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Sarcopenia

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Added 2023 ASCO, 2021 AASLD, 2021 AAFP, 2021 ESMO, 2020 ESPEN, and 2018 ICFSR guidelines for the diagnosis and management of sarcopenia.

Background

Overview

Definition
Sarcopenia is defined as a progressive and generalized skeletal muscle disorder characterized by accelerated loss of muscle mass and function.
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Pathophysiology
The pathophysiology of sarcopenia involves age-related structural changes and mechanisms at cellular and subcellular levels, including qualitative changes in posttranslational modifications of muscle proteins, loss of coordinated control between contractile, mitochondrial, and sarcoplasmic reticulum protein expression, and progressive loss of motoneurons leading to reduced muscle fiber number and size.
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Epidemiology
The prevalence of sarcopenia in community-dwelling older adults ranges from 9.9% to 40.4%, depending on the definition used. The prevalence of sarcopenia is reported to be 25-35% in patients with cancer and 40-70% in patients with liver cirrhosis.
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Risk factors
The primary risk factors for sarcopenia include advancing age, a sedentary lifestyle, inadequate nutrition, and certain chronic diseases such as diabetes, obesity, and liver cirrhosis.
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Disease course
Clinically, sarcopenia presents with decreased muscle strength, impaired physical performance, and an overall decline in functional abilities. It can lead to reduced mobility, diminished QoL, and increased risk of fall-related injuries.
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Prognosis and risk of recurrence
Sarcopenia is associated with adverse outcomes, including falls, functional decline, frailty, and a significantly higher risk of mortality, independent of population and sarcopenia definition.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of sarcopenia are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2023,2020), the American Academy of Family Physicians (AAFP 2021,2020), the American Association for the Study of Liver Diseases (AASLD 2021), the European Society of Medical Oncology (ESMO 2021), the European Society for ...
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Screening and diagnosis

Indications for screening
As per ICFSR 2018 guidelines:
Screen adults aged ≥ 65 years for sarcopenia annually or after major health events.
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Consider using gait speed or the SARC-F questionnaire for screening for sarcopenia.
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SARC-F questionnaire for sarcopenia
Strength: How much difficulty do you have in lifting and carrying 4.5 kg (10 pounds)?
No difficulty
Some difficulty
A lot of difficulty or unable
Assistance in walking: How much difficulty do you have walking across a room?
No difficulty
Some difficulty
A lot of difficulty, using aids, or unable
Rise from a chair: How much difficulty do you have transferring from a chair or bed?
No difficulty
Some difficulty
A lot of difficulty or unable without help
Climb stairs: How much difficulty do you have climbing a flight of 10 steps?
No difficulty
Some difficulty
A lot of difficulty or unable
Falls: How many times have you fallen in the past year?
None
1-3 falls
≥ 4 falls
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  • Diagnostic criteria

Diagnostic investigations

Physical examination: as per ICFSR 2018 guidelines, assess gait speed and grip strength to identify low levels of muscle strength and physical performance when diagnosing sarcopenia.
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  • DEXA

  • Screening for frailty

  • Evaluation of muscle weakness

Medical management

General principles: as per ICFSR 2018 guidelines, do not offer pharmacologic interventions as first-line therapy for the management of sarcopenia.
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  • Anabolic hormones

  • Management of frailty (general principles)

  • Management of frailty (physical activity)

  • Management of frailty (nutritional therapy)

  • Management of frailty (pharmacotherapy)

Nonpharmacologic interventions

Physical activity: as per ICFSR 2018 guidelines, consider offering resistance-based training to improve muscle strength, skeletal muscle mass, and physical function in patients with sarcopenia.
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  • Protein supplementation

  • Vitamin D supplementation

Specific circumstances

Patients with liver cirrhosis, prevention: as per AASLD 2021 guidelines, provide education, motivation, and behavioral skills support to reduce the risk of developing malnutrition, frailty, and sarcopenia in all patients with cirrhosis.
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  • Patients with liver cirrhosis (evaluation)

  • Patients with liver cirrhosis (physical activity)

  • Patients with liver cirrhosis (weight loss)

  • Patients with liver cirrhosis (nutrition)

  • Patients with liver cirrhosis (caloric requirements)

  • Patients with liver cirrhosis (protein supplementation)

  • Patients with liver cirrhosis (micronutrients)

  • Patients with liver cirrhosis (salt restriction)

  • Patients with liver cirrhosis (general principles of management)

  • Patients with liver cirrhosis (hormonal therapy)

  • Patients with liver cirrhosis (TIPS)

  • Patients with liver cirrhosis (liver transplantation)

  • Patients with cancer-associated cachexia (screening)

  • Patients with cancer-associated cachexia (counseling)

  • Patients with cancer-associated cachexia (general principles of nutrition)

  • Patients with cancer-associated cachexia (nutritional requirements)

  • Patients with cancer-associated cachexia (tube feeding)

  • Patients with cancer-associated cachexia (parenteral nutrition)

  • Patients with cancer-associated cachexia (dietary supplements)

  • Patients with cancer-associated cachexia (physical activity)

  • Patients with cancer-associated cachexia (general principles of management)

  • Patients with cancer-associated cachexia (corticosteroids)

  • Patients with cancer-associated cachexia (progesterone analogs)

  • Patients with cancer-associated cachexia (olanzapine)

  • Patients with cancer-associated cachexia (other agents)

  • Patients with cancer-associated cachexia (end-of-life care)