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Diagnosing sarcopenia: turn your eyes back on patients

Diagnosing sarcopenia: turn your eyes back on patients sacropenia, prevalence, diagnostic criteria Key points Definitions of sarcopenia are still evolving. Large differences are found in studies on the prevalence of sarcopenia. Differences depend on the use of various definitions, tools and techniques to measure muscle mass and function. However, research should not hinder the importance of diagnosing and treating sarcopenia in mainstream clinical practice. A global definition of sarcopenia is needed. Coined only a few decades ago in the nutrition and body composition field, the term sarcopenia is now successfully being incorporated into mainstream medicine and into a good number of medical and surgical disciplines [1]. Geriatricians have been the key in shaping current understanding of the term, as it became obvious that the concepts of sarcopenia and frailty are the key to prevent and treat physical disability, a key objective of Geriatric Medicine. However, practitioners and researchers may be confused by the number of conflicting and changing definitions published since 2010 by expert groups from Europe, Asia and the USA. The etymology of the word sarcopenia refers strictly to a low muscle mass, and this body composition approach prevailed in academic research for long until the recent turn to muscle function of contemporary definitions [2]. Unsurprisingly, many studies published in recent years by oncologist, surgeons and other organ specialists are still using a body composition approach. Searching and understanding articles on the field are hindered by this dual meaning of the term, which is used by some to describe low muscle mass only and by many to describe low muscle mass and function. Moreover, low muscle mass is also part of the definition of cachexia and has become the key in the new diagnostic criteria of malnutrition [3]. In this issue of Age and Ageing, Carvalho do Nascimento and colleagues present the results of a well-performed systematic review looking at the definitions, measures and prevalence of sarcopenia in community dwelling older people [4]. They found 91 articles including over 100,000 participants. Seven different definitions were used to estimate the prevalence of sarcopenia, displaying a large variability in the results. One out of three studies still held to the time-worn concept of sarcopenia as low muscle mass (and this is probably an underestimation, as studies in particular conditions as cancer or surgery were excluded). Within each definition, the use of different measurement tools, cut-off points and protocols for each parameter contributed to the inconsistencies, so real differences in the prevalence of sarcopenia between genders, races, populations or countries cannot be convincingly assessed. This review convincingly confirms some well-described issues. Even if dual-energy x-ray absorptiometry (DXA) is considered a standard, most available methods to estimate muscle mass—including DXA—are inconsistent, and this choice has a major impact on the prevalence of sarcopenia [5]. Similar issues have been described when measuring muscle function and physical performance [6]. Interestingly, this systematic review found relevant differences comparing hydraulic with digital dynamometers. Being hydraulic dynamometers usually cheaper, understanding the clinical relevance of this difference is important, if dynamometers ought to be introduced in geriatric clinics as tools as common as sphygmomanometers. Furthermore, the review confirms that all definitions used in prevalence studies (except those holding to muscle mass alone) agree on what, but not on how: they agree on the use of measures of muscle mass, muscle strength and physical performance but not on what technique, measure or cut-off point is appropriate. Muscle quality and muscle power or other measures of muscle function are still not here. Similar findings have been reported on studies on sarcopenic obesity [7]. However, the main problem underlying such academic discussions, as pointed out by the European and Asian working groups in their updated definitions, is that they seem to be precluding or delaying the introduction of sarcopenia in clinical practice [8]. The diagnosis of sarcopenia is still uncommonly used, even for patients cared by geriatricians. Patients may be losing a major opportunity to delay disability and prevent falls with exercise interventions and probably with the help of nutritional interventions, as recommended by sarcopenia guidelines [9]. When preparing the updated European definition, the idea generally underlying discussion—for instance, the use of more stringent cut-off points for muscle strength—was to foster the diagnosis of sarcopenia in clinical practice and to compel general practitioners, geriatricians and organ specialist to become familiar with the diagnosis and management of this condition by caring of patients with indisputable sarcopenia [10]. Following the lessons learned from the history cardiovascular medicine (i.e. the shifting cut-off points for blood pressure, glucose or cholesterol), it was expected that