Development of a UK core dataset for geriatric medicine research: a position statement and results from a Delphi consensus process.

BACKGROUND: There is lack of standardisation in assessment tools used in geriatric medicine research, which makes pooling of data and cross-study comparisons difficult. METHODS: We conducted a modified Delphi process to establish measures to be included within core and extended datasets for geriatric medicine research in the United Kingdom (UK). This included three complete questionnaire rounds, and one consensus meeting. Participants were selected from attendance at the NIHR Newcastle Biomedical Research Centre meeting, May 2019, and academic geriatric medicine e-mailing lists. Literature review was used to develop the initial questionnaire, with all responses then included in the second questionnaire. The third questionnaire used refined options from the second questionnaire with response ranking. RESULTS: Ninety-eight responses were obtained across all questionnaire rounds (Initial: 19, Second: 21, Third: 58) from experienced and early career researchers in geriatric medicine. The initial questionnaire included 18 questions with short text responses, including one question for responders to suggest additional items. Twenty-six questions were included in the second questionnaire, with 108 within category options. The third questionnaire included three ranking, seven final agreement, and four binary option questions. Results were discussed at the consensus meeting. In our position statement, the final consensus dataset includes six core domains: demographics (age, gender, ethnicity, socioeconomic status), specified morbidities, functional ability (Barthel and/or Nottingham Extended Activities of Daily Living), Clinical Frailty Scale (CFS), cognition, and patient-reported outcome measures (dependent on research question). We also propose how additional variables should be measured within an extended dataset. CONCLUSIONS: Our core and extended datasets represent current consensus opinion of academic geriatric medicine clinicians across the UK. We consider the development and further use of these datasets will strengthen collaboration between researchers and academic institutions.

Investigating the impact of fluid status on the ultrasound assessment of muscle quantity and quality in the diagnosis of sarcopenia - a multidimensional cross-sectional study.

BACKGROUND: Sarcopenia is a clinical manifestation of adverse ageing, characterised by progressive loss of muscle mass and function. Diagnosis requires assessment of muscle quantity and quality; ultrasound represents an emerging tool for this. However, ultrasound muscle assessment may be impacted by fluid balance. This is particularly important when assessing for acute sarcopenia in hospitalised patients, where fluid disturbance often occurs. The primary aim of this study was to characterise the impact of fluid status on ultrasound muscle assessment, such that this may be accounted for in sarcopenia diagnostics. METHODS: This Multidimensional Cross-sectional study involved 80 participants, who were inpatients at QEHB, a large UK tertiary centre. Fluid status was evaluated clinically and quantified using Bioelectrical Impedance Analysis (BIA). Muscle quantity was measured using Bilateral Anterior Thigh Thickness (BATT) with Rectus Femoris (RF) echogenicity used to assesses muscle adiposity and hence provide an inverse measure of muscle quality. RESULTS: A significant positive correlation was found between fluid status, measured using BIA, and BATT as a measure of muscle quantity, in males (rs = 0.662, p < 0.001) and females (rs = 0.638, p < 0.001). A significant negative correlation was found between fluid status and RF echogenicity (rs=-0.448, p < 0.001). CONCLUSIONS: These findings demonstrate associations between fluid balance and ultrasound assessment of muscle quantity and quality. Given the emerging use of ultrasound muscle assessment in sarcopenia diagnosis, there is a need to account for this in clinical practice. Future research should focus on the development of a corrective equation allowing assessment of muscle quantity and quality which account for changes in fluid status, hence aiding accurate diagnosis of sarcopenia.

Age and frailty are independently associated with increased COVID-19 mortality and increased care needs in survivors: results of an international multi-centre study.

