Pharmacologic Options for the Treatment of Sarcopenia

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

The Efficacy of the Novel Bioavailable Curcumin (Cureit) in the Management of Sarcopenia in Healthy Elderly Subjects: A Randomized, Placebo-Controlled, Double-Blind Clinical Study

Sarcopenia represents the progressive loss of skeletal muscles, which occurs as a result of aging. Plant-derived phytochemicals have the potential ability to manage sarcopenial conditions. The randomized, placebo-controlled, double-blind clinical study involving thirty subjects evaluated the efficacy of Cureit™ supplementation in the management of sarcopenial conditions by measuring the variables, such as hand grip strength, weight lift strength, time/distance before feeling tired after cycling, walking and climbing stairs, and Karnofsky performance scale index along with effects on general fitness, such as protein, urea, oxidative stress, and hematology parameters. The results showed that Cureit supplementation resulted in a significant increase of 1.43% (P < .001) in the handgrip strength compared with placebo. The weight-lifting capacity of subjects supplemented with Cureit showed an increase of 6.08%, whereas placebo showed a 4.54% decrease after the end of the study period. The results demonstrated that the Cureit tended to have a positive impact on distance covered before feeling tired as shown by an increase (P = .09) of 5.51%, compared with placebo group, which showed an increase of 2.29%. The time taken to walk the same distance was reduced in the Cureit group (1.15%), whereas in the placebo group, it was increased (2.02%). Cureit plays a significant role in the management of sarcopenia by anti-inflammatory action, increased hand grip strength, antifatigue effects, and muscle protein management. Clinical Trials Registry-India registration no. CTRI/2018/05/014176.

Sarcopenia: Clinical implications in ovarian cancer, diagnosis, etiology, and management

Sarcopenia, loss of skeletal muscle and function, is a common condition among the elderly and is known to cause adverse health outcomes and increased risk of morbidity and mortality. This progressive and generalized disorder imposes a considerable socioeconomic burden. Sarcopenia is observed commonly in cancer patients. As Asia is one of the fastest aging regions in the world, it is clear that incidences of both sarcopenia and ovarian cancer will increase together in Asian countries. Ovarian cancer patients are vulnerable to develop sarcopenia during the treatment course and progress of disease, and a considerable number of patients with ovarian cancer seems to have physical inactivity and sarcopenia already at the time of diagnosis. Therefore, management of sarcopenia should be conducted together in parallel with ovarian cancer treatment and surveillance. Thus, in this article, we will review the clinical importance of sarcopenia in the aspect of ovarian cancer. Definition of sarcopenia, diagnosis, etiology, and intervention will be also introduced.

Impact of Mitophagy and Mitochondrial Unfolded Protein Response as New Adaptive Mechanisms Underlying Old Pathologies: Sarcopenia and Non-Alcoholic Fatty Liver Disease

Mitochondria are the first-line defense of the cell in the presence of stressing processes that can induce mitochondrial dysfunction. Under these conditions, the activation of two axes is accomplished, namely, (i) the mitochondrial unfolded protein response (UPRmt) to promote cell recovery and survival of the mitochondrial network; (ii) the mitophagy process to eliminate altered or dysfunctional mitochondria. For these purposes, the former response induces the expression of chaperones, proteases, antioxidant components and protein import and assembly factors, whereas the latter is signaled through the activation of the PINK1/Parkin and BNIP3/NIX pathways. These adaptive mechanisms may be compromised during aging, leading to the development of several pathologies including sarcopenia, defined as the loss of skeletal muscle mass and performance; and non-alcoholic fatty liver disease (NAFLD). These age-associated diseases are characterized by the progressive loss of organ function due to the accumulation of reactive oxygen species (ROS)-induced damage to biomolecules, since the ability to counteract the continuous and large generation of ROS becomes increasingly inefficient with aging, resulting in mitochondrial dysfunction as a central pathogenic mechanism. Nevertheless, the role of the integrated stress response (ISR) involving UPRmt and mitophagy in the development and progression of these illnesses is still a matter of debate, considering that some studies indicate that the prolonged exposure to low levels of stress may trigger these mechanisms to maintain mitohormesis, whereas others sustain that chronic activation of them could lead to cell death. In this review, we discuss the available research that contributes to unveil the role of the mitochondrial UPR in the development of sarcopenia, in an attempt to describe changes prior to the manifestation of severe symptoms; and in NAFLD, in order to prevent or reverse fat accumulation and its progression by means of suitable protocols to be addressed in future studies.

Cardiac cachexia: the mandate to increase clinician awareness

PURPOSE OF REVIEW

Heart failure is a frequent problem in an ageing population, associated with high rates of morbidity and mortality. Today, it is important to not only treat heart failure itself but also the related comorbidities. Among them, cardiac cachexia is one of the major challenges. It is a complex multifactorial disease with a negative impact on quality of life and prognosis. Therefore, prevention, early recognition and treatment of cardiac cachexia is essential.

RECENT FINDINGS

Cardiac cachexia frequently presents with skeletal as well as heart muscle depletion. Imaging-based diagnostic techniques can help to identify patients with cardiac cachexia and muscle wasting. Several blood biomarkers are available to detect metabolic changes in cardiac cachexia.

SUMMARY

Several studies are currently ongoing to better comprehend the underlying pathophysiological mechanisms of cardiac cachexia and to find new treatments. It is essential to diagnose it as early as possible to initiate therapy.

Effects of vibration therapy on muscle mass, muscle strength and physical function in older adults with sarcopenia: a systematic review and meta-analysis

Background

Sarcopenia, a progressive loss of muscle mass and function with advancing age, is a prevalent condition among older adults. As most older people are too frail to do intensive exercise and vibration therapy has low risk and ease of participation, it may be more readily accepted by elderly individuals. However, it remains unclear whether vibration therapy would be effective among older adults with sarcopenia. This systematic review and meta-analysis examined the effect of vibration therapy including local vibration therapy and whole-body vibration therapy, for enhancing muscle mass, muscle strength and physical function in older people with sarcopenia.

