A short report review article regarding sarcopenia published in Post Reproductive Health

Rethinking Sarcopenia and Frailty in the Elderly

Abstract

Sarcopenia, or ‘frailty of the elderly’, is a condition of low muscle mass which is prevalent in older adults and post-menopausal women, leading to falls or worsening after falls. Age related muscle thinning contributes to falls and fractures. Fractures lead to a downward spiral toward the loss of independence in the elderly and ultimately, increased health care expenditures of approximately 4 billion pounds a year. The diagnosis of sarcopenia is based on muscle mass, muscle strength, and physical performance. Sarcopenia is caused by imbalance between the anabolic and catabolic processes on the protein production pathway, as well as a decrease in satellite cells. Denervation, inflammation, hormonal changes, and mitochondrial decline further complicate the issue. Is it time that physicians begin to rethink the diagnosis of sarcopenia or frailty as a process that begins in mid-life? In women, it begins menopause and end with falls, fractures, or immobility due to weakness. Physicians often question which came first; frailty causing the fall or the fall worsening frailty, which leads to challenges in treatment. Sarcopenia treatment involves resistance training, an appropriate diet and being proactive about the diagnosis. These low-risk lifestyle interventions should be recommended during mid-life well woman visits. Physicians can influence the outcomes of sarcopenia simply by providing an exercise prescription, supplement and diet recommendation in early menopause. This article aims to change the thinking around sarcopenia from an ‘end stage’ diagnosis to a mid- life discussion around disease prevention and maintenance of health muscle.

Introduction

Mid- life for women comes with a variety of challenges, including the loss of estrogen’s influence on muscle and bone mass. Sarcopenia, or more commonly, ‘frailty’, is a diagnosis given when the skeletal muscle mass index is below 8.9kg/m2, and performance and strength are impacted. Sarcopenia or ‘frailty of the elderly’ is an often underdiagnosed condition. The prevalence in the elderly varies, but hovers around 29% in a community setting and up to 50% in those 80 years or older.1 The diagnosis of sarcopenia is based on muscle mass, muscle strength, and physical performance according to the 2010 definition of the European Working Group on Sarcopenia in Older People. In essence, the diagnosis is made when low muscle mass, low muscle strength and low muscle performance are all present.2,3 Some retrospective studies propose that skeletal muscle mass declines by 6% every decade of life after midlife.3 Additionally, there is a ‘pre-sarcopenia’ diagnosis in which women have low muscle mass without influence on strength or performance. In a large study conducted in the UK screening 500,000 participants for pre-sarcopenia and sarcopenia while assessing for fractures, both categories were at higher risk for fractures.4 Fractures further contribute to the loss of muscle. It is estimated that sarcopenia in women after a hip fracture increases by 5- 6% per year.5,6 It is estimated that 40% of elderly people do not return to their previous level of functioning after a hip fracture, with an estimated cost of 4 billion pounds per year.7,8 As osteoporosis is often present in patient with hip fractures,, rheumatologists are wondering if new diagnosis of osteosarcopenia in which osteoporosis and sarcopenia are both present should be considered .9

Pathophysiology

As bone and muscle are a unit of function, and one influence the other, it makes sense to look at the pathophysiology of the entire bone/muscle unit. The ‘mechanostat’ theory states that muscle imposes mechanical forces on bone, and if these exceed a set threshold, the equilibrium of bone turnover shifts away from bone resorption to bone formation. Muscle mass plays a part by stretching the periosteum of the bone thereby increasing the muscle mass. Decreased muscle mass due to aging, hormone influence, inflammation and sedentary lifestyle, and loss of satellite cells and mitochondria further influence the unit of function. As both bone and muscle have estrogen receptors in women, early menopause without treatment is a risk. Conversely, hormone replacement therapy helps to preserve muscle function and bone integrity.10 There are factors associated with development of sarcopenia and osteoporosis both, including genetic factors, cigarette smoking, physical inactivity, diet and alcohol use, age, sex and ethnicity. 10,11,12,13,14, 15,16,17,18 There is a growing body of evidence that women’s post- climacteric decline in muscle mass is associated with loss of estrogen. Research findings show estrogen receptors (ER) are present in the chondrocyte and synoviocyte cells of the knee. In addition, radiologic studies demonstrate that women’s knee cartilage deteriorates faster than men’s, likely caused by the loss of estrogen effect on the chondrocyte. In addition, estrogen modulates macrophage maturation19,20,21,22 With the combined diagnosis of osteosarcopenia, muscle cells are needed to release bone-regulated cytokines. The cytokines cause the bone cells to then release IGF-1, which has potential muscle-stimulating properties. In essence, the development of healthy muscle is dependent on healthy bones, and vice versa

