The epidemiological trends that characterize our generation are the aging of the population. Aging results in a progressive loss of muscle mass and strength called sarcopenia, which is Greek for 'poverty of flesh'. Sarcopenia could lead to functional impairment, physical disability, and even mortality. Today, sarcopenia is a matter of immense public concern for aging prevention.
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Sarcopenia or muscle insufficiency is a geriatric syndrome characterized by a progressive and generalized loss of skeletal muscle mass and function which has adverse consequences, particularly physical disability, falls and death. It can develop slowly, as a chronic condition that emerges over many years, or acutely, generally due to immobilization associated with an acute disease.
The physiopathology of sarcopenia is complex, and affects both the muscle and its neurological and hormonal regulation. The prevalence of sarcopenia increases with age and in certain healthcare settings nursing homes, hospitals, rehabilitation centres. Once confirmed, a syndromic approach is needed, based on a comprehensive geriatric assessment in order to determine its causes and prepare a treatment plan which addresses the treatment of symptoms as well as the etiology.
Prevention of sarcopenia starts in the adult age, through the promotion of adequate nutritional habits, an increase in physical activity and, ideally, resistance exercise. Sarcopenia treatment must necessarily include resistance exercises that can be associated with other types of exercise and an improvement in diet, increasing protein intake up to 1.
In some cases, this will require the use of nutritional supplements, which can contain leucine, beta-hydroxy beta-methylbutyrate acid HMB and vitamin D, in order to optimize its effects on the muscle. There are still no medications available to treat sarcopenia. In recent years, the term sarcopenia has gone from being hidden in a bunch of research articles for experts to become, together with frailty, one of the trendy terms in Geriatrics, rapidly extending to other specialties.
The number of research articles is increasing at exponential rate. It is increasingly frequent for older patients to receive this diagnosis. What is happening? This article offers a brief review of sarcopenia, trying to emphasize some aspects particularly important for the pharmaceutical practice.
It was first proposed in in order to define a well-known problem in older persons, but for which there was no adequate descriptive term so far: the loss of muscle mass and function, associated with age, which deteriorates mobility, nutrition status, and physical independence 1.
Even though sarcopenia causes major consequences on the life and physical ability of loss persons, it has not been acknowledged as a disease, in the International Classification of Diseases ICD until The best way to understand sarcopenia is as an organ impairment muscle insufficiency or muscle failure 2.
It generally appears in a chronic and latent manner, and settles slowly with ageing; but it can also appear rapidly, usually associated with an acute immobility or severe disease such as during hospitalization. Sarcopenia is closely associated with physical frailty 3 , 4.
Sarcopenia is one of the main causes for physical frailty. Both sarcopenia and frailty are factors predicting the development of physical disability; this is why research looking how to stop these conditions before disability apperes is so relevant. Currently, sarcopenia is defined as a geriatric syndrome characterized by a progressive and generalized loss of skeletal muscle mass and function, which increases the risk to suffer problems such as death, falls, physical disability and impaired quality of life 5.
It is not yet clear whether its prevalence is higher in women or in men, because there is no agreement between different studies, partly depending on the cut-off points used to determine muscle mass.
In clinical practice, three measurements are needed in order to diagnose sarcopenia: muscle mass, muscle strength, and physical performance Table 1. It must be considered that the cut-off points for each measurement can vary according to gender and age, and often also to race or country of origin.
Densitometry is becoming the standard procedure for measuring muscle mass; this can be conducted with the same equipment used for bone densitometry. Appendicular mass of the limbs will often be measured.
The usual alternative is bioimpedantiometry, which is a portable test. Many pharmacies and obesity clinics have foot bioimpedance meters, which are the least reliable in measuring muscle mass. The easiest measurement of muscle strength is a hand grip device. Physical performance a concept addressing the physical ability of the whole body, and not that of an isolated muscle it can be measured with simple tests, such as a four-meters gait speed test.
It is convenient to remember that sarcopenia is not the only disease which causes a generalized loss of muscle mass. This can be caused by other conditions mostly malnutrition and cachexia, and it is not always easy to differentiate between these three problems 7 , which can be interlinked, and therefore difficult to separate. Malnutrition causes loss of lean muscle mass as well as fat mass, and it is caused by an inadequate update of nutrients.