Methods

A systematic literature search was conducted in March 2019 in the following 5 electronic databases: PubMed, CINAHL, Embase, PEDro, and the Cochrane Central Register of Controlled Trials, with no restriction of language or the year of publication. Randomized controlled trials and quasi-experimental studies examining effects of vibration therapy on muscle mass, muscle strength or physical function in older adults with sarcopenia were included in this systematic review. Two reviewers independently assessed the methodological quality of the selected studies.

Results

Of the 1972 identified studies, seven publications from six studies involving 223 participants were included in this systematic review. Five of them conducted whole-body vibration therapy, while two conducted local vibration therapy. A meta-analysis of randomized controlled studies indicated that muscle strength significantly increased after whole-body vibration therapy (SMD 0.69, 95% CI 0.28 to 1.11, I² = 0%, P = 0.001) and local vibration therapy (SMD 3.78, 95% CI 2.29 to 5.28, P < 0.001). Physical performance measured by the sit-to-stand test and the timed-up-and-go test were significantly improved after the intervention (SMD -0.79, 95% CI − 1.21 to − 0.37, I² = 0%, P < 0.001) and SMD -0.83, 95% CI − 1.56 to − 0.11, I² = 64%, P = 0.02, respectively).

Conclusion

Vibration therapy could be a prospective strategy for improving muscle strength and physical performance in older adults with sarcopenia. However, due to the limited number of the included studies, caution is needed when interpreting these results. More well-designed, large sample size studies should be conducted to further explore and validate the benefits of vibration therapy for this population.

Muscle Wasting and Sarcopenia in Heart Failure-The Current State of Science

Sarcopenia is primarily characterized by skeletal muscle disturbances such as loss of muscle mass, quality, strength, and physical performance. It is commonly seen in elderly patients with chronic diseases. The prevalence of sarcopenia in chronic heart failure (HF) patients amounts to up to 20% and may progress into cardiac cachexia. Muscle wasting is a strong predictor of frailty and reduced survival in HF patients. Despite many different techniques and clinical tests, there is still no broadly available gold standard for the diagnosis of sarcopenia. Resistance exercise and nutritional supplementation represent the currently most used strategies against wasting disorders. Ongoing research is investigating skeletal muscle mitochondrial dysfunction as a new possible target for pharmacological compounds. Novel agents such as synthetic ghrelin and selective androgen receptor modulators (SARMs) seem promising in counteracting muscle abnormalities but their effectiveness in HF patients has not been assessed yet. In the last decades, many advances have been accomplished but sarcopenia remains an underdiagnosed pathology and more efforts are needed to find an efficacious therapeutic plan. The purpose of this review is to illustrate the current knowledge in terms of pathogenesis, diagnosis, and treatment of sarcopenia in order to provide a better understanding of wasting disorders occurring in chronic heart failure.

Characteristics of sarcopenia by European consensuses and a phenotype score

BACKGROUND

We aimed to assess the clinical characteristics of sarcopenia by the original and revised European Working Group on Sarcopenia in Older People (EWGSOP 1 and 2), and to propose a new sarcopenia phenotype score (SPS) to improve relevance of clinical outcomes.

METHODS

Analyses were performed in 1408 older adults of the Aging Study of PyeongChang Rural Area, a community-based cohort in Korea. For sarcopenia definitions, we used EWGSOP 1, EWGSOP 2, and SPS, a new index counting number of abnormal domains among components of grip strength, gait speed, or muscle mass. Frailty status by the frailty index and the Cardiovascular Health Study frailty score was compared with sarcopenia measures. Prediction ability for composite outcome combining death and institutionalization due to functional decline was assessed among sarcopenia measures.

RESULTS

Generally, sarcopenia spectrum by both EWGSOP 1 and 2 was associated with worse functional status in parameters of geriatric assessments. However, population who were considered as sarcopenic by EWGSOP 1, but not by EWGSOP 2, showed increased risk of composite outcome and worse frailty status, compared with people who were classified as not sarcopenic by both EWGSOP 1 and 2. With SPS, dose-response relationship was observed with both frailty status and outcome prediction. Prediction for composite outcome was better in SPS than in EWGSOP 2 classification.

CONCLUSIONS

A new SPS might be used to classify sarcopenic burden in older adults to resolve possible inconsistencies in phenotype correlation and outcome prediction of EWGSOP 2 criteria.

Commentary on the effects of receptor activator of nuclear factor-B ligand inhibition on bone mass and muscle strength

The pathophysiology of osteoporosis and sarcopenia.

Inactivity and Skeletal Muscle Metabolism: A Vicious Cycle in Old Age

Aging is an inevitable and gradually progressive process affecting all organs and systems. The musculoskeletal system makes no exception, elderly exhibit an increased risk of sarcopenia (low muscle mass),dynapenia (declining muscle strength), and subsequent disability. Whereas in recent years the subject of skeletal muscle metabolic decline in the elderly has been gathering interest amongst researchers, as well as medical professionals, there are many challenges yet to be solved in order to counteract the effects of aging on muscle function efficiently. Noteworthy, it has been shown that aging individuals exhibit a decline in skeletal muscle metabolism, a phenomenon which may be linked to a number of predisposing (risk) factors such as telomere attrition, epigenetic changes, mitochondrial dysfunction, sedentary behavior (leading to body composition alterations), age-related low-grade systemic inflammation (inflammaging), hormonal imbalance, as well as a hypoproteic diet (unable to counterbalance the repercussions of the age-related increase in skeletal muscle catabolism). The present review aims to discuss the relationship between old age and muscle wasting in an effort to highlight the modifications in skeletal muscle metabolism associated with aging and physical activity.

