Rolland

Yves ROLLANDInserm U1027, University of Toulouse, Gerontopôle, FRANCE

Evaluation of sarcopenia

4th International Seminar on Preventive Geriatrics & 1st International Seminar on Geriatric Rehabilitation

A - Why a consensual definition of sarcopenia ?

B - The different clinical approaches

C – European Working Group on Sarcopenia

Agenda



C – European Working Group on Sarcopenia

Agenda

4th International Seminar on Preventive Geriatrics


Irwin Rosenberg (1989)

Sarcopenia : the observed age-related decline in muscle mass

Age-related loss of muscle mass

Age-related loss of muscle strength

Low muscle mass in old age

Loss of muscle mass

Loss of muscle strength

Low muscle strength in old age

Low muscle mass, muscle strength and function in old age

Since 1989

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10

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30

40

50

60

NMEHS NHANES III CHS ABC ABC ABC ABC REP

women men black w black m

American Cohorts

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10

20

30

40

50

60

INCHIANTI INCHIANTI EPIDOS LASA CHINESE

women menHistogrammes 3D 3 Histogrammes 3D 4

European and Asiatic Cohorts

%

%


A - Why a consensual definition of sarcopenia ? What is the prevalence among countries or ethnicities ?

Prevalence ?

Target population ?

Generalization of the results ?


A - Why a consensual definition of sarcopenia ? Sarcopenia, an overlapping condition ?

Cachexia, sarcopenia, starvation, frailty -overlapping conditions

Cachexia

Starvation

Sarcopenia

Frailty

An unclear distinction !

Medline Pubmed 2010 : 773 publications with “sarcopenia”

28 publications with “sarcopenia” + “RCT”


A - Why a consensual definition of sarcopenia ? DRUGS FOR IMPROVING FUNCTIONAL STATUS IN OLDER PERSONS



Yearly costs, (US)

Osteoporotic fractures

$16.3 billion $18.5 billion

Sarcopenia



Map of 721 studies found by search of: osteoporosis

JUNE 2010

http://www.nih.gov/

http://www.nlm.nih.gov/

http://www.os.dhhs.gov/



Map of 38 studies found by search of: sarcopenia

Only a handful of clinical trials are under way to treat sarcopenia

JUNE 2010

http://www.nih.gov/

http://www.nlm.nih.gov/

http://www.os.dhhs.gov/



The FDA may not consider sarcopenia itself as an indication for treatment.

How treatments of mobility limitation should be Developed ? Tested ?



An operational definition of sarcopenia that can be used both for research and clinical practice is

needed



C – Sarcopenia working group (European Union Geriatric Medicine Society)

Agenda

ANTHROPOMETRY Low cost, easy, low accuracy

BIOLOGY (creatinine excretion, 40K)Complicated

BIA (bio-impedancemetry)Low cost, easy, low accuracy

IMAGING MRI and CT

Muscle quality, high cost, difficult to perform, radiations

DXA Low cost, accurate, easy, No information about muscle quality



Assessment of muscle mass

ANTHROPOMETRY Low cost, easy, low accuracy

BIOLOGY (creatinine excretion, 40K)Complicated

BIA (bio-impedancemetry)Low cost, easy, low accuracy

IMAGING MRI and CT

Muscle quality, high cost, difficult to perform, radiations

DXA Low cost, accurate, easy, No information about muscle quality



Assessment of muscle mass

skeletal muscle mass index (SMI) = ASM/height² in kg/m²

SMI less than 2 SD below the mean SMI of a reference young population from the Rosetta study are considered sarcopenic. Men < 7.26 kg/m² Women < 5.45 kg/m²


B - The different clinical approaches Dual X-ray Absorptiometry (DXA) Baumgartner et al. (1998)

Osteoporosis


Fracture threshold

Men

Woman

Mobilitylimitation threshold

Men

Woman

Muscle massBone Mineral DensitySarcopenia ?

Age (years) Age (years)



Associations of sarcopenia with physical disability or a history of injuryNew Mexico Elder Health Survey, 1993-1995

t OR for >3 disabilities were adjusted for age, ethnicity, obesity, income, alcohol intake, physical activity score, current smoking, and comorbidity.

OR for all other variables were adjusted for age, ethnicity, obesity, comorbidity, and alcohol intake.



B - The different clinical approaches ASM/height²

Advantages

- Easy to apply- Understandable

Disadvantages

- Need a DXA- The threshold- Obese and thin - Muscle mass : the most important clinical parameter


B - The different clinical approaches Need a DXA

Already used in the diagnosis of osteoporosisbut

Low access to the DXA, specially for frail elderly

Osteoporosis ≠ Sarcopenia


B - The different clinical approaches What threshold ?

Mobilitylimitation threshold

Men

Woman

Muscle mass

Reference population ?

How to define mobillity limitation ?