INTRODUCTION: Increased mortality has been demonstrated in older adults with coronavirus disease 2019 (COVID-19), but the effect of frailty has been unclear. METHODS: This multi-centre cohort study involved patients aged 18 years and older hospitalised with COVID-19, using routinely collected data. We used Cox regression analysis to assess the impact of age, frailty and delirium on the risk of inpatient mortality, adjusting for sex, illness severity, inflammation and co-morbidities. We used ordinal logistic regression analysis to assess the impact of age, Clinical Frailty Scale (CFS) and delirium on risk of increased care requirements on discharge, adjusting for the same variables. RESULTS: Data from 5,711 patients from 55 hospitals in 12 countries were included (median age 74, interquartile range [IQR] 54-83; 55.2% male). The risk of death increased independently with increasing age (>80 versus 18-49: hazard ratio [HR] 3.57, confidence interval [CI] 2.54-5.02), frailty (CFS 8 versus 1-3: HR 3.03, CI 2.29-4.00) inflammation, renal disease, cardiovascular disease and cancer, but not delirium. Age, frailty (CFS 7 versus 1-3: odds ratio 7.00, CI 5.27-9.32), delirium, dementia and mental health diagnoses were all associated with increased risk of higher care needs on discharge. The likelihood of adverse outcomes increased across all grades of CFS from 4 to 9. CONCLUSION: Age and frailty are independently associated with adverse outcomes in COVID-19. Risk of increased care needs was also increased in survivors of COVID-19 with frailty or older age.

Interventions to ameliorate reductions in muscle quantity and function in hospitalised older adults: a systematic review towards acute sarcopenia treatment.

OBJECTIVE: Assimilate evidence for interventions to ameliorate negative changes in physical performance, muscle strength and muscle quantity in hospitalised older adults. METHODS: We searched for articles using MEDLINE, Embase, CINAHL and Cochrane library using terms for randomised controlled trials, older adults, hospitalisation and change in muscle quantity, strength or physical performance. Two independent reviewers extracted data and assessed risk of bias. We calculated standardised mean differences for changes in muscle function/quantity pre- and post-intervention. RESULTS: We identified 9,805 articles; 9,614 were excluded on title/abstract; 147 full texts were excluded. We included 44 studies including 4,522 participants; mean age 79.1. Twenty-seven studies (n = 3,417) involved physical activity interventions; a variety were trialled. Eleven studies involved nutritional interventions (n = 676). One trial involved testosterone (n = 39), two involved Growth Hormone (n = 53), one involved nandrolone (n = 29), and another involved erythropoietin (n = 141). Three studies (n = 206) tested Neuromuscular Electrical Stimulation. Evidence for effectiveness/efficacy was limited. Strongest evidence was for multi-component physical activity interventions. However, all studies exhibited at least some concerns for overall risk of bias, and considering inconsistencies of effect sizes across studies, certainty around true effect sizes is limited. CONCLUSION: There is currently insufficient evidence for effective interventions to ameliorate changes in muscle function/quantity in hospitalised older adults. Multiple interventions have been safely trialled in heterogeneous populations across different settings. Treatment may need to be stratified to individual need. Larger scale studies testing combinations of interventions are warranted. Research aimed at understanding pathophysiology of acute sarcopenia will enable careful risk stratification and targeted interventions.

Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults.

BACKGROUND: Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, comorbid adults. Awareness of atypical presentations is critical to facilitate early identification. OBJECTIVE: To assess how frailty affects presenting COVID-19 symptoms in older adults. DESIGN: Observational cohort study of hospitalised older patients and self-report data for community-based older adults. SETTING: Admissions to St Thomas' Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application. SUBJECTS: Hospital cohort: patients aged 65 and over (n = 322); unscheduled hospital admission between 1 March 2020 and 5 May 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n = 535); reported test-positive for COVID-19 from 24 March (application launch) to 8 May 2020. METHODS: Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19. RESULTS: Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults and fatigue and shortness of breath. CONCLUSIONS: This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium.

Muscle quantity and function measurements are acceptable to older adults during and post- hospitalisation: results of a questionnaire-based study.

BACKGROUND: To evaluate the acceptability of handgrip strength, gait speed, quadriceps ultrasound, and Bioelectrical Impedance Analysis (BIA) to older adults conducted during and following hospitalisation. METHODS: Questionnaire-based study conducted upon completion of prospective cohort study, with follow-up in either Queen Elizabeth Hospital Birmingham (QEHB), UK, or participant's own home following recent admission to QEHB. Outcome measures were acceptability as defined by total multi-domain score for each test (maximum score 35), and by frailty status. RESULTS: Forty adults aged 70 years and older admitted for emergency abdominal surgery, elective colorectal surgery, or acute bacterial infections (general medicine) participated. Handgrip strength (median 33, IQR 30-35; p = 0.001), gait speed (median 32, IQR 30-35; p = 0.002), ultrasound quadriceps (median 33, IQR 31-35; p = 0.001), and BIA (median 33.5, IQR 31-35; p = 0.001) were considered highly acceptable. Participants responded positively that they enjoyed participating in these tests, and considered these tests of importance. There was no difference in scores between tests (p = 0.166). Individual total test scores did not differ between patients with and without frailty. Qualitative data are also presented on drivers for research participation. CONCLUSIONS: Handgrip strength, gait speed, ultrasound quadriceps, and BIA are acceptable tests to older adults during and following hospitalisation. Our results may serve as standards when evaluating acceptability of other tests. TRIAL REGISTRATION: Prospectively registered February 2019: https://clinicaltrials.gov/ct2/show/NCT03858192.