Sarcopenia: A Time for Action. An SCWD Position Paper

The term sarcopenia was introduced in 1988. The original definition was a "muscle loss" of the appendicular muscle mass in the older people as measured by dual energy x-ray absorptiometry (DXA). In 2010, the definition was altered to be low muscle mass together with low muscle function and this was agreed upon as reported in a number of consensus papers. The Society of Sarcopenia, Cachexia and Wasting Disorders supports the recommendations of more recent consensus conferences, i.e. that rapid screening, such as with the SARC-F questionnaire, should be utilized with a formal diagnosis being made by measuring grip strength or chair stand together with DXA estimation of appendicular muscle mass (indexed for height2). Assessments of the utility of ultrasound and creatine dilution techniques are ongoing. Use of ultrasound may not be easily reproducible. Primary sarcopenia is aging associated (mediated) loss of muscle mass. Secondary sarcopenia (or disease-related sarcopenia) has predominantly focused on loss of muscle mass without the emphasis on muscle function. Diseases that can cause muscle wasting (i.e. secondary sarcopenia) include malignant cancer, COPD, heart failure, and renal failure and others. Management of sarcopenia should consist of resistance exercise in combination with a protein intake of 1 to 1.5 g/kg/day. There is insufficient evidence that vitamin D and anabolic steroids are beneficial. These recommendations apply to both primary (age-related) sarcopenia and secondary (disease related) sarcopenia. Secondary sarcopenia also needs appropriate treatment of the underlying disease. It is important that primary care health professionals become aware of and make the diagnosis of age-related and disease-related sarcopenia. It is important to address the risk factors for sarcopenia, particularly low physical activity and sedentary behavior in the general population, using a life-long approach. There is a need for more clinical research into the appropriate measurement for muscle mass and the management of sarcopenia. Accordingly, this position statement provides recommendations on the management of sarcopenia and how to progress the knowledge and recognition of sarcopenia.

Stem cell derived exosomes: microRNA therapy for age-related musculoskeletal disorders

Age-associated musculoskeletal disorders (MSDs) have been historically overlooked by mainstream biopharmaceutical researchers. However, it has now been recognized that stem and progenitor cells confer innate healing capacity for the musculoskeletal system. Current evidence indicates that exosomes are particularly important in this process as they can mediate sequential and reciprocal interactions between cells to initiate and enhance healing. The present review focuses on stem cells (SCs) derived exosomes as a regenerative therapy for treatment of musculoskeletal disorders. We discuss mechanisms involving exosome-mediated transfer of RNAs and how these have been demonstrated in vitro and in vivo to affect signal transduction pathways in target cells. We envision that standardized protocols for stem cell culture as well as for the isolation and characterization of exosomes enable GMP-compliant large-scale production of SCs-derived exosomes. Hence, potential new treatment for age-related degenerative diseases can be seen in the horizon.

Therapeutic approaches to osteosarcopenia: insights for the clinician

Osteopenia/osteoporosis and sarcopenia are both age-related conditions. Given the well-defined bone and muscle interaction, when osteopenia and sarcopenia occur simultaneously, this geriatric syndrome is defined as ‘osteosarcopenia’. Evidence exists about therapeutic interventions common to both bone and muscle, which could thereby be effective in treating osteosarcopenia. In addition, there are roles for common nonpharmacological strategies such as nutritional intervention and physical exercise prescription in the management of this condition. In this review we summarize the evidence on current and upcoming therapeutic approaches to osteosarcopenia.

Is There Enough Evidence for Osteosarcopenic Obesity as a Distinct Entity? A Critical Literature Review

The co-existence of impaired bone health (osteopenia/osteoporosis), reduced muscle mass and strength (sarcopenia), and increased adiposity (obesity) in middle-aged and older people has been identified in recent studies, leading to a proposal for the existence of "osteosarcopenic obesity" as a distinct entity. Evidence for the pathophysiological overlap of these conditions is mounting, although a causal relationship is yet to be established. Each component condition occurs frequently with increasing age, and with shared risk factors in many instances, thus, an overlap of these three conditions is not surprising. However, whether the concurrent existence of sarcopenia, osteoporosis and obesity leads to an increased risk of adverse musculoskeletal outcomes and mortality above and beyond the risks associated with the sum of the component parts remains to be proven and is a question of research interest. In this article, we review evidence for the existence of osteosarcopenic obesity including the current operational definition of osteosarcopenic obesity, prevalence, pathophysiology, outcomes and exploratory approaches to the management of components. We conclude that, there is insufficient evidence to support a discrete clinical entity of osteosarcopenic obesity at this time. To expand knowledge and understanding in this area, there is a need for consensus on a definition of osteosarcopenic obesity which will allow for identification, further epidemiological studies and comparisons between studies. Additionally, studies should assess whether the clinical outcomes associated with osteosarcopenic obesity are worse than the mere addition of those linked with its components. This will help to determine whether defining a person as having this triad will eventually result in a more effective treatment than addressing each of the three conditions separately.

Regulatory mechanisms and clinical manifestations of musculoskeletal aging

Aging is the strongest risk factor for degenerative bone and joint diseases. Clinical therapies for age-related musculoskeletal disorders face significant challenges as their pathogenic mechanisms remain largely unclear. This review article focuses on the recent advances in the understanding of regulatory mechanisms of musculoskeletal aging and their clinical relevance. We begin with the prevalence and socioeconomic impacts of major age-related musculoskeletal disorders such as sarcopenia, osteoporosis, osteoarthritis, and degenerative tendinopathy. The current understanding of responsible biological mechanisms involved in general aging is then summarized. Proposed molecular, cellular, and biomechanical mechanisms relevant to the clinical manifestations of aging in the musculoskeletal system are discussed in detail, with a focus on the disorders affecting muscle, bone, articular cartilage, and tendon. Although musculoskeletal aging processes share many common pathways with the aging of other body systems, unique molecular and cellular mechanisms may be involved in the aging processes of musculoskeletal tissues. Advancements in the understanding of regulatory mechanisms of musculoskeletal aging may promote the development of novel treatments for age-related musculoskeletal disorders. Finally, future research directions for major musculoskeletal tissues including functional interaction between the tissues and their clinical relevance to age-related musculoskeletal disorders are highlighted in the Future Prospects section. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1475-1488, 2019.

