Novel Approaches to the Diagnosis of Sarcopenia

doi:10.1016/j.jocd.2015.04.010

Journal of Clinical Densitometry

Volume 18, Issue 4, October 2015, Pages 472-477

https://doi.org/10.1016/j.jocd.2015.04.010 Get rights and content

Highlights:

•
Sarcopenia is common in older people and is associated with significant morbidity.
•
There is currently no universally accepted definition of sarcopenia.
•
Most operational definitions include assessments of muscle mass and muscle function.
•
Score-based approaches may be used in the future to provide a wider evaluation of musculoskeletal health.

Abstract

Sarcopenia is common in older people and is associated with disability, reduced mobility, hospitalization, and various comorbidities. Although it has been recognized for over a quarter of a century, we do not currently have a universally adopted definition. This limits our ability to compare results from different studies and impedes the development of novel therapies. Although sarcopenia was initially defined purely based on low muscle mass, the importance of measures of muscle function has been realized and these have been included in recent operational definitions. These continue to evolve with some including an assessment of adiposity and others adding further components of musculoskeletal health in a score-based approach. This review describes the importance of reaching a widely accepted method to define sarcopenia in both research and clinical practice. It details the ways in which the definition has changed since its initial inception and explores how it may continue to evolve in the future. The different methods by which components of sarcopenia can be measured are described, and the various advantages and disadvantages of these techniques are evaluated. Clearly, there are several other similar syndromes in older people, such as frailty and cachexia; their relationships and overlap with sarcopenia are also explored.

Introduction

The term sarcopenia was first introduced a quarter of a century ago in 1989 by Irwin Rosenberg to describe the loss of muscle mass with age. Over the intervening years, the definition has evolved to acknowledge the significance of a concurrent decline in muscle function. However, there is still no universally accepted operational definition of sarcopenia for use in research or clinical practice. Sarcopenia is an important clinical problem by virtue of its considerable prevalence within the older population along with its associations with adverse health outcomes. The prevalence of sarcopenia was initially estimated at around 50% in individuals aged more than 80 years. However, more recent studies have shown sarcopenia prevalence to be lower but still on the order of 10%–20% when assessed in terms of muscle mass alone (1).

Specific risk factors for developing sarcopenia include advancing age, female sex, adverse developmental factors in early life, dietary issues, lack of physical activity, and various chronic diseases. It is associated with frailty, disability, reduced mobility, hospitalization, and specific comorbidities including poorer bone health or osteoporosis, obesity, and type 2 diabetes 2, 3. Most importantly, a decline in muscle health, particularly strength, has also been shown to predict future mortality from middle age into later life (4). It has been estimated that, in the United States, sarcopenia resulted in additional health care costs of more than $18 billion in 2001 (5), and given the current changes in population demographics with increasing longevity, this figure will likely continue to increase.

Section snippets

The Importance of Defining Sarcopenia

Clearly, if the presence of sarcopenia is a predictor of premature death, it is necessary to identify individuals at risk not only to assess the natural history of the condition and its consequences but also to provide treatment when appropriate. Interventions may include dietary manipulation, exercise-related therapies, and in the future, pharmaceutical agents. Any definition to be used in clinical practice must be practical, acceptable to patients, and not prohibitively expensive. Within a

Current Operational Definitions of Sarcopenia

Over the last 5 years, 3 main consensus definitions for sarcopenia have been suggested 1, 6, 7. Although they all differ to some degree, each includes a measurement of muscle size and another of muscle function (Table 1). The rationale for using muscle function, in addition to muscle size, is that the latter alone would provide too narrow a definition which may limit clinical value and that the relationship between muscle mass and strength is not linear (6). Like muscle mass, muscle function

Current Overlap with Other Syndromes

Although sarcopenia is a geriatric syndrome in its own right, features of the condition are also found in other disorders such as frailty and cachexia. Frailty occurs because of an age-related decline in several physiologic systems. It can lead to a reduction in the individual's ability to withstand an insult resulting in their increased vulnerability to adverse health outcomes including mortality. Although other operational definitions of frailty have been developed, one of the most widely