Growing research in geriatric medicine: a trainee perspective.

Growing research in geriatric medicine is a priority area. Currently, involvement of geriatricians in research lags behind other specialties. The reasons for this are multifactorial, but a lack of training infrastructure within geriatric medicine higher specialist training is contributory. This is widespread across European countries and internationally. The Geriatric Medicine Research Collaborative (GeMRC) offers an opportunity to engage trainees in research, regardless of their previous individual research experiences. Utilising national trainee networks, GeMRC is able to conduct large-scale projects within short periods of time that can have real impact upon patient care. We consider that embedding GeMRC within higher specialist training with formal college support will assist to upskill trainee geriatricians in research methodology. Collaboratives are internationally recognised across disciplines. Expansion across European and international countries offers the opportunity for international collaboration in geriatric medicine. International trainee-led networks will enable the conduct of large-scale global projects in geriatric medicine.

Protocol for understanding acute sarcopenia: a cohort study to characterise changes in muscle quantity and physical function in older adults following hospitalisation.

BACKGROUND: Older adults are vulnerable to the effects of acute sarcopenia (acute muscle insufficiency) following hospitalisation. However, this condition remains poorly characterised to date. It is hypothesised that acute sarcopenia arises due to a combination of bed rest and inflammatory surge. This study aims to characterise changes in muscle quantity and function, determining which factors (clinical and biological) are most predictive, and how these relate to change in physical function at 13 weeks. METHODS: This study will include three groups of patients aged 70 years and older; patients undergoing elective colorectal surgery, patients admitted for emergency abdominal surgery, and patients admitted under general medicine with acute bacterial infections. Changes in muscle quantity (Bilateral Anterior Thigh Thickness with ultrasound and bioelectrical impedance analysis) and muscle function (muscle strength, physical performance) within 1 week of hospitalisation or surgery will be characterised, with follow-up of patients at 13 weeks. Physical function will be measured using the Patient Reported Outcome Measures Information System, and the Short Physical Performance Battery (or gait speed alone within 1 week of surgery). DISCUSSION: This study will fully characterise changes in muscle quantity and function in hospitalised older adults and enable risk stratification towards targeted interventions in clinical practice. The results of this study will inform further research involving interventions to ameliorate changes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03858192 ; Prospectively registered 28th February 2019.

Geriatric medicine and old age psychiatry joint training pre-feasibility pilot study: an innovative approach to collaborative postgraduate training.

BACKGROUND: Physical and psychological health problems are prevalent in older adults and rarely exist in isolation. Treating these problems in isolation is resourceful and can be potentially harmful to patients due to delays in diagnosis and treatment and incomplete holistic care plans. Historically, trainees in geriatric medicine and old age psychiatry within the United Kingdom have completed very different training programmes. METHODS: We undertook a pre-feasibility pilot study of collaborative postgraduate training between trainees in geriatric medicine and old age psychiatry within the West Midlands training region, United Kingdom. Trainees in each specialty were paired with each other and advised to arrange appropriate training opportunities for their counterpart; these included shadowing each other in their workplace and arranging opportunities to attend training opportunities with their consultants. Pre- and post-pilot surveys were completed by all trainees and reflections from trainees were collated. RESULTS: Five trainee pairs were formed and arranged shadowing and training opportunities between October 2017 and May 2018. This included a combination of inpatient, outpatient, and community work. For both specialties, trainees' confidence in topics relating to their counterparts' specialty increased between the pre- and post-pilot surveys. Recurrent themes included within reflections included the benefits of collaborative training. CONCLUSIONS: Our pilot has demonstrated that it is feasible to implement a programme of joint training into postgraduate medical training, and that this can have a positive impact upon the confidence of both specialties. An extended pilot is planned for the training year 2018-2019.

