This article is based on a GM webinar from October 2020 about maintaining muscle strength to reduce the risk of falls. The webinar was held by Dr Sanjay Suman, a consultant physician (general medicine and elderly care) at Medway NHS Foundation Trust. The recording can be accessed at www.gmjournal.co.uk/events.
- Sarcopenia is a key risk factor for falls and fragility fractures
- Frailty, sarcopenia and osteoporosis are overlapping conditions that have a negative impact on health and wellbeing
- Managing patients who are at high risk of falls will require a multidisciplinary approach, including nutrition and exercise plans.
What is sarcopenia and what causes it?
Sarcopenia is an involuntary loss of skeletal muscle mass, strength and function. The main causes of sarcopenia are ageing, diseases and malnutrition (Figure 1).
Sarcopenia has a negative impact on health and requirements multidisciplinary management, including optimising protein intake and a strict exercise regime to improve strength and balance.
Why is sarcopenia an important issue?
Once you start to develop muscle weakness, it becomes a self-fulfilling prophecy: "muscle weakness begets muscle weakness," explains Dr Suman. This means that patients can easily fall victim to a negative spiral of events (Figure 2).
Losing muscle mass leaves patients at increased risk of falls, fractures and developing frailty, all of which can lead to hospital admission. While in hospital, patients are at increased risk of malnutrition and typically lose more muscle mass as they spend long periods of time in bed or immobile. Dr Suman says this leads to a perpetual cycle of losing more and more muscle mass.
As seen in Figure 2, there is a significant correlation between loss of muscle mass and the various clinical risks that the individual is exposed to.
The risk of infection also increases as you lose more muscle mass. For example, individuals who have lost 40% of their muscle mass are at a significantly increased risk of death, usually from pneumonia.
Trajectory of ageing
Men and women both typically acquire more muscle mass in early adulthood, but between the ages of 40 and 70, there’s about an 8% decline. By the age of 70, the risk of muscle mass loss is even greater, at 15% per decade. It is therefore unsurprising that the risk of sarcopenia is highest in older adults, with around 50% of adults over the age of 80 developing sarcopenia.
This gentle drift down can be accelerated by sudden declines of episodic muscle loss during periods of inactivity, acute illness and hospitalisations. As you age, it is much more difficult to return to previous levels of muscle mass and function (Figure 3).
Pathophysiology of sarcopenia
Reduced muscle protein synthesis as a result of age or disease related processes is one of the main reasons people develop sarcopenia. This can be through ribosomal dysfunction, anabolic resistance or malnutrition.
Other reasons include: neuromuscular intracellular changes (through motor unit loss and remodelling, mitochondrial dysfunction and satellite cell loss), microvascular changes, inflammation and hormonal changes of ageing (Figure 4).
Ageing-related causes of protein shortfall
Older adults often do not get an adequate dietary intake. Indeed, between the ages of 40 to 70, there is a decline of around 25% of the amount of nutrition that we consume. This can be for a variety of reasons, but age-related loss of appetite plays a key role.
Anabolic resistance, or a reduced ability to use available protein, and a greater need for protein (due to disease and inflammation) are key reasons older adults do not get enough protein.
Why do patients become malnourished?
Malnutrition may occur for a number of reasons, including:
- Problems with feeding (dysphagia, chewing, dementia)
- Anorexia (ageing, medication side effects)
- Problems with meal preparation
- Inappropriate calorie restriction
- Malabsorption (reduced nutrient bioavailability).
Clinicians should also consider psychological aspects, such as whether the patient has anxiety, depression or dementia, as this may cause a loss of interest in food.
Furthermore, doctors should consider the patient’s financial situation. Is the patient able to afford nutritious meals? If not, they should be signposted to the relevant services available in their area.
Recognising sarcopenia as a key feature of frailty
Malnutrition plays a significant role in muscle wasting, and once a patient has sarcopenia, they are at heightened risk of frailty.
As we get older, we are more susceptible to minor stressors such as infection, dehydration, falls and the introduction of a new medication. While we are all exposed to these minor stressors, older, frailer people recover at a much slower rate, and many will not return to baseline function (Figure 5).