Dual X-ray Absorptiometry (DXA)Janssen, Baumgartner, Ross, Rosenberg, Roubenoff (2004)

4,449 participants from the Third NHANES 1988–1994


Moderate risk SMI 5.76-6.75 womenSMI 8.51-10.75 men




High risk SMI ≤5.75 women SMI ≤8.50 men




ASM/height²

High muscle masswith mobility limitations

Low Muscle mass without mobility limitations

Thin Obese


B - The different clinical approaches (DXA) ASM/height²

6414 persons (NHANES III)


B - The different clinical approaches ASM/weight x100

Sarcopenia :1 SD below the mean = class I

2 SD below the mean = class II

Men

class 1 = 31.5 – 37% class 2 = <31.5%

Women

class 1 = 22.1 – 27.6% class 2 = <22.1


B - The different clinical approaches Residual method

Height (m)

Ap

pen

dic

ula

r M

usc

le M

ass

(kg

)

menr=0.49

Residual method


B - The different clinical approaches Residual method

Lean Mass is derived by adjusting for fat mass in addition to height

Newman et al.


B - The different clinical approaches ASM/height² ASM/weight Residual method

Advantages

- More or less easy to apply in clinical practice- Understandable

Disadvantages

- Need a DXA- The threshold- Obese and thin - Muscle mass : the most important clinical parameter


B - The different clinical approaches Muscle mass : the most important clinical parameter ?

A strong interrelationship between lower extremity muscle mass and muscle strength

muscle mass accounted for 60% of the total variance in muscle strength

Lower extremity muscle mass and muscle strength are independent determinants

of the severity of mobility-disability.

Potential sites and physiological mechanisms

that regulate strength

J Geront Med Sci 2008: 829-834


B - The different clinical approaches Muscle mass : the most important clinical parameter ?

Decreased cortical

excitability

Decreased spinal excitability

Decreased maximal motor unit discharge rate

slowed nerve conduction

5Alterations in muscle

architecture

6 & 7Decreased muscle mass; Increased myocellular lipid

content

E-C uncoupling

Physical performance or muscle strength tests



Physical performance or muscle strength tests



Assessed by:knee extensionisometric torque, handgrip, lower extremity muscle power, 4-meter walk test6-min walk testShort physical performance batteryChair stand test, One-leg balance test

Instrumental and Activity Daily Living

Lack of physical activityLoss of neuro-muscular functionAlteration in endocrine functionApoptosisPro-inflammatory cytokinesGeneticLow food intake

Physical disability

Functional limitation

SarcopeniaMechanisms

DXAImpedancemetryMRIUtrasonographyAnthropometrics measure


B - The different clinical approaches Grip strength, knee ext strength, muscle power…

Advantages

- More or less easy to apply in clinical practice- Understandable- Simple (hand grip strength, …) or no device

Disadvantages

- Which functional test ?- The threshold- Depend on motivation, willpower, pain (osteoarthritis) - Muscle strength : the most important parameter



C – Sarcopenia working group (European Union Geriatric Medicine Society)

Agenda

Definition & Diagnosis of Sarcopenia

Endorsed by European Society for Clinical Nutrition & Metabolism

International Association of Gerontology & Geriatrics

International Academy of Nutrition & Aging

European Union Geriatric Medicine Society


C - SARCOPENIA WORKING GROUP

C - EWGSOP Working Definition of Sarcopenia


Cruz-Jentoft AJ et al. Sarcopenia: European consensus on definition and diagnosis. Report of the European Working Group on Sarcopenia in Older People. Age Ageing 2010

Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death.

CRITERIA FOR THE DIAGNOSIS OF SARCOPENIACRITERIA FOR THE DIAGNOSIS OF SARCOPENIA

LOW MUSCLE

MASS

LOW MUSCLE

MASS

LOW PHYSICAL PERFORMANCELOW PHYSICAL PERFORMANCE

LOW MUSCLE STRENGTH

LOW MUSCLE STRENGTH

OR SARCOPENIA



Sarcopenia staging, which reflects the severity of the condition, is a concept that can help guide clinical

management of the condition.



Stage Muscle mass Muscle strength Performance

Presarcopenia ↓

Sarcopenia ↓ ↓ Or ↓

Severe sarcopenia ↓ ↓ ↓



LOW MUSCLE

MASS

LOW PHYSICAL PERFORMANCE

LOW MUSCLE STRENGTH

ORSARCOPENIA

SEVERESARCOPENIA

PRE-SARCOPENIAAND







EWGSOP Categories of sarcopeniaEWGSOP Categories of sarcopenia

PrimaryAge-relatedPrimary

Age-related

SecondarySecondary



Suggested measures to diagnose sarcopeniaSuggested measures to diagnose sarcopenia



Case findingCase findingSubject >65 years

Usual gait speed

No sarcopenia

Muscle mass

Grip stregth

No sarcopenia

Sarcopenia

NORMAL

NORMAL

SLOW

LOW

LOW

NORMAL

LOW MUSCLE

STRENGTH

An operational definition of sarcopenia that can be used both for research and clinical practice is urgently needed

Sarcopenia is a syndrome characterized by progressive loss of muscle mass and strength with a risk of adverse outcomes

Sarcopenia is a geriatric syndrome; i.e. is prevalent, has multi-factorial pathogenesis and poor outcome

The current proposed classification and staging of sarcopenia has to be validated in future studies


Summary

Rolland

Health & Medicine

sarcopenia agenda

prevalence of sarcopenia

international seminar

preventive geriatrics

preventive geriatrics

muscle mass nhanes

old age low muscle mass

ct muscle quality