Obstacles to the Early Diagnosis and Management of Sarcopenia: Current Perspectives.

Research in sarcopenia has grown exponentially over the last 15 years in geriatrics and gerontology, as well as other specialties, including oncology and hepatology. There is now strong evidence for the role of resistance exercise to prevent declines in muscle strength and function, especially when combined with nutritional optimization with protein supplementation. However, there remains a disparity between research evidence and clinical practice. There are multiple factors for this, which relate to the current diagnostic criteria for sarcopenia, practical and logistical aspects of diagnosis of sarcopenia, clinician knowledge of both diagnosis and management, and the availability of pathways for interventions. Sarcopenia is currently defined based on the identification of muscle strength, in combination with muscle size or quality, below cut-off thresholds at a single timepoint. This defines sarcopenia as a binary process of either present or not present, thus early diagnosis can be challenging. In this article, we summarize current obstacles to early diagnosis and management of sarcopenia in clinical practice, and make recommendations to how these might be overcome. This includes our recommendation of incorporation of handgrip strength measurement into standard care, to enable dynamic assessment and identification of early declines in handgrip strength, so that interventions can be implemented to prevent disability.

Establishing Predictors of Acute Sarcopenia: A Proof-Of-Concept Study Utilising Network Analysis.

Dynamic changes in sarcopenia status following stressor events are defined as acute sarcopenia; it is currently unknown how to stratify risk. Prospective observational study involving elective colorectal surgery, emergency abdominal surgery, and medical patients with infections aged ≥70 years-old. Handgrip strength, muscle quantity (ultrasound Bilateral Anterior Thigh Thickness, BATT, and Bioelectrical Impedance Analysis), and muscle quality (rectus femoris echogenicity) were measured preoperatively in the elective group, and within 48hours, 7days after, and 13weeks after admission/surgery. Serum/plasma samples were collected preoperatively (elective group) and within 48hours of admission/surgery (all groups). LASSO models adjusting for baseline sarcopenia status were performed. Seventy-nine participants were included (mean age 79.1, 39.2% female). Chronic Obstructive Pulmonary Disease (COPD) (48hours ß 0.67, CI 0.59-0.75), and prescription of steroids during admission (48hours ß 1.11, CI 0.98-1.24) were positively associated with sarcopenia at 7days. Delirium was negatively associated with change in BATT to 7days (7days ß -0.47, CI -0.5- -0.44). COPD (Preoperative ß 0.35, CI 0.12-0.58) and delirium (48hours ß 0.13, CI 0.06-0.2) were positively associated with change in echogenicity to 7days in analysis including systemic biomarkers. Participants with sarcopenia at baseline had higher IL-7 concentrations during acute phase of illness (median 8.78pg/mL vs 6.52pg/mL; p=0.014). IL-1b within 48hours of admission/surgery was positively associated with sarcopenia status at 7days (ß 0.24, CI 0.06-0.42). Patients most at risk of acute sarcopenia or reductions in muscle quantity and quality included those prescribed steroids, with COPD or delirium, or with heightened systemic inflammation.

Baseline Nutritional Status and In-Hospital Step Count are Associated with Muscle Quantity, Quality, and Function: Results of an Exploratory Study.

This exploratory study aimed to assess associations of baseline nutritional status and in-hospital step count with muscle quantity, quality, and function. Seventy-nine participants aged ≥70 years (mean age 79.1 years, 44.3% female) were recruited (elective colorectal surgery, emergency abdominal surgery, and general medical patients with infections). Baseline nutrition (Mini Nutritional Assessment) and in-hospital step count (Fitbit Inspire devices) were assessed. Ultrasound quadriceps, bioelectrical impedance analysis, and physical function were assessed at baseline and 7 (±2) days and 13 (±1) weeks post-admission/post-operatively. Baseline nutritional status was associated with baseline rectus femoris ultrasound echogenicity (normal: 58.5, at risk: 68.5, malnourished: 81.2; p = 0.025), bilateral anterior thigh thickness (normal: 5.07 cm, at risk: 4.03 cm, malnourished: 3.05 cm; p = 0.021), and skeletal muscle mass (Sergi equation) (normal: 21.6 kg, at risk: 18.2 kg, malnourished: 12.0 kg; p = 0.007). Step count was associated with baseline patient-reported physical function (<900 37.1, ≥900 44.5; p = 0.010). There was a significant interaction between nutrition, step count, and time for skeletal muscle mass (Janssen equation) (p = 0.022).