once clear cases were incorporated into routine clinical practice, refined cut-off points in future updates of the definition would help to find and treat milder cases. A long journey will be close to end when all physicians become familiar with the measure of grip strength and are aware that a low grip strength predicts impaired medical and functional outcomes in older people [11] and when they understand that physical performance measures (gait speed, SPPB, get up and go test) translate the effect of low muscle function (and function of other organs and systems) on body function before full disability is established. Of course, ongoing research and organisational changes should support this journey. Better practical measures of active muscle mass (as the promising D3-creatine dilution method [12] or ultrasound-based measures [13]) are needed to overcome the limitations of DXA or CT/MRI estimations. Protocols for a consistent measure of handgrip strength and gait speed should be widespread. The use of muscle strength and physical performance as intermediate outcomes that can be used by patients to understand the effects of therapeutic interventions needs to be clarified. Simplified methods to present results of measures that depend on gender, race or body frame should be developed, probably learning on the experience of osteoporosis or the international normalised ratio to report coagulation results by different labs and techniques. Standardised resistance exercise protocols that improve muscle function should be made widely available. In addition, of course, a global definition of sarcopenia based on an agreement on the interpretation of evidence by the major working groups from different continents would surely help. That being said, many geriatricians may need to turn back their eyes to their patients, consider if their sarcopenia diagnosis and management practices are appropriate or need rethinking and new training and start showing their peers that diagnosing and treating sarcopenia is relevant for many older patients. Declaration of Conflicts of Interest None. Declaration of Sources of Funding None. References 1. Yang M , Tan L, Li W. Landscape of sarcopenia research (1989–2018): a bibliometric analysis . J Am Med Dir Assoc 2020 ; 21 : 436 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Sanchez-Rodriguez D , Marco E, Cruz-Jentoft AJ. Defining sarcopenia: some caveats and challenges . Curr Opin Clin Nutr Metab Care 2020 ; 23 : 127 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Cederholm T , Jensen GL, Correia MITD et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community . Clin Nutr 2019 ; 38 : 1 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Carvalho do Nascimento PR , Bilodeau M, Poitras S. How do we define and measure sarcopenia? A meta-analysis of observational studies . Age Ageing 2021 ; afab148. In press . Google Scholar OpenURL Placeholder Text WorldCat 5. Buckinx F , Landi F, Cesari M et al. Pitfalls in the measurement of muscle mass: a need for a reference standard . J Cachexia Sarcopenia Muscle 2018 ; 9 : 269 – 78 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Beaudart C , Rolland Y, Cruz-Jentoft AJ et al. Assessment of muscle function and physical performance in daily clinical practice: a position paper endorsed by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) . Calcif Tissue Int 2019 ; 105 : 1 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Donini LM , Busetto L, Bauer JM et al. Critical appraisal of definitions and diagnostic criteria for sarcopenic obesity based on a systematic review . Clin Nutr 2020 ; 39 : 2368 – 88 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Offord NJ , Clegg A, Turner G et al. Current practice in the diagnosis and management of sarcopenia and frailty - results from a UK-wide survey . J Frailty Sarcopenia Falls 2019 ; 4 : 71 – 7 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 9. Dent E , Morley JE, Cruz-Jentoft AJ et al. International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management . J Nutr Health Aging 2018 ; 22 : 1148 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Cruz-Jentoft AJ , Bahat G, Bauer J et al. Sarcopenia: revised European consensus on definition and diagnosis . Age Ageing 2019 ; 48 : 16 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Nagaoka S , Yoshimura Y, Eto T et al. Low handgrip strength is associated with reduced functional recovery and longer hospital stay in patients with osteoporotic vertebral compression fractures: a prospective cohort study . Eur Geriatr Med 2021 ; 12 : 767 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Cawthon PM , Blackwell T, Cummings SR et al. Muscle mass assessed by the D3-creatine dilution method and incident self-reported disability and mortality in a prospective observational study of community-dwelling older men . J Gerontol A Biol Sci Med Sci 2021 ; 76 : 123 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Perkisas S , Bastijns S, Baudry S et al. Application of ultrasound for muscle assessment in sarcopenia: 2020 SARCUS update . Eur Geriatr Med 2021 ; 12 : 45 – 59 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Age and Ageing Oxford University Press