In cachexia, the loss of lean and fat mass is caused by a severe disease such as cancer. In sarcopenia, the fat mass is usually normal or increased; the latest is known as sarcopenic obesity 8. Once diagnosed, it is convenient to approach sarcopenia in the same way as other geriatric syndromes 9 , conducting a Comprehensive Geriatric Assessment in search of its causes Table 2. From the point of view of the pharmacist, it is important to review those medications that could be associated with sarcopenia 10 , 11 , It is best to conduct this task in an interdisciplinary approach which is adapted to the healthcare setting where the intervention is being conducted The physiopathology of sarcopenia is quite complex, including muscle processes as well as endocrinological and neurological regulatory processes 14 , With normal ageing, the quality of muscle fibers deteriorateds, with a reduction in their maximum potency, shortening speed and elasticity.
This deterioration in muscle cell function can be due to different changes associated with age, including the loss of anabolic stimulus secondary to a reduction in testosterone and other anabolic hormones, age-related sub-clinical inflammation inflammaging and molecular changes in cell contraction mechanisms.
Some of these changes can be partially reversed through continuous physical exercise. Anatomic changes also occur, such as a reduction in the number and activation of muscle satellite cells, a reduction in the number of muscular fibers particularly those of type IIA and fat infiltration of muscle, both at macro and microscopic level. The circulating levels of myostatin a growth factor that limits muscle mass growth also increase with age; and there is a modification in the regulation of different genes that regulate the muscle protein metabolism.
The neurological control of movement is also affected in sarcopenia, with a relevant role control by the loss of motor plates, which has not been fully understood yet. Many other neurological, endocrinological, and even microvascular mechanisms seem to be involved in the genesis of this disease. The prevalence of sarcopenia increases with age; thus, older people present a higher risk of sarcopenia.
Its frequency is so high at very advanced ages that it would be probably worth using screening tests to detect it in this population; however, there is still no agreement about the age at which this screening should start, and it has not been proved that population screening improves relevant clinical outcomes. Screening can be conducted using tools such as the SARC-F 16 questionnaire, currently under validation in several European languages.
The measure of walk speed could also be used, and all those people who walk less than 1 metre per second should be considered at risk. An alternative approach is to search for sarcopenia in certain healthcare settings or risk populations. The groups at special risk are older people admitted in hospitals, nursing homes or rehabilitation centres, and those who attend Geriatric outpatient clinics. Acute sarcopenia will frequently appear during hospitalization, as a consequence of long stays in bed and the presence of acute diseases.
Another alternative is to search for sarcopenia in risk populations, such as patients with repeated falls, those who seem to walk slower, show prolonged limitation in their physical activity, use a cane, or have problems getting up from their seat Sarcopenia prevention should start in adult age, because the loss of muscle mass and function starts at around age year-old, and becomes more evident when patients are over year-old.
Prevention is based on maintaining a high level of physical activity in daily life, conducting specific resistance exercises muscle strength , an adequate diet adherence to Mediterranean Diet, with a special emphasis on a high protein intake and avoiding risk behaviours smoking, drinking alcohol.
Implementing these habits can delay the development of sarcopenia possibly in over a decade, depending on the age at which changes start. Once established, it will be important to detect sarcopenia at the earliest stage possible. There are data suggesting that severe sarcopenia is more difficult to reverse than mild sarcopenia. The first step is to identify and treat its causes, generally through a Comprehensive Geriatric Assessment and a sequential therapeutic approach Figure 1.
Nutritional intervention and exercise will be the basis of treatment There are no medications approved for sarcopenia, though some are already in clinical research Figure 1.
Outline of sarcopenia management. First of all, it must be understood that exercise and physical activity are different concepts. The American Institute of Medicine defines physical activity as any movement caused by the contraction of skeletal muscles that increases the use of energy, and exercise as planned, structured and repetitive movements that seek to improve or maintain one or more components of physical fitness.
Physical activity includes any daily activity housework, going for a walk, moving around the house, hobbies ; physical exercise needs dedication and planning. There are very comprehensive recommendations by the American College of Sports Medicine on physical activity and exercise in older people 20 , and recent recommendations about how to promote them in persons living in nursing homes Sarcopenia management requires both an increase in physical activity and conducting a specific program of exercises, which must include resistance exercises with weights or elastic bands, to improve muscle function of lower limbs; therefore, it is usually beneficial to start them under the supervision of an expert in exercise.