Prevalence of physical frailty, including risk factors, up to 1 year after hospitalisation for COVID-19 in the UK: a multicentre, longitudinal cohort study.

Background: The scale of COVID-19 and its well documented long-term sequelae support a need to understand long-term outcomes including frailty. Methods: This prospective cohort study recruited adults who had survived hospitalisation with clinically diagnosed COVID-19 across 35 sites in the UK (PHOSP-COVID). The burden of frailty was objectively measured using Fried's Frailty Phenotype (FFP). The primary outcome was the prevalence of each FFP group-robust (no FFP criteria), pre-frail (one or two FFP criteria) and frail (three or more FFP criteria)-at 5 months and 1 year after discharge from hospital. For inclusion in the primary analysis, participants required complete outcome data for three of the five FFP criteria. Longitudinal changes across frailty domains are reported at 5 months and 1 year post-hospitalisation, along with risk factors for frailty status. Patient-perceived recovery and health-related quality of life (HRQoL) were retrospectively rated for pre-COVID-19 and prospectively rated at the 5 month and 1 year visits. This study is registered with ISRCTN, number ISRCTN10980107. Findings: Between March 5, 2020, and March 31, 2021, 2419 participants were enrolled with FFP data. Mean age was 57.9 (SD 12.6) years, 933 (38.6%) were female, and 429 (17.7%) had received invasive mechanical ventilation. 1785 had measures at both timepoints, of which 240 (13.4%), 1138 (63.8%) and 407 (22.8%) were frail, pre-frail and robust, respectively, at 5 months compared with 123 (6.9%), 1046 (58.6%) and 616 (34.5%) at 1 year. Factors associated with pre-frailty or frailty were invasive mechanical ventilation, older age, female sex, and greater social deprivation. Frail participants had a larger reduction in HRQoL compared with before their COVID-19 illness and were less likely to describe themselves as recovered. Interpretation: Physical frailty and pre-frailty are common following hospitalisation with COVID-19. Improvement in frailty was seen between 5 and 12 months although two-thirds of the population remained pre-frail or frail. This suggests comprehensive assessment and interventions targeting pre-frailty and frailty beyond the initial illness are required. Funding: UK Research and Innovation and National Institute for Health Research.

Outcomes in adults living with frailty receiving cardiopulmonary resuscitation: A systematic review and meta-analysis.

Background: Frailty is a clinical expression of adverse ageing which could be a valuable predictor of outcomes from cardiac arrest. The aim of this systematic review was to evaluate survival outcomes in adults living with frailty versus adults living without frailty receiving cardiopulmonary resuscitation (CPR) following cardiac arrest. Methods: A comprehensive search of MEDLINE, EMBASE, CINAHL, and Web of Science databases was performed using pre-defined search terms, with no date or language restrictions applied. Prospective and retrospective observational studies measuring outcomes from CPR in adults assessed for frailty using an accepted clinical definition were selected. Results: Eight eligible studies were included. Seven retrospective observational studies presenting high methodological quality were included in a meta-analysis comprising 1704 participants. Frailty was strongly associated with an increased likelihood of mortality after CPR, with moderate inter-study heterogeneity (OR = 3.56, 95% CI = 2.74-4.63, I2 = 71%). Discussion: This review supports the consideration of frailty status in a holistic approach to CPR. The present findings suggest that frailty status provides valuable prognostic information and could complement other known pre-arrest prognostic factors such as comorbidities in the context of Do Not Attempt CPR consideration. Awareness of the poorer outcomes in those living with frailty could support the identification of individuals less likely to benefit from CPR. Validation of our findings and evaluation of quality-of-life in frail individuals surviving cardiac arrest are prerequisites for the future integration of frailty status into CPR clinical decision-making. Registration: Prospectively registered on PROSPERO: CRD42020223670.

The feasibility of conducting acute sarcopenia research in hospitalised older patients: a prospective cohort study.