Methods of Measuring Muscle Size, Strength, and Physical Performance

Various methods of assessing body composition including muscle mass exist 14, 15. These include traditional approaches using anthropometric measurements, air displacement plethysmography, underwater weighing, and dilution techniques. These methods all have limitations, for example, they are not precise (anthropometric measures) or they are very equipment or time intensive (plethysmography, underwater weighing). D₃ creatine dilution is a promising method that is under investigation but has not

Novel Methods of Defining Sarcopenia

The most recently proposed definition of sarcopenia was developed by researchers that came together under the umbrella of the Foundation for the National Institutes of Health (FNIH) sarcopenia project (8). This group had access to data from 9 large observational studies with more than 25,000 participants in total. After analyzing this large data set, they recommended defining sarcopenia based on 3 components. Two of these, muscle mass and grip strength, were included in the prior definitions

References (25)

R.A. Fielding et al.
Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International Working Group on Sarcopenia
J Am Med Dir Assoc
(2011)
M. Edwards et al.
Muscle size, strength and physical performance and their associations with bone structure in the Hertfordshire Cohort Study
J Bone Miner Res
(2013)
A.A. Sayer et al.
Type 2 diabetes, muscle strength, and impaired physical function: the tip of the iceberg?
Diabetes Care
(2005)
R. Cooper et al.
Objectively measured physical capability levels and mortality: systematic review and meta-analysis
BMJ
(2010)
I. Janssen et al.
The healthcare costs of sarcopenia in the United States
J Am Geriatr Soc
(2004)
A.J. Cruz-Jentoft et al.
Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People
Age Ageing
(2010)
M. Muscaritoli et al.
Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”
Clin Nutr
(2010)
S.A. Studenski et al.
The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates
J Gerontol Ser A Biol Sci Med Sci
(2014)
W.R. Frontera et al.
Aging of skeletal muscle: a 12-yr longitudinal study
J Appl Physiol (1985)
(2000)
A.B. Newman et al.
Sarcopenia: alternative definitions and associations with lower extremity function
J Am Geriatr Soc
(2003)

B.C. Clark et al.

Sarcopenia =/= dynapenia

J Gerontol A Biol Sci Med Sci

(2008)

L.P. Fried et al.

Frailty in older adults: evidence for a phenotype

J Gerontol A Biol Sci Med Sci

(2001)

Cited by (32)

