Recognition and multidisciplinary prevention are the key

Sometimes it’s obvious. You might notice sarcopenia in an elderly patient who is clearly frail.

But other times it’s not so easily picked up. Someone who is overweight may have lost a lot of muscle without it being noticeable, or an athletic person may lose significant muscle mass while recovering from an injury, for example.

Macquarie University Professor Simon Willcock, a GP with a special academic interest in musculoskeletal health, says many at-risk patients are going missed — and the consequences can be significant.

Downstream effects of sarcopenia include loss of balance, weakness and falls. It’s also linked with increased mortality risk from comorbidities including cancer, CVD, lung, liver and renal diseases.

Given all this, it’s clear we need to do more to prevent and manage sarcopenia before it becomes severe, Professor Willcock says.

What are the signs and risk factors?

Sarcopenia is often associated with weight loss, functional deficit, and more frequent trips and falls.

Professor Willcock says we’re all at risk as we age.

“The amount of muscle in your thigh decreases hugely between your 20s and your 70s. In women you lose around 6 kg of muscle and in men it’s around 10 kg, and that’s just the normal aging process, so everybody’s going to be at risk of sarcopenia,” he says.

Extended periods of immobility, such as following surgery, increase sarcopenia further, even in younger patients.

“For three to 10 days of bed rest in elderly patients, you’re going to lose at least a kilo of muscle mass,” Professor Willcock says, “and that’s not necessarily going to come back when they’re up and mobile again.”

Muscle loss after joint replacement surgery is particularly common. Other risk factors include periods of immobility associated with prolonged medical conditions (e.g. heart attacks, severe respiratory infections, inflammatory arthritic conditions etc.), as well as sedentary lifestyle due to long work hours or shift work.

Screening for sarcopenia

“Assessing for sarcopenia requires some sort of measurement of quality and quantity of muscle mass,” Professor Willcock says.

He recommends the SARC-F screening tool which can be used quickly in rooms by the GP or practice nurse. The validated tool assesses self-reported strength, walking, ability to rise from chairs or climb stairs, and number of falls in the past year. A score of 4 or more suggests high risk of sarcopenia.

Professor Willcock recommends adding the SARC-F tool to yearly health assessments in people over 75.

Low muscle mass plus low muscle strength or poor physical performance is diagnostic for sarcopenia. If the patient has all three, it is considered severe.

Those who score highly on the SARC-F should have muscle strength objectively tested to make a diagnosis, Professor Willcock says.

Tests that can be done in-clinic include using a dynamometer to measure grip strength, which gives you an indication of muscle strength. You can also test physical function and performance by having the patient sit-to-stand from a chair five times. To do this, the patient should start seated but without touching their back to the chair. If it takes more than 12 seconds to stand and then re-sit five times, the test is considered “positive” for low muscle strength.

Preventing and managing sarcopenia

While the above tests are a good indication of poor muscle health, Professor Willcock says it’s crucial to start managing if you suspect someone is at risk — even if they don’t meet the diagnostic threshold.

“Effective management of sarcopenia is an evolving science,” Professor Willcock says.

There is good evidence for resistance training, especially in the lower limbs, but Professor Willcock says any physical activity increases muscle mass and decreases the risk of falls. Reducing sedentary behaviour and optimising nutrition are also key.

Professor Willcock says most patients will claim to eat well, but a validated nutritional assessment is important to objectively assess risk of malnutrition.

A balanced diet is important, as is reducing alcohol use. There is also good evidence for increased protein intake, above the usual age-based recommendations, Professor Willcock says.

Look for supplements which have the essential amino acid leucine and its metabolite HMB (B-OH B-methyl butyrate) “which exerts anabolic effects and is already used widely by athletes, with some promising results in trials with older people and those with reduced mobility,” Professor Willcock says.

“Early indications of the value of Vitamin D supplementation have not been supported,” he adds—with the caveat that vitamin D is obviously important for bone quality, and thus still worth checking.

There are no drugs registered for use in sarcopenia, but studies are underway. Selective androgen receptor modifiers are looking promising, so watch this space, Professor Willcock says.

In the meantime, lifestyle modification is the mainstay, and a team-based approach is key.

“Preventive care is team-based care – make use of practice nurses, nutritionists, exercise physiologists, physiotherapists, psychologists,” Professor Willcock sums up.