PURPOSE: To assess feasibility of conducting acute sarcopenia research in complex populations of hospitalised older adults. METHODS: Patients ≥ 70 years old were recruited to three cohorts: elective colorectal surgery, emergency (abdominal) surgery, medical patients with infections. Participants were recruited to the elective cohort in preoperative assessment clinic, and acutely admitted participants from surgical and medical wards at the Queen Elizabeth Hospital Birmingham. Serial measures of muscle quantity (ultrasound quadriceps, bioelectrical impedance analysis), muscle function (hand grip strength, physical performance), and questionnaires (mini-nutritional assessment, physical function) were performed at baseline, within 7 (± 2) days of admission/surgery, and 13 (± 1) weeks post-admission/surgery. Feasibility outcomes were assessed across timepoints including recruitment and drop-out rates, and procedure completion rates. RESULTS: Eighty-one participants were recruited (mean age 79, 38.3% females). Recruitment rates were higher in elective (75%, 24/32) compared to emergency surgery (37.2%, 16/43), and medical participants (45.1%, 41/91; p = 0.003). Drop-out rates varied from 8.3 to 19.5% at 7 days, and 12.5-43.9% at 13 weeks. Age and gender did not differ between patients assessed for eligibility, approached, or recruited. Completion rates were highest for ultrasound quadriceps (98.8%, 80/81 across all groups at baseline). Gait speed completion rates were lower in medical (70.7%, 29/41) compared to elective participants (100%, 24/24) at baseline. CONCLUSION: Higher participation refusal and drop-out rates should be expected for research involving recruitment of participants from the acute setting. Assessment of muscle quantity/quality through ultrasound is recommended in early-stage trials in the acute setting, where completion rates of physical performance testing are expected to be lower.

Induced frailty and acute sarcopenia are overlapping consequences of hospitalisation in older adults.

Objectives: To determine the effects of hospitalisation upon frailty and sarcopenia. Methods: Prospective cohort study at single UK hospital including adults ≥70 years-old admitted for elective colorectal surgery, emergency abdominal surgery, or acute infections. Serial assessments for frailty (Fried, Frailty Index, Clinical Frailty Scale [CFS]), and sarcopenia (handgrip strength, ultrasound quadriceps and/or bioelectrical impedance analysis, and gait speed and/or Short Physical Performance Battery) were conducted at baseline, 7 days post-admission/post-operatively, and 13 weeks post-admission/post-operatively. Results: Eighty participants were included (mean age 79.2, 38.8% females). Frailty prevalence by all criteria at baseline was higher among medical compared to surgical participants. Median and estimated marginal CFS values and Fried frailty prevalence increased after 7 days, with rates returning towards baseline at 13 weeks. Sarcopenia incidence amongst those who did not have sarcopenia at baseline was 20.0%. However, some participants demonstrated improvements in sarcopenia status, and overall sarcopenia prevalence did not change. There was significant overlap between diagnoses with 37.3% meeting criteria for all four diagnoses at 7 days. Conclusions: Induced frailty and acute sarcopenia are overlapping conditions affecting older adults during hospitalisation. Rates of frailty returned towards baseline at 13 weeks, suggesting that induced frailty is reversible.

Trajectories of muscle quantity, quality and function measurements in hospitalized older adults.

AIM: Acute sarcopenia is defined by the development of incident sarcopenia (low muscle quantity/quality and function) within 6 months of a stressor event. However, outcome measures for clinical trials have not been validated. This study aimed to characterize changes in muscle quantity, quality, strength, and physical function during and after hospitalization. METHODS: Patients aged ≥70 years admitted for elective colorectal surgery, emergency abdominal surgery or acute infections were recruited from a single university hospital. Assessments were carried out at baseline, and within 7 ± 2 days and 13 ± 1 weeks postoperatively or post-admission. RESULTS: A total of 79 participants (mean age 79 years, 39% female) were included. Physical function defined by the Patient-Reported Outcome Measures Information System T-score declined from baseline (42.3, 95% CI 40.2-44.3) to 7 days (36.6, 95% CI 34.5-38.8; P = 0.001), with improvement after 13 weeks (40.5, 95% CI 37.9-43.0). Changes in muscle quantity, quality and function measurements were overall heterogeneous, with few significant changes at the study population level. Change in rectus femoris echogenicity over 13 weeks correlated with changes in handgrip strength (r = 0.53; P < 0.001) and gait speed (r = 0.59; P = 0.003) over the same period. CONCLUSIONS: Patient-Reported Outcome Measures Information System T-score provides a sensitive measure of change in physical function in hospitalized older patients. However, changes in muscle quantity, quality and function measurements were heterogeneous, and not significant at the study population level. Further research should assess for factors that might be predictive of changes within individuals to enable stratified interventions. Geriatr Gerontol Int 2022; 22: 311-318.