It seems advisable to associate resistance exercise with other types of exercise aerobic, balance and flexibility in order to obtain the maximum benefit of said exercise. There are increasingly more resources available on-line videos and written material on exercise for older persons.
Currently it seems clear that a low protein intake in the adult age will predict to a high extent the risk of suffering physical disability in the future Therefore, it is reasonable to start by advising older patients with sarcopenia about their diet, correcting any nutritional deficiency found. Protein intake recommendations have experienced a great variation in recent years, going from 0. It is also recommended to distribute proteins regularly throughout the day, insisting on protein intake immediately after exercise, because the muscle appears to have the priority at that time in terms of receiving the proteins ingested.
For this reason, several interventions have been studied in order to improve the quality and quantity of diet in patients with sarcopenia, even though there are still limited data available The intake of essential aminoacids especially those rich in leucine represents a powerful stimulus for protein formation in the muscle, even though isolated protein supplements have not yet demonstrated benefits in clinical practice.
The same applies to creatine supplements. Beta-hydroxy beta-methylbutyrate acid HMB , a metabolic derivate of leucine, seems to have an important effect in mass improvement, and particularly in muscle function; however, in most clinical trials, it has been studied as part of a complete nutritional supplement.
Even though many of the previously mentioned supplements are used in Sports Medicine, the most robust studies in older people have been made with complete nutritional supplements, covering the needs in terms of calories as well as proteins; therefore, high-protein preparations are usually recommended. Rosenberg IH. Sarcopenia: Origins and Clinical Relevance. J Nutrition, ;SS. Cruz-Jentoft AJ. Sarcopenia, the last organ insufficiency. Eur Geriatr Med. From sarcopenia to frailty: a road less traveled.
Journal of Cachexia, Sarcopenia and Muscle. Sarcopenia: a useful paradigm for physical frailty. Age Ageing. Estimation of skeletal muscle mass by bioelectrical impedance analysis. J Appl Physiol. Thomas DR. Loss of skeletal muscle mass in aging: examining the relationship of starvation, sarcopenia and cachexia. Clin Nutr. J Nutr Health Aging. Understanding sarcopenia as a geriatric syndrome. Farm Hosp.
Fisiología de la sarcopenia. Similitudes y diferencias con la caquexia neoplásica
Sarcopenia or muscle insufficiency is a geriatric syndrome characterized by a progressive and generalized loss of skeletal muscle mass and function which has adverse consequences, particularly physical disability, falls and death. It can develop slowly, as a chronic condition that emerges over many years, or acutely, generally due to immobilization associated with an acute disease. The physiopathology of sarcopenia is complex, and affects both the muscle and its neurological and hormonal regulation. The prevalence of sarcopenia increases with age and in certain healthcare settings nursing homes, hospitals, rehabilitation centres. Once confirmed, a syndromic approach is needed, based on a comprehensive geriatric assessment in order to determine its causes and prepare a treatment plan which addresses the treatment of symptoms as well as the etiology. Prevention of sarcopenia starts in the adult age, through the promotion of adequate nutritional habits, an increase in physical activity and, ideally, resistance exercise. Sarcopenia treatment must necessarily include resistance exercises that can be associated with other types of exercise and an improvement in diet, increasing protein intake up to 1.
Sarcopenia: Definition, Epidemiology, and Pathophysiology
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. Resumen es: Las alteraciones que acontecen durante el proceso canceroso y el envejecimiento comparten bastantes vias metabolicas asi como tambien mediadores. Dado qu View PDF.
Sarcopenia is defined as an age-associated loss of skeletal muscle mass and is a major contributory factor in disability and loss of independence in the elderly. Several mechanisms, both intrinsic to muscle itself and changes in the central nervous system, are involved in the etiopathogenesis of this process. Hormonal factors and lifestyles are also involved. Changes intrinsic to muscle include a reduction in the proportion of rapid type II fibers and mitochondrial DNA injury. In the spinal cord, loss of motor units occurs. Several hormones and cytokines affect muscle function and mass.