Elevated serum γ-glutamyl transferase is associated with low muscle function in adults independent of muscle mass
2022, Nutrition
Citation Excerpt :
A large community-based cohort revealed that changes in muscle function have a better clinical prognostic value for predicting fractures than muscle mass [15]. Jump power (JP) measurement using a ground force plate has been proposed as an alternative method to measure muscle function in complex, high-intensity tasks [16]. Low JP is associated with an increased risk for falls, fracture, sarcopenia, or dysmobility syndrome [17–19].
Elevated serum γ-glutamyl transferase (GGT), a hepatic cholestasis or liver damage marker, has been associated with low lean mass and adiposity. However, whether serum GGT can predict muscle function in adults remains unclear. The aim of this study was to determine whether an elevated serum GGT is associated with low peak weight-corrected jump power (JP) and low handgrip strength (HGS).
This study included 662 individuals aged ≥50 y in the final cohort (women, 86%; mean age, 64.8 y). The primary outcome was low peak weight-corrected JP defined as <23.8 W/kg and <19W/kg in men and women, respectively, and the secondary outcome was low HGS (<28 kg in men; <18 kg in women).
Participants with low JP had a higher GGT level, older age, lower HGS, and higher body fat than those without low JP. Serum GGT showed a negative association with JP (adjusted β = –1.16, P = 0.005) and HGS (adjusted β = –0.92, P = 0.018). One log-unit increment in GGT was associated with elevated odds of low JP (adjusted odds ratio [aOR] 2.13, P = 0.002) after adjustment for age, sex, lean mass, and body fat percentage, particularly in individuals without hepatic steatosis (aOR, 2.30) versus those with hepatic steatosis (aOR, 0.80; P_interaction = 0.020).
Elevated serum GGT was associated with low muscle function in adults independent of age, muscle mass, and adiposity, indicating that serum GGT may play a role as an independent marker of muscle function. <END ABSTRACT>
Implications of lower extremity muscle power and force for walking and fatigability in multiple sclerosis – An exploratory pilot-study
2022, Clinical Biomechanics
Citation Excerpt :
Whilst higher mobility disability status was accompanied by decrements in baseline outcomes, higher fatigability status was accompanied by higher decrement in walking speed. Since differences in muscle power/force between the PDDS Low and High groups were substantial during the chair rise task but not during the plantar flexion, this indicate that more complex dynamic tasks such as chair rise may require a more optimal motor control in order to synchronise different muscular groups (Edwards and Buehring, 2015) and might be more sensitive in terms of detecting motor deficiency across disability status in pwMS. Although associations between plantar flexion muscle power/force during and walking capacity, mobility disability status as well as subjective fatigue were observed (corresponding to weak associations), chair rise muscle power/force (i.e. a more complex motor task) presented better associations with walking capacity, mobility disability and subjective fatigue (corresponding to weak-to-moderate associations).
Limitations in physical function are common in Multiple Sclerosis (MS), yet it is neither clear how muscle power implicates physical function and walking-fatigability. This pilot-study aims to investigate (1) deficits in muscle power/force alongside walking in persons with MS; (2) associations between muscle power/force and physical functions and (3) the impact of prolonged walking in muscle power/force.
30 relapse-remitting persons with MS and 28 healthy controls performed chair rise and plantar flexion on a force platform before and after 12-minutes of intermittent walking to measure lower extremity muscle power/force. GaitRite measured walking speed. The percentage change in distance walked was also calculated. Persons with MS were classified into subgroups according to walking-fatigability and mobility disability status (Patient Determined Disease Steps).
Higher deficits in muscle power compared to force were observed in persons with MS vs. healthy controls particularly in persons with MS having higher disability. Muscle power and force were associated with walking capacity, mobility disability and subjective fatigue, but not with percentage change in distance walked. Persons with MS slowed down over the course of the 12-min intermittent walking, whereas decrements in walking speed and muscle power/force (derived from chair rise) were observed in persons with MS presenting walking-fatigability only.
Muscle power and force are impaired in persons with MS and appear to be critical for physical function in MS. This exploratory pilot study further suggests that muscle power/force from chair rise could contributes to walking-fatigability which therefore offer future treatment targets.
Global prevalence of sarcopenic obesity in older adults: A systematic review and meta-analysis
2021, Clinical Nutrition
Sarcopenic obesity (SO), which refers to the coexistence of sarcopenia and obesity. It can lead to physical disability, morbidity, and even mortality. This systematic review and meta-analysis aimed to estimate the global prevalence of SO in older adults.
We searched PubMed, Embase, and Web of Science for studies reporting the prevalence of SO from inception to December 2020. Two researchers independently screened the literature, evaluated study quality, and extracted data. A random-effects model was used to pool the estimates for the prevalence of SO. Subgroup analysis, sensitivity analysis, and meta-regression analysis were conducted. Publication bias was assessed using a funnel plot and the Egger test. All statistical analyses were performed using Stata 15.0 software.
This review included 50 studies, we found that the global prevalence of SO in older adults was 11%. Subgroup analyses showed that the prevalence of SO was higher among studies using diagnostic criteria of muscle mass alone (15%) to diagnose sarcopenia, using dual-energy X-ray absorptiometry (15%) to assess muscle mass, and those focused on age ≥ 75 years old (23%), hospitalized (16%), South Americans (21%) and North Americans (19%). There were no significant differences in the prevalence of SO among studies using body fat percentage (10%), body mass index (13%), waist circumference (16%) to diagnose obesity and in female (14%), male (10%) patients. Sensitivity analysis showed that none of the studies affected the overall pooled results. Meta-regression analysis found that publication year, geographical region, study setting, and the diagnostic criteria of sarcopenia were sources of heterogeneity.
This meta-analysis indicated SO affects more than one in ten older adults globally. Therefore, we should attach importance to the screening and early diagnosis of SO in older adults, then selecting appropriate interventions to reduce the occurrence of it and various adverse outcomes in this demographic.
Jump power, leg press power, leg strength and grip strength differentially associated with physical performance: The Developmental Epidemiologic Cohort Study (DECOS)
2021, Experimental Gerontology
Citation Excerpt :
Additionally, critical biomechanical differences exist between weight-bearing and non-weight-bearing tests. Countermovement jump tests include both eccentric and concentric muscle action, as well as velocity of movement and other neuromuscular factors (e.g., postural control) (Edwards and Buehring, 2015) that are required to complete physical performance measures. These countermovement jumps performed under unrestricted conditions may be more similar to physical performance measures than tests with other postural set-ups, such as the Nottingham leg press power and Keiser leg strength/power testing completed in the seated position.