Machine learning of COVID-19 clinical data identifies population structures with therapeutic potential.

Clinical outcomes for patients with COVID-19 are heterogeneous and there is interest in defining subgroups for prognostic modeling and development of treatment algorithms. We obtained 28 demographic and laboratory variables in patients admitted to hospital with COVID-19. These comprised a training cohort (n = 6099) and two validation cohorts during the first and second waves of the pandemic (n = 996; n = 1011). Uniform manifold approximation and projection (UMAP) dimension reduction and Gaussian mixture model (GMM) analysis was used to define patient clusters. 29 clusters were defined in the training cohort and associated with markedly different mortality rates, which were predictive within confirmation datasets. Deconvolution of clinical features within clusters identified unexpected relationships between variables. Integration of large datasets using UMAP-assisted clustering can therefore identify patient subgroups with prognostic information and uncovers unexpected interactions between clinical variables. This application of machine learning represents a powerful approach for delineating disease pathogenesis and potential therapeutic interventions.

Development and external validation of prognostic models for COVID-19 to support risk stratification in secondary care.

OBJECTIVES: Existing UK prognostic models for patients admitted to the hospital with COVID-19 are limited by reliance on comorbidities, which are under-recorded in secondary care, and lack of imaging data among the candidate predictors. Our aims were to develop and externally validate novel prognostic models for adverse outcomes (death and intensive therapy unit (ITU) admission) in UK secondary care and externally validate the existing 4C score. DESIGN: Candidate predictors included demographic variables, symptoms, physiological measures, imaging and laboratory tests. Final models used logistic regression with stepwise selection. SETTING: Model development was performed in data from University Hospitals Birmingham (UHB). External validation was performed in the CovidCollab dataset. PARTICIPANTS: Patients with COVID-19 admitted to UHB January-August 2020 were included. MAIN OUTCOME MEASURES: Death and ITU admission within 28 days of admission. RESULTS: 1040 patients with COVID-19 were included in the derivation cohort; 288 (28%) died and 183 (18%) were admitted to ITU within 28 days of admission. Area under the receiver operating characteristic curve (AUROC) for mortality was 0.791 (95% CI 0.761 to 0.822) in UHB and 0.767 (95% CI 0.754 to 0.780) in CovidCollab; AUROC for ITU admission was 0.906 (95% CI 0.883 to 0.929) in UHB and 0.811 (95% CI 0.795 to 0.828) in CovidCollab. Models showed good calibration. Addition of comorbidities to candidate predictors did not improve model performance. AUROC for the International Severe Acute Respiratory and Emerging Infection Consortium 4C score in the UHB dataset was 0.753 (95% CI 0.720 to 0.785). CONCLUSIONS: The novel prognostic models showed good discrimination and calibration in derivation and external validation datasets, and performed at least as well as the existing 4C score using only routinely collected patient information. The models can be integrated into electronic medical records systems to calculate each individual patient's probability of death or ITU admission at the time of hospital admission. Implementation of the models and clinical utility should be evaluated.

Engagement in research during specialist geriatric medicine training: results of a national trainee survey.

INTRODUCTION: Meaningful ageing research across the UK is dependent on a network of engaged geriatricians. The research in geriatric specialty training (RGST) survey aimed to establish current research opportunities available to geriatric medicine specialty trainees in the UK. METHODS: The RGST survey was disseminated to UK higher specialist trainees in geriatric medicine in 2019 via the Geriatric Medicine Research Collaborative network. RESULTS: Among the 36.9% (192/521) of respondents, 44% (83/188) reported previous research involvement and 7% (n=8) held a PhD or MD. Of the respondents with no research experience to date, 59.0% (n=49) reported a desire to undertake a period of research. One-third (31%) of geriatric registrars surveyed felt that they had gained sufficient research experience during their training. Perceived encouragement and support to undertake research was low (30.7%). Enablers and barriers to research engagement were identified. CONCLUSION: Research opportunity and engagement in geriatric medicine training is lacking. This could jeopardise the future workforce of research-active geriatricians in the UK and limit patient access to emerging research and innovation. Interventions to promote research engagement among geriatric medicine trainees are needed to facilitate integration of research into routine clinical practice to improve the health and care of older people.