Rethinking Treatment

The roots of both osteoporosis and sarcopenia begin in mid-life, yet physicians often wait until there is an ‘official’ diagnosis to initiate a program of treatment,assist with prevention, or make recommendations to delay further progression. Much emphasis has been placed on menopausal hormone decline and appropriate timing to end exogenous hormones. Unfortunately, there is less understanding of the effects of hormone decline on collagen tissue, bones and joints, which often causes a delay in treatment. Treatment should start with a conversation in a women’s 50’s around lifestyle, diet, and exercise for example. The benefits of diet and exercise in sarcopenia are clear, specifically the benefits of resistance training for improving muscle mass and decreasing fat mass.23 The Mediterranean Diet has been shown to play a positive role in both muscle strength and bone density.16 Adequate protein intake is needed for sarcopenia patients to have foundations for muscle development. Several studies have combined 20 mg of whey protein with 800 iu dose of Vitamin D with good results, including increased lean muscle mass.24 The role of supplementation is controversial and no known ‘protocol’ for supplementation has been established. There is some evidence that CoQ10 may be beneficial to patients with known sarcopenia. In a scoping review of 4 studies, CoQ10 supplementation of 100-300mg daily in patients with known sarcopenia made a statistically significant improvement on frailty and falls.25In one retrospective meta- analysis of 196 records on β-hydroxy-β-methylbutyrate (HMB) supplementation, there was improvement in muscle mass and strength but not performance, though more research is needed.26

Early treatment with resistance training can be accomplished with weights, therapy bands or assistive devices such as a Pilates reformer or weight machines. One study on prevention of sarcopenia used low blood flow weight training, or KAATSU training with free weights or weight machines. This method uses an elastic band to moderately restrict the blood flow while the patient does the workout. This method assists with recruitment of fast twitch fibers and growth hormone.27

While sarcopenia is often associated with frailty, there is a subset of sarcopenic patients that are obese. Sarcopenic obesity occurs when the BMI is >25 and the patient meets the diagnostic criteria for sarcopenia. In one study comparing non-sarcopenic patients, sarcopenic patient without obesity and obese sarcopenic patients for osteoarthritis (OA) of the knee, the obese sarcopenic patients had the highest incidence of knee OA. In the sarcopenic obesity group knee osteoarthritis was highest at 61.49% vs 41.82 % in the control group.28 Dietary needs in the sarcopenic obese group should focus on reduction of fat while improving muscle mass, but caloric intake is usually not an issue as it often is with undernourished or frail sarcopenic patients.

Conclusion

Sarcopenia is a challenging diagnosis for men and women alike, but for mature adult women it can lead to a downward spiral towards the loss of independence when not treated early, leading to increased health care expenditures. Inactivity, loss of estrogen and physiologic changes tip the scale toward muscle decline. The additional diagnosis of osteoporosis may further complicate the picture. Rethinking these conditions as a continuum starting in mid-life and progressing to eventual falls or fractures may be needed. Since many of the interventions are lifestyle oriented, especially for sarcopenia, physicians should intervene earlier with recommendations for muscle preservation for all patients. Counseling during well women visits regarding exercise, specifically resistance training, lifestyle interventions and dietary changes may protect patients prior to development of the disease. In addition, suggesting added protein, supplements such HMB and CoQ10 100-300 daily and 800iu of vitamin D for those in northern latitudes might provide even further protection. Physicians should check 25-hydroxy vitamin D levels if there is a concern. Future research is needed, specifically around women and prevention of sarcopenia. Only then will there be answers to the conundrum of which came first: sarcopenia causing falls or falls worsening sarcopenia.



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