Weight-bearing jump tests that measure lower-extremity muscle power may be more strongly related to physical performance measures vs. non-weight-bearing leg press power, leg press strength and grip strength. We investigated if multiple muscle function measures differentially related to standard physical performance measures.
In the Developmental Epidemiologic Cohort Study (DECOS; N = 68; age 78.5 ± 5.5 years; 57% women; 7% minorities), muscle function measures included power in Watts/kg (functional, weight-bearing: jump; mechanical: Nottingham power rig; Keiser pneumatic leg press) and strength in kg/kg body weight (Keiser pneumatic leg press; hand-held dynamometry). Physical performance outcomes included 6 m usual gait speed (m/s), usual-paced 400 m walk time (seconds), and 5-repeated chair stands speed (stands/s).
Women (N = 31; 79.8 ± 5.0 years) had lower muscle function and slower gait speed compared to men (N = 25; 78.7 ± 6.6 years), though similar 400 m walk time and chair stands speed. In partial Pearson correlations adjusted for age, sex, race and height, muscle function measures were moderately to strongly correlated with each other (all p < 0.05), though the individual correlations varied. In multiple regression analyses, each muscle function measure was statistically associated with all physical performance outcomes in models adjusted for age, sex, race, height, self-reported diabetes, self-reported peripheral vascular disease and self-reported pain in legs/feet (all p < 0.05). Jump power (β = 0.75) and grip strength (β = 0.71) had higher magnitudes of association with faster gait speed than lower-extremity power and strength measures (β range: 0.32 to 0.58). Jump power (β = 0.56) had a slightly lower magnitude of association with faster 400 m walk time vs. Keiser power_{70% 1-RM} (β = 0.61), and a higher magnitude of association vs. Nottingham power, Keiser strength and grip strength (β range: 0.41 to 0.47). Jump power (β = 0.38) had a lower magnitude of association with chair stands speed than any other power or strength measures (β range: 0.50 to 0.65).
Jump power/kg and grip strength/kg may be more strongly related to faster gait speed, a standard measure of physical function and vital sign related to disability and mortality in older adults, compared to leg press power/strength. However, jump power/kg had a similar magnitude of association with 400 m walk time as Keiser power_{70% 1-RM}/kg and a lower magnitude of association with faster chair stands speed than the other muscle function measures. Importantly, choice of muscle function measures should carefully reflect the study focus and methodologic considerations, including population.
Lower extremity muscle strength across the adult lifespan in multiple sclerosis: Implications for walking and stair climbing capacity
2020, Experimental Gerontology
Persons with multiple sclerosis (pwMS) accumulate impairments in muscle strength and limitations in physical function as the disease progresses. The same symptoms are seen in the biological process of aging (years of age > 60 years). Nonetheless, no previous studies have examined the combined effects of aging and multiple sclerosis (MS) in regards to lower extremity muscle strength concomitant with physical function (e.g. walking capacity). The aim of this cross-sectional study was to examine potential differences in pwMS vs. healthy controls (HC) across the adult lifespan in these outcomes.
A total of n = 53 pwMS and n = 48 age-matched HC were enrolled, and divided into groups of young (≤ 44 years), middle-aged (45–59 years), and old (≥ 60 years). Assessment of knee extensor (KE) and plantar flexor (PF) muscle force-velocity characteristics (isometric and dynamic concentric force at contraction velocities of 0–300 deg^.s⁻¹) alongside assessment of timed 25 ft walk tests (T25FWT), two minute walk tests (2MWT), and 9-step stair ascend (9SSA) were carried out.
Overall, substantial impairments in KE and PF isometric (ranging from −18 to −23%) and dynamic muscle strength (ranging from −26 to −38%) alongside limitations in T25FWT, 2MWT, and 9SSA (ranging from −24 to −33%) were observed in pwMS vs. HC (p < 0.05). With advanced age (young → middle-aged → old), more pronounced impairments in PF (but not KE) isometric and dynamic muscle strength, alongside limitations in T25FWT, 2MWT, and 9SSA, were observed in pwMS vs. HC (p < 0.05). In pwMS, associations were observed between physical function and isometric KE + PF muscle strength (r² = 0.21–0.45) as well as dynamic KE + PF muscle strength (r² = 0.36–0.61) (p < 0.05).
Substantial impairments of KE and PF muscle strength occur in pwMS across the adult lifespan accompanied by/associated with limitations in walking and stair climbing capacity, with PF muscle strength being preferentially affected in pwMS vs. HC.
Minerals and Sarcopenia; The Role of Calcium, Iron, Magnesium, Phosphorus, Potassium, Selenium, Sodium, and Zinc on Muscle Mass, Muscle Strength, and Physical Performance in Older Adults: A Systematic Review
2018, Journal of the American Medical Directors Association
Minerals may contribute to prevent and treat sarcopenia, the age-related loss of muscle mass, muscle strength, and physical performance. So far, there is no comprehensive review on the impact of minerals on sarcopenia outcomes. The aim of this systematic review is to evaluate the role of calcium, iron, magnesium, phosphorus, potassium, selenium, sodium, and zinc on muscle mass, muscle strength, and physical performance in older adults.
A systematic search was conducted between March 2016 and July 2016, in the PubMed database using predefined search terms. Articles on the role of dietary mineral intake or mineral serum concentrations on muscle mass, muscle strength, physical performance, and/or the prevalence of sarcopenia in healthy or frail older adults (average age ≥ 65 years) were selected. Only original research publications were included. The search and data extraction were conducted in duplicate by 2 independent researchers. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was followed in constructing this systematic review. The Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of the selected articles.
From the 3346 articles found, a total of 10 studies met the inclusion criteria. Observational studies showed that serum selenium (n = 1) and calcium intake (n = 1) were significantly associated with muscle mass, and magnesium (n = 1), selenium (n = 1), iron (n = 1), and zinc (n = 1) intake were significantly and positively associated with physical performance in older adults. Furthermore, magnesium (n = 2), selenium (n = 2), calcium (n = 2), and phosphorus (n = 1) intake were associated with the prevalence of sarcopenia. Magnesium supplementation improved physical performance based on one randomized controlled trial. No studies on the role of sodium or potassium on muscle mass, muscle strength, or physical performance were found.
Minerals may be important nutrients to prevent and/or treat sarcopenia. Particularly, magnesium, selenium, and calcium seem to be most promising. Most of the included studies, however, were observational studies. Therefore, more randomized controlled trials are needed to elucidate the potential benefits of mineral intake to prevent and/or treat sarcopenia and support healthy aging.

