrative synthesis.

Results

Our search strategy found 1174 titles; 25 studies were included in the review. Study size ranged from 8 to 72 participants. Data on baseline functional status were not available, but 7 studies were in healthy older adults. The intervention duration ranged from a single dose to twelve weeks. Most studies had high or unclear risk of bias; three had low risk of bias. One hundred and nineteen outcomes were reported; 62 were physical performance measures and 57 were muscle strength measures. Twenty-nine outcomes showed significant improvement, two showed significant worsening and 88 showed no statistically significant difference. Results that showed significant improvement did not group together under any particular outcome measure, supplementation product or duration. Meta-analysis was not possible due to heterogeneity of populations, intervention duration and outcome measures.

Conclusion

Current evidence suggests that increasing intake of dietary nitrates may be beneficial for physical performance and muscle strength in older people, however data are limited. Future studies should be longer, larger and target older people with sarcopenia or impaired physical performance.