Diagnosing sarcopenia: turn your eyes back on patients

Cruz-Jentoft, Alfonso J
Age and Ageing , Volume 50 (6): 2 – Sep 10, 2021
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Publisher
Oxford University Press
Copyright
© The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN
0002-0729
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1468-2834
DOI
10.1093/ageing/afab184
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Abstract

sacropenia, prevalence, diagnostic criteria Key points Definitions of sarcopenia are still evolving. Large differences are found in studies on the prevalence of sarcopenia. Differences depend on the use of various definitions, tools and techniques to measure muscle mass and function. However, research should not hinder the importance of diagnosing and treating sarcopenia in mainstream clinical practice. A global definition of sarcopenia is needed. Coined only a few decades ago in the nutrition and body composition field, the term sarcopenia is now successfully being incorporated into mainstream medicine and into a good number of medical and surgical disciplines [1]. Geriatricians have been the key in shaping current understanding of the term, as it became obvious that the concepts of sarcopenia and frailty are the key to prevent and treat physical disability, a key objective of Geriatric Medicine. However, practitioners and researchers may be confused by the number of conflicting and changing definitions published since 2010 by expert groups from Europe, Asia and the USA. The etymology of the word sarcopenia refers strictly to a low muscle mass, and this body composition approach prevailed in academic research for long until the recent turn to muscle function of contemporary definitions [2]. Unsurprisingly, many studies published in recent years by oncologist, surgeons and other organ specialists are still using a body composition approach. Searching and understanding articles on the field are hindered by this dual meaning of the term, which is used by some to describe low muscle mass only and by many to describe low muscle mass and function. Moreover, low muscle mass is also part of the definition of cachexia and has become the key in the new diagnostic criteria of malnutrition [3]. In this issue of Age and Ageing, Carvalho do Nascimento and colleagues present the results of a well-performed systematic review looking at the definitions, measures and prevalence of sarcopenia in community dwelling older people [4]. They found 91 articles including over 100,000 participants. Seven different definitions were used to estimate the prevalence of sarcopenia, displaying a large variability in the results. One out of three studies still held to the time-worn concept of sarcopenia as low muscle mass (and this is probably an underestimation, as studies in particular conditions as cancer or surgery were excluded). Within each definition, the use of different measurement tools, cut-off points and protocols for each parameter contributed to the inconsistencies, so real differences in the prevalence of sarcopenia between genders, races, populations or countries cannot be convincingly assessed. This review convincingly confirms some well-described issues. Even if dual-energy x-ray absorptiometry (DXA) is considered a standard, most available methods to estimate muscle mass—including DXA—are inconsistent, and this choice has a major impact on the prevalence of sarcopenia [5]. Similar issues have been described when measuring muscle function and physical performance [6]. Interestingly, this systematic review found relevant differences comparing hydraulic with digital dynamometers. Being hydraulic dynamometers usually cheaper, understanding the clinical relevance of this difference is important, if dynamometers ought to be introduced in geriatric clinics as tools as common as sphygmomanometers. Furthermore, the review confirms that all definitions used in prevalence studies (except those holding to muscle mass alone) agree on what, but not on how: they agree on the use of measures of muscle mass, muscle strength and physical performance but not on what technique, measure or cut-off point is appropriate. Muscle quality and muscle power or other measures of muscle function are still not here. Similar findings have been reported on studies on sarcopenic obesity [7]. However, the main problem underlying such academic discussions, as pointed out by the European and Asian working groups in their updated definitions, is that they seem to be precluding or delaying the introduction of sarcopenia in clinical practice [8]. The diagnosis of sarcopenia is still uncommonly used, even for patients cared by geriatricians. Patients may be losing a major opportunity to delay disability and prevent falls with exercise interventions and probably with the help of nutritional interventions, as recommended by sarcopenia guidelines [9]. When preparing the updated European definition, the idea generally underlying discussion—for instance, the use of more stringent cut-off points for muscle strength—was to foster the diagnosis of sarcopenia in clinical practice and to compel general practitioners, geriatricians and organ specialist to become familiar with the diagnosis and management of this condition by caring of patients with indisputable sarcopenia [10]. Following the lessons learned from the history cardiovascular medicine (i.e. the shifting cut-off