New insights into the pathogenesis and treatment of sarcopenia in chronic heart failure

Sarcopenia is an age-related geriatric syndrome that is characterized by a progressive loss of muscle mass, strength and function. Chronic heart failure (CHF), the final stage of various cardiovascular diseases, may be closely correlated with the occurrence of sarcopenia. Accumulating evidence has demonstrated that CHF can promote the development of sarcopenia through multiple pathophysiological mechanisms, including malnutrition, inflammation, hormonal changes, oxidative stress, autophagy, and apoptosis. Additionally, CHF can aggravate the adverse outcomes associated with sarcopenia, including falls, osteoporosis, frailty, cachexia, hospitalization, and mortality. Sarcopenia and CHF are mutually interacting clinical syndromes. Patients with these two syndromes seem to endure a double burden, with no particularly effective way to hinder their progression. However, the combination of physical exercise, nutritional supplements, and drug therapy may counteract the development of these maladies. In this review, we will summarize the latest progress in the pathogenesis and treatment of sarcopenia in patients with CHF.

Efficacy of Xianling Gubao capsule in treating sarco-osteopenia: Protocol for a systematic review and meta-analysis

BACKGROUND

Sarco-osteopenia (SOP) is a new type of geriatric syndrome, resulting from the combination of sarcopenia (SP) and osteoporosis (OP). Xianling Gubao capsule (XLGBC), made from several traditional Chinese medicine, is reported to have a therapeutic effect on diseases of bones and joints. This protocol will be designed to assess the efficacy of XLGBC in the treatment of SOP.

METHODS

Relevant randomized controlled trial literatures evaluating the effect of XLGBC on patients with SOP will be obtained by searching the following 7 electronic databases: Cochrane Library, PubMed, Embase, Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Chinese Biomedical and Medical Database (CBM), and Wanfang Database, from inception to March 2019. The primary outcomes will be bone mineral density, skeletal muscle mass index, handgrip strength, and gait speed. Stata V.13.0 software will be used for data synthesis and analysis, sensitivity analysis, subgroup analysis, and risk of bias assessment. Reporting bias will be evaluated utilizing a funnel, with Egger tests assessing funnel plot symmetries. Quality of evidence will be evaluated according to guidance of the Recommendations Assessment, Development, and Evaluation guideline.

RESULT

This study will provide a rational synthesis of current evidences for XLGBC on SOP.

CONCLUSION

The conclusion of this study will provide evidence to judge the effectiveness and safety of XLGBC on SOP.

ETHICS AND DISSEMINATION

This systematic review will be contributed to peer-reviewed publications, aiming to provide evidence about efficacy of XLGBC on SOP.

TRIAL REGISTRATION NUMBER

CRD42019128223.

The Beneficial Effects of Taurine to Counteract Sarcopenia

Aging is a multifactorial process characterized by several features including low-grade inflammation, increased oxidative stress and reduced regenerative capacity, which ultimately lead to alteration in morpho-functional properties of skeletal muscle, thus promoting sarcopenia. This condition is characterized by a gradual loss of muscle mass due to an unbalance between protein synthesis and degradation, finally conveying in functional decline and disability. The development of specific therapeutic approaches able to block or reverse this condition may represent an invaluable tool for the promotion of a healthy aging among elderly people. It is well established that changes in the quantity and the quality of dietary proteins, as well as the intake of specific amino acids, are able to counteract some of the physiopathological processes related to the progression of the loss of muscle mass and may have beneficial effects in improving the anabolic response of muscle in the elderly. Taurine is a non-essential amino acid expressed in high concentration in several mammalian tissues and particularly in skeletal muscle where it is involved in the modulation of intracellular calcium concentration and ion channel regulation and where it also acts as an antioxidant and anti-inflammatory factor. The aim of this review is to summarize the pleiotropic effects of taurine on specific muscle targets and to discuss its role in regulating signaling pathways involved in the maintenance of muscle homeostasis. We also highlight the potential use of taurine as a therapeutic molecule for the amelioration of skeletal muscle function and performance severely compromised during aging.

Multimodal Intervention to Improve Functional Status in Hypertensive Older Adults: A Pilot Randomized Controlled Trial

This pilot randomized controlled trial (RCT) was designed to provide the preliminary data necessary to conduct a full-scale trial to compare the efficacy of differing first-line antihypertensive medications in improving functional status in older adults, when combined with exercise. The primary objectives were to assess study feasibility, safety, and protocol integrity. Dependent outcomes included gait speed, exercise capacity, body composition, and systemic cardiometabolic biomarkers. Thirty-one physically inactive older adults (70.6 ± 6.1 years) with hypertension and functional limitations were randomly assigned to (1) Perindopril (8 mg/day n = 10), (2) Losartan (100 mg/day; n = 13), or (3) Hydrochlorothiazide (HCTZ: 25 mg/day; n = 8). Participants were also assigned to a 24-week multimodal exercise intervention, separated into an aerobic and concurrent (aerobic + resistance) phase to evaluate potential mode effects. Retention was 84% (26/31), and compliance was >90% and >79% with medication and exercise, respectively. A total of 29 adverse events (Perindopril = 5; Losartan = 12; HCTZ = 11) and one unrelated serious adverse event were observed throughout the trial. Overall, this pilot RCT provided critical data and identified several challenges to ultimately designing and implementing a fully powered trial.