How do we recognise frailty?
Clinicians should assess frailty using the clinical frailty scale (CFS). The scale runs from ‘very fit’ all the way to ‘terminally ill’.
Considering the above case study, we can see that Doris has some dependency as she needs help with shopping and heavy household work. This puts her at ‘mild frailty’.
Patients who require some help with the more personal activities of daily living (such as brushing your teeth, going to the toilet and bathing) would be classed as moderately frail, while those who are completely dependent on this help are severely frail.
Those who are approaching the end of their life are classed as ‘terminally ill’, which is at the more extreme end of the frailty scale.
Figure 6. *The CFS is now available to download from the Apple and Android App store.
Why is frailty important?
Older individuals with both frailty and sarcopenia have a higher risk of negative health outcomes including risk of falls, greater injury severity, hospitalisations, mortality, slower healing and recovery and functional decline.
For this reason, it is important to think about holistic treatment. Intervention strategies must address all these factors (frailty, malnutrition and sarcopenia) if they are to be successful.
Risk of falls and fractures
The risk of falls increases with age, and sarcopenia is one of the reasons behind this. Indeed, around a third of people over the age of 65 will fall annually, and this rises to around half of people over the age of 80. There is also a high risk of recurrence, with to 50% of fallers falling again.
Significant injuries occur in about a quarter of individuals and fear of falling occurs in around a third of people, both of which can cause people to become inactive and develop sarcopenia.
So, why do people fall? This could be due to age-related changes (e.g. impaired vision and hearing), comorbidities, frailty, dementia (due to hazard awareness, polypharmacy and inadequate nutrition), high risk drugs and environmental factors.
Whether you experience a fracture or not is dependent on the force of the fall, but also on bone fragility. For this reason, when assessing falls risk, osteoporosis is also an important factor to consider, as these patients are more prone to breaks and fractures than those with healthy bones.
NICE Guidelines: Falls
The latest NICE guidance is from 2013, but it is still relevant, according to Dr Suman. The guideline advises clinicians to first identify the patient’s risk level. To do this, they should ask if the patient has had any falls in the last 12 months, find out whether the patient has reduced muscle strength, impaired gait or balance, and about any medications they are on.
The guidelines also advise all healthcare professionals who frequently deal with patients at risk of falling to develop and maintain basic professional competence in falls assessment and prevention. This means regularly familiarising yourself with key risk factors for falls.
Once the patient’s risk level has been identified, NICE recommends undertaking a multifactorial assessment. This means asking the patient about their medical history, gait and balance, muscle strength, nutrition, blood pressure and their medication.
History of falls
Healthcare professionals should ask the patient about the frequency of their falls, whether they have had any injuries, whether they are able to get back up and whether they get dizzy before a fall or experience any loss of consciousness. This is important as one third of fallers can’t remember how they fell. If possible, this history should be confirmed by an eye witness.
Gait and balance
To measure gait and balance, practitioners should first of all observe how the person walks into the room. By doing so, you can see if the patient is unsteady or unbalanced, whether they are using a stick or frame properly, and their ability to sit down/stand up.
For a more formal assessment, clinicians should use the Timed Up and Go (TUG) test, which is a universally accepted tool for assessing gait and balance, but also the risk of falling.
To do the test, you should ask the individual to start from a seated position. You then start the timer, ask them to stand up and walk three metres at their own pace (with their usual walking aid if they require one), and then turn around, walk back and sit down where they started.
If the person takes more than 12 seconds, they are at high risk of falls. If the patient has difficulty getting up and takes more than three steps to turn 180 degrees, these are further indicators that the patient is at high risk of falls.
The European Working Group on Sarcopenia in Older Persons (EWGSOP) has developed a flow chart which allows clinicians to assess for muscle strength objectively (Figure 7).
The first step is to identify the groups who should be targeted for a muscle strength assessment. These are individuals who are at risk of falls, are frail, sarcopenic, weak, malnourished, fatigued and who have difficult doing daily activities.