points for blood pressure, glucose or cholesterol), it was expected that once clear cases were incorporated into routine clinical practice, refined cut-off points in future updates of the definition would help to find and treat milder cases. A long journey will be close to end when all physicians become familiar with the measure of grip strength and are aware that a low grip strength predicts impaired medical and functional outcomes in older people [11] and when they understand that physical performance measures (gait speed, SPPB, get up and go test) translate the effect of low muscle function (and function of other organs and systems) on body function before full disability is established. Of course, ongoing research and organisational changes should support this journey. Better practical measures of active muscle mass (as the promising D3-creatine dilution method [12] or ultrasound-based measures [13]) are needed to overcome the limitations of DXA or CT/MRI estimations. Protocols for a consistent measure of handgrip strength and gait speed should be widespread. The use of muscle strength and physical performance as intermediate outcomes that can be used by patients to understand the effects of therapeutic interventions needs to be clarified. Simplified methods to present results of measures that depend on gender, race or body frame should be developed, probably learning on the experience of osteoporosis or the international normalised ratio to report coagulation results by different labs and techniques. Standardised resistance exercise protocols that improve muscle function should be made widely available. In addition, of course, a global definition of sarcopenia based on an agreement on the interpretation of evidence by the major working groups from different continents would surely help. That being said, many geriatricians may need to turn back their eyes to their patients, consider if their sarcopenia diagnosis and management practices are appropriate or need rethinking and new training and start showing their peers that diagnosing and treating sarcopenia is relevant for many older patients. Declaration of Conflicts of Interest None. Declaration of Sources of Funding None. References 1. Yang M , Tan L, Li W. Landscape of sarcopenia research (1989–2018): a bibliometric analysis . J Am Med Dir Assoc 2020 ; 21 : 436 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Sanchez-Rodriguez D , Marco E, Cruz-Jentoft AJ. Defining sarcopenia: some caveats and challenges . Curr Opin Clin Nutr Metab Care 2020 ; 23 : 127 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Cederholm T , Jensen GL, Correia MITD et al. GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community . Clin Nutr 2019 ; 38 : 1 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Carvalho do Nascimento PR , Bilodeau M, Poitras S. How do we define and measure sarcopenia? A meta-analysis of observational studies . Age Ageing 2021 ; afab148. In press . Google Scholar OpenURL Placeholder Text WorldCat 5. Buckinx F , Landi F, Cesari M et al. Pitfalls in the measurement of muscle mass: a need for a reference standard . J Cachexia Sarcopenia Muscle 2018 ; 9 : 269 – 78 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Beaudart C , Rolland Y, Cruz-Jentoft AJ et al. Assessment of muscle function and physical performance in daily clinical practice: a position paper endorsed by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) . Calcif Tissue Int 2019 ; 105 : 1 – 14 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Donini LM , Busetto L, Bauer JM et al. Critical appraisal of definitions and diagnostic criteria for sarcopenic obesity based on a systematic review . Clin Nutr 2020 ; 39 : 2368 – 88 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Offord NJ , Clegg A, Turner G et al. Current practice in the diagnosis and management of sarcopenia and frailty - results from a UK-wide survey . J Frailty Sarcopenia Falls 2019 ; 4 : 71 – 7 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 9. Dent E , Morley JE, Cruz-Jentoft AJ et al. International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management . J Nutr Health Aging 2018 ; 22 : 1148 – 61 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Cruz-Jentoft AJ , Bahat G, Bauer J et al. Sarcopenia: revised European consensus on definition and diagnosis . Age Ageing 2019 ; 48 : 16 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Nagaoka S , Yoshimura Y, Eto T et al. Low handgrip strength is associated with reduced functional recovery and longer hospital stay in patients with osteoporotic vertebral compression fractures: a prospective cohort study . Eur Geriatr Med 2021 ; 12 : 767 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Cawthon PM , Blackwell T, Cummings SR et al. Muscle mass assessed by the D3-creatine dilution method and incident self-reported disability and mortality in a prospective observational study of community-dwelling older men . J Gerontol A Biol Sci Med Sci 2021 ; 76 : 123 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Perkisas S , Bastijns S, Baudry S et al. Application of ultrasound for muscle assessment in sarcopenia: 2020 SARCUS update . Eur Geriatr Med 2021 ; 12 : 45 – 59 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Age and Ageing – Oxford University Press

Published: Sep 10, 2021

Keywords: sacropenia; prevalence; diagnostic criteria

There are no references for this article.