Mitochondria as a Target for Mitigating Sarcopenia

Sarcopenia is the loss of muscle mass, strength, and physical function that is characteristic of aging. The progression of sarcopenia is gradual but may be accelerated by periods of muscle loss during physical inactivity secondary to illness or injury. The loss of mobility and independence and increased comorbidities associated with sarcopenia represent a major healthcare challenge for older adults. Mitochondrial dysfunction and impaired proteostatic mechanisms are important contributors to the complex etiology of sarcopenia. As such, interventions that target improving mitochondrial function and proteostatic maintenance could mitigate or treat sarcopenia. Exercise is currently the only effective option to treat sarcopenia and does so, in part, by improving mitochondrial energetics and protein turnover. Exercise interventions also serve as a discovery tool to identify molecular targets for development of alternative therapies to treat sarcopenia. In summary, we review the evidence linking mitochondria and proteostatic maintenance to sarcopenia and discuss the therapeutic potential of interventions addressing these two factors to mitigate sarcopenia.

The prevalence of sarcopenia in community-dwelling older adults, an exploration of differences between studies and within definitions: a systematic review and meta-analyses

Background

sarcopenia in ageing is a progressive decrease in muscle mass, strength and/or physical function. This review aims to summarise the definitions of sarcopenia in community-dwelling older adults and explore similarities and differences in prevalence estimates by definition.

Methods

a systematic review was conducted to identify articles which estimated sarcopenia prevalence in older populations using search terms for sarcopenia and muscle mass. Overall prevalence for each sarcopenia definition was estimated stratified by sex and ethnicity. Secondary analyses explored differences between studies and within definitions, including participant age, muscle mass measurement techniques and thresholds for muscle mass and gait speed.

Results

in 109 included articles, eight definitions of sarcopenia were identified. The lowest pooled prevalence estimates came from the European Working Group on Sarcopenia/Asian Working Group on Sarcopenia (12.9%, 95% confidence interval: 9.9-15.9%), International Working Group on Sarcopenia (9.9%, 3.2-16.6%) and Foundation for the National Institutes of Health (18.6%, 11.8-25.5%) definitions. The highest prevalence estimates were for the appendicular lean mass (ALM)/weight (40.4%, 19.5-61.2%), ALM/height (30.4%, 20.4-40.3%), ALM regressed on height and weight (30.4%, 20.4-40.3%) and ALM / body mass index (24.2%, 18.3-30.1%) definitions. Within definitions, the age of study participants and the muscle mass cut points used were substantive sources of between-study differences.

Conclusion

estimates of sarcopenia prevalence vary from 9.9 to 40.4%, depending on the definition used. Significant differences in prevalence exist within definitions across populations. This lack of agreement between definitions needs to be better understood before sarcopenia can be appropriately used in a clinical context.

Bridging the gap between the laboratory and the clinic for patients with sarcopenia

Sarcopenia—the age-related loss of skeletal muscle mass and strength—is a major public health issue. Sarcopenia is associated with an increased risk of falls, disability, dependency, institutionalization, hospital stay and early death. Finding interventions to stabilize, reverse or prevent sarcopenia is therefore a key goal for clinical ageing research. If patients are to eventually benefit from discovery science on ageing skeletal muscle, we need to build a translational pipeline that facilitates progress from laboratory science and epidemiology, through feasibility testing to early-phase, and eventually late-phase clinical trials. A number of barriers need to be overcome to make this pipeline work—in particular challenges around identifying people with sarcopenia in routine clinical practice, ensuring that we study patients with clearly defined sarcopenia rather than related conditions such as functional impairment, developing capacity to run trials for older people, and selecting trial outcomes of relevance to older people with multimorbidity. A further key point is that interventions should ideally have pleiotropic actions—i.e. beneficial actions across multiple organ systems, rather than treating sarcopenia alone. Such pleiotropic interventions may be the only way to avoid the perils of polypharmacy and drug interactions that bedevil care for many older people. Maximising the potential for scientific discoveries in the biology of ageing muscle to improve health requires that discovery scientists, translational clinical scientists and clinicians come together to exchange findings and shape each others ideas within a shared culture.

Skeletal muscle wasting in chronic heart failure

Patients suffering from chronic heart failure (CHF) show an increased prevalence (~20% in elderly CHF patients) of loss of muscle mass and muscle function (i.e. sarcopenia) compared with healthy elderly people. Sarcopenia, which can also occur in obese patients, is considered a strong predictor of frailty, disability, and mortality in older persons and is present in 5–13% of elderly persons aged 60–70 years and up to 50% of all octogenarians. In a CHF study, sarcopenia was associated with lower strength, reduced peak oxygen consumption (peak VO₂, 1173 ± 433 vs. 1622 ± 456 mL/min), and lower exercise time (7.7 ± 3.8 vs. 10.22 ± 3.0 min, both P < 0.001). Unfortunately, there are only very limited therapy options. Currently, the main intervention remains resistance exercise. Specialized nutritional support may aid the effects of resistance training. Testosterone has significant positive effects on muscle mass and function, and low endogenous testosterone has been described as an independent risk factor in CHF in a study with 618 men (hazard ratio 0.929, P = 0.042). However, the use of testosterone is controversial because of possible side effects. Selective androgen receptor modulators have been developed to overcome these side effects but are not yet available on the market. Further investigational drugs include growth hormone, insulin‐like growth factor 1, and several compounds that target the myostatin pathway. The continuing development of new treatment strategies and compounds for sarcopenia, muscle wasting regardless of CHF, and cardiac cachexia makes this a stimulating research area.

Strengthening the Brain-Is Resistance Training with Blood Flow Restriction an Effective Strategy for Cognitive Improvement?