There is a questionnaire available (Figure 8) which can be posted or emailed to patients if they are unable to make it to their GP. A score of 4 or more is predictive of sarcopenia.
The next step is to assess the patient for muscle strength. To do this, clinicians should use the ‘chair stand test’, in which you ask the patient to sit down and stand up five times in a row. If they take more than 15 seconds to complete five sit to stands, then sarcopenia is probable.
There is also an instrument called a handheld dynamometer which measures grip strength. For men, a pose of 27kg or less indicates sarcopenia, while 16kg or less indicates sarcopenia in women.
To confirm whether a person is sarcopenic, you can ask for a DXA scan. However, this is for research purposes only and is not recommended for use by practising clinicians.
To measure the severity of sarcopenia, clinicians should use the ‘four metre walk test’. If a person takes more than five seconds to walk four metres, the gait speed is less 0.8m per second which is a predictor of severe sarcopenia.
Figure 7 Figure 8
Assessing for malnutrition
Clinicians should use the MUST screening tool to assess for malnutrition (Figure 9). The tool uses information about the patient such as BMI, weight loss and acute disease impact to create a score. Using the case study above, Doris has a score of 4 meaning she is at high risk of malnutrition and will need to be referred for specialist dietary support.
Assessing for orthostatic hypotension (OH)
It is important that practitioners assess for OH as it is a common cause for syncope (transient loss of consciousness).
To do this, you should check the patient’s lying/standing blood pressure, and if the drop in systolic blood pressure is more than 20, or diastolic more than 10, then the patient should be diagnosed with postural hypotension. This is important to identify because patients with OH have a 52% increased risk of falls.
Clinicians should also conduct a thorough medication review for fallers (Figure 10). This is particularly important for older patients who are more susceptible to adverse effects of medications.
For example, OH is a common side effect of various drugs including ACE-inhibitors, Alpha Blockers and diuretics. Clinicians should therefore assess, define and analyse the risk vs the benefit for each and every medication. There are now specialist, clinical pharmacists who can undertake this kind of review.
Referral criteria for specialist falls assessment
The flow chart below (Figure 11) shows how clinicians should decide whether to refer a patient to falls clinic.
If the patient has a single fall and has normal gait and muscle strength, education and information will be sufficient. However, if the patient has been experiencing recurrent falls and/or has impaired gait and balance, then they will need to be referred to the falls clinic.
The falls clinic will do a much more comprehensive assessment, which includes the home hazard assessment, a cognitive and visual assessment and a medication review.
Investigation and management
Clinicians should use a holistic management approach when treating patients. In Doris’ case, a problem list was produced, she had surgery for her fractured neck of femur, she was given vitamin D supplements, and she was taken off sulfonylurea.
Doris was also seen by a physiotherapist and occupational therapist and given falls prevention exercises. She also received help and support from social services as well as nutritional support to prevent further malnutrition.
People who are at high risk of vitamin D deficiency, including older, frailer people, those who are not exposed to much sunlight and people from ethnic minority groups, may need oral vitamin D3 supplements.
It is good practice to routinely check people with poor muscle strength for vitamin D levels, as supplementing can help them to gain some strength back.
A free online tool, known as the FRAX tool (Figure 12) allows you to input information about the patient. The tool will calculate the 10 year fracture risk and will also offer recommendations for treatment.
Recommendations for maintaining healthy muscle with ageing
Optimal protein intake should be at least 1 to 1.5 grams protein per kg bodyweight, but in certain circumstances, such as acute illness and malnutrition, the protein requirements should be as high as two grams per kilo of bodyweight.
These patients may therefore need protein supplements and should also be told to do muscle-strengthening and balance exercises, as well as resistance training. These exercises should be tailored to the individual and done regularly in combination with their nutrition plan to build up muscle strength.
There is a free booklet from Public Health England, Get Up and Go, which tackles common myths about falling and provides a checklist to help patients decide whether they are at risk. There’s also plenty of advice on how you can reduce your chances of having a fall by improving your balance, muscle strength and more.