NASHVILLE, TN – Function, not muscle size, matters most when it comes to diagnosing sarcopenia, advised John Morley, MD, to clinicians attending AMDA Long Term Care Medicine—2014. “The whole concept of sarcopenia is turning upside down,” said Dr. Morley, professor of internal medicine and endocrinology at St. Louis University. People with low muscle mass can have a great deal of strength, and those with a great deal of muscle mass can have limited strength, he explained. In a recent paper, Dr. Morley and his colleagues noted that international groups have shifted from the original definition of sarcopenia as an age-associated loss of muscle mass. They now define the decline in muscle function based on either walking speed or grip strength, with a loss of muscle mass. The condition can lead to frailty, disability, falls, and increased mortality. It has been linked with an increased prevalence of osteoporosis, which further deepens its association with hip fractures (JAMDA 2013;14[8]:531–2). Effective screening for sarcopenia based on this new definition can be achieved using the SARC-F scale, he added. The simple, easy-to-use tool has been validated in several studies. SARC-F stands for strength (difficulty in lifting or carrying 10 lbs.), assistance needed for walking, rise from a chair difficulty, climbing stairs difficulty, and falls. “It turns out that if you look at 50- to 55-year-olds, [SARC-F] is highly predictive of outcomes both cross-sectionally and longitudinally,” Dr. Morley said. In frail patients, assessing sarcopenia can help identify the cause of the frailty and can guide treatment decisions, he said. Keep in mind, however, that what may appear to be sarcopenia in a patient aged 50–70 years may actually be inclusion body myositis – a “relatively common” but rarely diagnosed condition, he said. Effective treatments for the condition are emerging, Dr. Morley said, so it is important to consider, based primarily on a patient's age, before assuming that he or she has sarcopenia. A biopsy is required to diagnose inclusion body myositis, he noted. Among the causes of sarcopenia are decreased physical activity, mitochondrial abnormalities, genetic abnormalities, cytokine excess, decreased anabolic hormones, vitamin D deficiency, problems with insulin growth factor, and decreased ciliary neurotrophic factor (CNTF). This last may be the most important factor because decreased CNTF causes a decrease in motor neurons and muscle fibers, Dr. Morley explained. The key to preventing or stopping both sarcopenia and frailty is resistance exercise, he said, noting that this activity has been shown to increase functional performance, walking speed, chair-stand performance, stair climbing, and balance, and to decrease depression and fear of falling. “You have to screen patients,” he added, stressing that this should take place when a patient comes into the nursing home, not after the person has had several falls. If the new resident screens positive, a resistance exercise program is a must, Dr. Morley said. The “FRAIL scale” remains an excellent tool, Dr. Morley said. Like SARC-F, it is well-validated, quick, and easy and identifies people in whom interventions – aerobic and resistance exercise, reduction of polypharmacy, vitamin D supplementation, and nutritional supplementation – can help, he said. The scale assesses patients in five specific areas: fatigue, resistance, ambulation, illnesses, and loss of weight. A positive finding for three or more of the factors indicates frailty. Fatigue can be particularly telling, Dr. Morley said. Its emergence should prompt an evaluation for anemia and vitamin B-12 deficiency. If these don't appear to be contributing to the frailty, look for an endocrine disorder. Sleep disorders, in particular, are a common cause of frailty, he noted. If weight loss is present, remember that medication and depression are the “big two” when it comes to causes of weight loss. At a consensus conference last year, delegates from six major international and United States societies agreed on four consensus points with respect to frailty. “Physical frailty is an important medical syndrome,” the experts agreed, adding that the condition has multiple causes and contributors and is characterized by diminished strength, endurance, and reduced physiologic function. This contributes to increased dependency and mortality (JAMDA 2013;14[6]:392–7). The other three points the panel made are: Frailty can be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and reduction of polypharmacy. Simple, rapid, and validated screening tests, such as the FRAIL scale, are available to allow for objective evaluation of patients; and all persons over age 70 years and all individuals with weight loss of 5% or more due to chronic disease should be screened for frailty.
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Feb 10, 2022
Chang Won Won 