Aging is accompanied by a decrease in physical capabilities (e.g., strength loss) and cognitive decline. The observed bidirectional relationship between physical activity and brain health suggests that physical activities could be beneficial to maintain and improve brain functioning (e.g., cognitive performance). However, the exercise type (e.g., resistance training, endurance training) and their exercise variables (e.g., load, duration, frequency) for an effective physical activity that optimally enhance cognitive performance are still unknown. There is growing evidence that resistance training induces substantial brain changes which contribute to improved cognitive functions. A relative new method in the field of resistance training is blood flow restriction training (BFR). While resistance training with BFR is widely studied in the context of muscular performance, this training strategy also induces an activation of signaling pathways associated with neuroplasticity and cognitive functions. Based on this, it seems reasonable to hypothesize that resistance training with BFR is a promising new strategy to boost the effectiveness of resistance training interventions regarding cognitive performance. To support our hypothesis, we provide rationales of possible adaptation processes induced by resistance training with BFR. Furthermore, we outline recommendations for future studies planning to investigate the effects of resistance training with BFR on cognition.

Get a grip: individual variations in grip strength are a marker of brain health

Demonstrations that grip strength has predictive power in relation to a range of health conditions-even when these are assessed decades later-has motivated claims that hand-grip dynamometry has the potential to serve as a "vital sign" for middle-aged and older adults. Central to this belief has been the assumption that grip strength is a simple measure of physical performance that provides a marker of muscle status in general, and sarcopenia in particular. It is now evident that while differences in grip strength between individuals are influenced by musculoskeletal factors, "lifespan" changes in grip strength within individuals are exquisitely sensitive to integrity of neural systems that mediate the control of coordinated movement. The close and pervasive relationships between age-related declines in maximum grip strength and expressions of cognitive dysfunction can therefore be understood in terms of the convergent functional and structural mediation of cognitive and motor processes by the human brain. In the context of aging, maximum grip strength is a discriminating measure of neurological function and brain health.

Muscle wasting and sarcopenia in heart failure and beyond: update 2017

Sarcopenia (loss of muscle mass and muscle function) is a strong predictor of frailty, disability and mortality in older persons and may also occur in obese subjects. The prevalence of sarcopenia is increased in patients suffering from chronic heart failure. However, there are currently few therapy options. The main intervention is resistance exercise, either alone or in combination with nutritional support, which seems to enhance the beneficial effects of training. Also, testosterone has been shown to increased muscle power and function; however, a possible limitation is the side effects of testosterone. Other investigational drugs include selective androgen receptor modulators, growth hormone, IGF‐1, compounds targeting myostatin signaling, which have their own set of side effects. There are abundant prospective targets for improving muscle function in the elderly with or without chronic heart failure, and the continuing development of new treatment strategies and compounds for sarcopenia and cardiac cachexia makes this field an exciting one.

Neural and musculotendinous mechanisms underpinning age-related force reductions

Ageing leads to substantial force production capacity reductions, which is an indicator of frailty and disability, and a mortality predictor in elders. Understanding the age-dependent neuromuscular mechanisms underlying force reductions can optimize healthcare professionals' exercise protocol choices for patients and allows researchers to investigate new interventions to mitigate these reductions. Our primary goal was to provide an updated review about the main neural and musculotendinous mechanisms underpinning age-related reductions in force capacity. Our secondary goal was to summarize how aerobic and strength training can lessen these age-related reductions. This review suggests that several steps in the force production pathway, from cortical to muscular mechanisms, are negatively affected by ageing. However, combining aerobic and strength training can attenuate these effects. Strength training (i.e. moderate to high- intensity, progressive volume, accentuated eccentric loading and fast concentric contraction velocity) can increase overall force production capacity by producing beneficial neural and musculotendinous adaptations. Additionally, aerobic training (i.e. moderate and high intensities) plays an essential role in preserving the structure and function of the neuromuscular system.

Current Status of Sarcopenia in Korea: A Focus on Korean Geripausal Women

Sarcopenia is defined as an age-associated decline in muscle mass and function caused by several etiologies and mechanisms. Muscle mass and function do not decrease concurrently, and a loss of muscle function may be more highly associated with adverse health outcomes. Despite the clinical significance of sarcopenia, no universally operational definition of sarcopenia or standardized intervention programs are currently available. Sarcopenia, osteoporosis, and obesity share several pathophysiological mechanisms, and a combination of these entities may lead to an increased risk of musculoskeletal, cardio-metabolic, and psychological morbidities especially in geripause populations. Treatment for sarcopenia is mainly nonpharmacological, however, various drugs are currently being developed. It is conceivable that sarcopenia is the next immediate clinical target in musculoskeletal science.

Improving the comprehension of sarcopenic state determinants: An multivariate approach involving hormonal, nutritional, lifestyle and genetic variables

It is known that sarcopenia is a multifaceted phenomenon, which involves genetic, nutritional, hormonal and living habits aspects. Then, an integrated analysis, as a multivariate approach, could improve the comprehension about the determinants of sarcopenic state in old adults. The present study aimed to investigate the interaction among serum vitamin D, daily caloric and protein intake, lifestyle habits, ACE I/D gene polymorphism and sarcopenic state in community-dwelling old adults. One hundred one community-dwelling old adults were clinically stratified as sarcopenic or non-sarcopenic. Serum vitamin D, daily caloric and protein intake, lifestyle habits (smoking, physical activity level and sedentary behavior) and ACE I/D gene polymorphism were recorded. A multivariate logistic regression technique was applied to investigate the interaction among the selected independent variables and the sarcopenic state. The independent variables age, smoking, serum Vitamin D and ACE I/D polymorphism achieved the statistical criteria to be inserted in the multivariate analysis. After a stepwise procedure from the multivariate logistic regression, the variables age, serum Vitamin D and ACE I/D polymorphism remained, together, in the final model. Sarcopenic state was significantly associated to older age, II-genotype and low serum Vitamin D in old adults from 60 years old.