View all citing articles on Scopus

View full text

Special Section: SarcopeniaNovel Approaches to the Diagnosis of Sarcopenia

Highlights:

Abstract

Introduction

Section snippets

The Importance of Defining Sarcopenia

Current Operational Definitions of Sarcopenia

Current Overlap with Other Syndromes

Methods of Measuring Muscle Size, Strength, and Physical Performance

Novel Methods of Defining Sarcopenia

Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International Working Group on Sarcopenia

J Am Med Dir Assoc

Muscle size, strength and physical performance and their associations with bone structure in the Hertfordshire Cohort Study

J Bone Miner Res

Type 2 diabetes, muscle strength, and impaired physical function: the tip of the iceberg?

Diabetes Care

Objectively measured physical capability levels and mortality: systematic review and meta-analysis

BMJ

The healthcare costs of sarcopenia in the United States

J Am Geriatr Soc

Sarcopenia: European consensus on definition and diagnosis: report of the European Working Group on Sarcopenia in Older People

Age Ageing

Consensus definition of sarcopenia, cachexia and pre-cachexia: joint document elaborated by Special Interest Groups (SIG) “cachexia-anorexia in chronic wasting diseases” and “nutrition in geriatrics”

Clin Nutr

The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates

J Gerontol Ser A Biol Sci Med Sci

Aging of skeletal muscle: a 12-yr longitudinal study

J Appl Physiol (1985)

Sarcopenia: alternative definitions and associations with lower extremity function

J Am Geriatr Soc

Sarcopenia =/= dynapenia

J Gerontol A Biol Sci Med Sci

Frailty in older adults: evidence for a phenotype

J Gerontol A Biol Sci Med Sci

Special Section: Sarcopenia
Novel Approaches to the Diagnosis of Sarcopenia