Sarcopenia: assessment of disease burden and strategies to improve outcomes

Life expectancy is increasing worldwide, with a resultant increase in the elderly population. Aging is characterized by the progressive loss of skeletal muscle mass and strength - a phenomenon called sarcopenia. Sarcopenia has a complex multifactorial pathogenesis, which involves not only age-related changes in neuromuscular function, muscle protein turnover, and hormone levels and sensitivity, but also a chronic pro-inflammatory state, oxidative stress, and behavioral factors - in particular, nutritional status and degree of physical activity. According to the operational definition by the European Working Group on Sarcopenia in Older People (EWGSOP), the diagnosis of sarcopenia requires the presence of both low muscle mass and low muscle function, which can be defined by low muscle strength or low physical performance. Moreover, biomarkers of sarcopenia have been identified for its early detection and for a detailed identification of the main pathophysiological mechanisms involved in its development. Because sarcopenia is associated with important adverse health outcomes, such as frailty, hospitalization, and mortality, several therapeutic strategies have been identified that involve exercise training, nutritional supplementation, hormonal therapies, and novel strategies and are still under investigation. At the present time, only physical exercise has showed a positive effect in managing and preventing sarcopenia and its adverse health outcomes. Thus, further well-designed and well-conducted studies on sarcopenia are needed.

Testosterone and Sarcopenia

Aging affects metabolism, leading to physiological and functional impairments, and is also related to changes in body composition, including reduced skeletal muscle mass and increased body fat. These changes are correlated with the pathophysiology of sarcopenia, which is defined as age-related loss of skeletal muscle mass and strength. Low testosterone levels are associated with unfavorable body composition changes, and sex hormones decrease with aging. Androgen deficiency, along with lack of exercise and poor nutrition, may be among the modifiable contributors to sarcopenia. Testosterone treatment has been reported to have beneficial effects on muscle mass and function, but the results have been inconsistent. Here, we discuss the correlation between testosterone and muscle mass and function, the impact of testosterone on sarcopenia, and the probable mechanisms underlying these effects.

[Becoming older with axial spondyloarthritis]

The combination of physiological age-related changes (e. g. reduction in muscle mass and function, reduction in organ function and degenerative changes in joints) and disease-specific changes of ankylosing spondylitis (AS), make older AS patients vulnerable for additional diseases. In this patient population various processes lead to a reduction in physical function, changes in posture, osteoporosis and sarcopenia, which then can result in falls and fractures, especially vertebral fractures. Mortality is increased in patients with AS, particularly in men due to an increase in cardiovascular mortality. Although the standardized assessment of cardiovascular risk factors in patients with inflammatory rheumatic diseases (independent of age) has been recommended for years, it is rarely done in clinical practice. Overall, data on comorbidities and risk factors are only available for AS patients and are lacking for other forms of spondyloarthritides.

Interventions for Treating Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

BACKGROUND

Much interest has been focused on interventions for treating sarcopenia; however, the effects have gained little evidence.

OBJECTIVE

To analyze the effectiveness of exercise, nutritional, drug, and combinational interventions for treating sarcopenia in older people.

METHOD

We systematically searched MEDLINE via PubMed, the Cochrane Library of Cochrane Reviews and Cochrane Central Register of Controlled Trials, and Ichushi-Web for randomized controlled trials (RCTs) from January 2000 to December 2016. We have assessed the type of intervention, the cohort used, the way sarcopenia was diagnosed, the outcomes, and the quality of evidence. We meta-analyzed the outcomes with the net difference between-group treatment from baseline to the end of the study.

RESULTS

We screened a total of 2668 records and included seven RCTs that investigated the effects of exercise (4 RCTs), nutrition (5 RCTs), drug (1 RCT), and combination (4 RCTs) on muscle mass, strength, and function in older people with sarcopenia. Very low to low-quality evidence suggests that (1) exercise interventions may play a role in improving muscle mass, muscle strength, and walking speed in 3 months of intervention; (2) nutritional interventions may be effective in improving muscle strength in 3 months of intervention; (3) as drug intervention, selective androgen receptor modulator had no clear effect on muscle mass, strength, and physical function; and (4) a combined intervention of exercise and nutrition may have positive effects in improving the walking speed in 3 months of intervention.

CONCLUSION

Our systematic review and meta-analysis showed some positive effects of exercise and nutritional interventions for treating sarcopenia in older people, although the quality of the evidence was low. Future high-quality RCTs should be implemented to strengthen the results.

SARC-F questionnaire identifies physical limitations and predicts post discharge outcomes in elderly patients with cardiovascular disease

Background A simple and inexpensive sarcopenia screening tool would be beneficial in clinical practice. This study was performed to determine whether SARC-F questionnaire can be used to identify physical limitations and poor prognosis in elderly cardiovascular disease (CVD) patients.Methods The study population consisted of 257 Japanese patients ≥65 years old admitted to our hospital for CVD. Prior to discharge from hospital, SARC-F, handgrip strength, usual gait speed, short physical performance battery score, and 6-minute walking distance were measured in all patients. The patients were divided into two groups according to SARC-F score: SARC-F <4 and SARC-F ≥4. The study endpoint was the first occurrence of all-cause emergency readmission or all-cause mortality.Results The prevalence rate of SARC-F ≥4 was 26.8%, and increased with age and number of comorbidities. Even after adjusting for covariates, physical function was significantly poorer and the risks of physical function measurements below the critical cut-off values were higher in the SARC-F ≥4 group compared to the SARC-F <4 group. Sixty (23.3%) patients were readmitted and 17 (6.6%) died over a median follow-up period of 11 months (interquartile range: 6–13 months). SARC-F score was a significant predictor of adverse events after discharge. Patients with SARC-F ≥4 showed higher event risk than those with SARC-F <4 (adjusted hazard ratio: 1.78; 95% confidence interval: 1.03–3.07; P = 0.040).Conclusions SARC-F questionnaire is useful to identify patients at high risk of physical limitations and to predict post-discharge outcomes in elderly CVD patients.

Physical activity unveils the relationship between mitochondrial energetics, muscle quality, and physical function in older adults

BACKGROUND

The concept of mitochondrial dysfunction in ageing muscle is highly controversial. In addition, emerging evidence suggests that reduced muscle oxidative capacity and efficiency underlie the aetiology of mobility loss in older adults. Here, we hypothesized that studying well-phenotyped older cohorts across a wide range of physical activity would unveil a range of mitochondrial function in skeletal muscle and in turn allow us to more clearly examine the impact of age per se on mitochondrial energetics. This also enabled us to more clearly define the relationships between mitochondrial energetics and muscle lipid content with clinically relevant assessments of muscle and physical function.

METHODS

Thirty-nine volunteers were recruited to the following study groups: young active (YA, n = 2 women/8 men, age = 31.2 ± 5.4 years), older active (OA, n = 2 women/8 men, age = 67.5 ± 2.7 years), and older sedentary (OS, n = 8 women/11 men, age = 70.7 ± 4.7 years). Participants completed a graded exercise test to determine fitness (VO₂ peak), a submaximal exercise test to determine exercise efficiency, and daily physical activity was recorded using a tri-axial armband accelerometer. Mitochondrial energetics were determined by (i) ³¹ P magnetic resonance spectroscopy and (ii) respirometry of fibre bundles from vastus lateralis biopsies. Quadriceps function was assessed by isokinetic dynamometry and physical function by the short physical performance battery and stair climb test.

RESULTS

Daily physical activity energy expenditure was significantly lower in OS, compared with YA and OA groups. Despite fitness being higher in YA compared with OA and OS, mitochondrial respiration, maximum mitochondrial capacity, Maximal ATP production/Oxygen consumption (P/O) ratio, and exercise efficiency were similar in YA and OA groups and were significantly lower in OS. P/O ratio was correlated with exercise efficiency. Time to complete the stair climb and repeated chair stand tests were significantly greater for OS. Interestingly, maximum mitochondrial capacity was related to muscle contractile performance and physical function.

CONCLUSIONS

Older adults who maintain a high amount of physical activity have better mitochondrial capacity, similar to highly active younger adults, and this is related to their better muscle quality, exercise efficiency, and physical performance. This suggests that mitochondria could be an important therapeutic target for sedentary ageing associated conditions including sarcopenia, dynapenia, and loss of physical function.

What Is Important Besides Getting the Bone to Heal? Impact on Tissue Injury Other Than the Fracture

Fracture surgeons do a great job of managing bone issues, but they may overlook the associated soft tissue injuries that play a significant role in the final outcome after musculoskeletal injury. The soft tissue reconstruction ladder can help guide reconstructive procedures based on the least complex procedure that allows the best chance of fracture healing. Muscle injury, volume loss, and deconditioning occur with traumatic injury and during the recovery phase. Neuromuscular stimulation, nutrition, and strength training are potential ways to aid in recovery. Complex periarticular knee injuries have a high rate of associated soft tissue injuries that may affect outcome if associated with knee instability. Identifying and addressing these injuries can increase the likelihood of a good outcome. Articular cartilage loss can make articular reconstruction impossible. Large fresh osteoarticular allografts can be a reconstructive option. Addressing all the damaged structures involved with a fracture may be the next step in improving patient outcomes.

Leucine and ACE inhibitors as therapies for sarcopenia (LACE trial): study protocol for a randomised controlled trial

BACKGROUND

Sarcopenia (the age-related loss of muscle mass and function) is a major contributor to loss of mobility, falls, loss of independence, morbidity and mortality in older people. Although resistance training is effective in preventing and reversing sarcopenia, many older people are sedentary and either cannot or do not want to exercise. This trial examines the efficacy of supplementation with the amino acid leucine and/or angiotensin converting enzyme inhibition to potentially improve muscle mass and function in people with sarcopenia. Promising preliminary data exist from small studies for both interventions, but neither has yet been tested in adequately powered randomised trials in patients with sarcopenia.

METHODS

Leucine and ACE inhibitors in sarcopenia (LACE) is a multicentre, masked, placebo-controlled, 2 × 2 factorial randomised trial evaluating the efficacy of leucine and perindopril (angiotensin converting enzyme inhibitor (ACEi)) in patients with sarcopenia. The trial will recruit 440 patients from primary and secondary care services across the UK. Male and female patients aged 70 years and over with sarcopenia as defined by the European Working Group on Sarcopenia (based on low total skeletal muscle mass on bioimpedance analysis and either low gait speed or low handgrip strength) will be eligible for participation. Participants will be excluded if they have a contraindication to, or are already taking, an ACEi, angiotensin receptor blocker or leucine. The primary clinical outcome for the trial is the between-group difference in the Short Physical Performance Battery score at all points between baseline and 12 months. Secondary outcomes include appendicular muscle mass measured using dual-energy X-ray absorptiometry, muscle strength, activities of daily living, quality of life, activity using pedometer step counts and falls. Participants, clinical teams, outcomes assessors and trial analysts are masked to treatment allocation. A panel of biomarkers including microRNAs, neurohormones, genetic polymorphisms and markers of inflammation relevant to muscle pathophysiology will be measured to explore predictors of response and further elucidate mechanisms underlying sarcopenia. Participants will receive a total of 12 months of either perindopril or placebo and either leucine or placebo.

DISCUSSION

The results will provide the first robust test of the overall clinical and cost-effectiveness of these novel therapies for older patients with sarcopenia.

TRIAL REGISTRATION

ISRCTN, ISRCTN90094835 . Registered on 18 February 2015.