Review
Sarcopenia in Nursing Home Residents

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The age-associated loss of muscle mass and muscle strength described by the term sarcopenia is highly relevant for functionality among nursing home residents. Nevertheless, the scientific literature concentrating on sarcopenia in this population is scarce. For practical reasons, common definitions of this entity, which rely on dual energy x-ray absorptiometry (DEXA) and bioimpedance analysis (BIA), cannot be applied in this setting. Anthropometric measurements like arm muscle circumference and calf circumference seem to be most suitable. Handgrip may be used as an alternative. Prevalence data show a wide range but are mostly high. There is a close association of the degree of sarcopenia with dependence among residents. The pathophysiology of sarcopenia in this population is strongly influenced by comorbidity and often there is significant overlap with the cachexia syndrome.

At present, physical exercise is regarded to be the most promising therapeutic option, with resistance training being superior to endurance programs. Physical exercise has been successful even among Alzheimer patients and physically restrained residents. It has to be accompanied by the provision of adequate and diverse meals based on individual energy and nutrient requirements. Special attention should be paid to the treatment of vitamin D deficiency if present. New therapeutic options include Whole Body Vibration, oral supplements with essential amino acids and leucine, ACE-inhibitors, and cytokine-modifying drugs.

Section snippets

Definitions of Sarcopenia

At present, there is still no consensus definition of this syndrome. According to Baumgartner et al,12 sarcopenia is diagnosed when the muscle mass of an elderly individual falls below the second standard deviation of a young reference population. Baumgartner and coworkers measured muscle mass by dual energy x-ray absorptiometry (DEXA). In analogy to the body mass index, they used the ratio of appendicular muscle mass and squared body height (Table 1).

Alternatively, Janssen et al9 estimated

Practical Approaches Toward a Diagnosis of Sarcopenia in Nursing Home Residents

Taking the above-mentioned difficulties into account, a more practical approach toward the diagnosis of sarcopenia is warranted in this population. Anthropometric measurements have to be regarded as first choice under these circumstances.

In elderly persons, one has to be aware that steady or even increasing weight often masks the loss of muscle mass. This may be especially true for nursing home residents. Therefore, body mass index (BMI) measurement alone is not a reliable indicator of

Prevalence of Low Muscle Mass in Nursing Home Residents

Up to now, anthropometric parameters have been used to estimate muscle mass in the nursing home population. The number of residents included varied between 16 and 227 participants. As mentioned before, not a single study was performed applying the criteria for diagnosing sarcopenia introduced by Baumgartner and Janssen.

An early study in 1980 on 115 nursing home residents in the United States found a prevalence of 85% for low arm muscle circumference, thus pointing toward a high prevalence of

Pathophysiology

The pathophysiology of sarcopenia is complex and at present there is no concept that integrates all the potential causal factors in one model. There is a series of internal and external processes that contribute to the development of sarcopenia (Table 2). With regard to internal processes, the most important influences are a reduction of anabolic hormones (testosterone, estrogens, growth hormone, insulin like growth factor-1), an increase of proinflammatory cytokines (especially TNF α, IL-6),

Treatment Options for Sarcopenia in Nursing Home Inhabitants

Treatment options in sarcopenic nursing home inhabitants comprise physical training, modifications of nutritional intake, and pharmacological substances (Table 3).

Training

The participation in activities of daily living may be regarded as a first step toward stabilization of the individual level of physical performance. Residents should be regularly encouraged by the nursing staff to use their capabilities in doing so.

Physical exercise has been proven successful for the treatment of sarcopenia in the community-dwelling elderly.31 In nursing home inhabitants, only a very limited number of intervention studies have addressed muscle mass and muscle strength. In

Nutrition

Adequate nutritional intake has to be regarded as a fundamental prerequisite for any successful therapeutic regime in sarcopenic elderly persons. To ensure this, the individual caloric demand has to be calculated and the appropriate meal size has to be provided for all nursing home residents. If oral intake is inadequate or weight loss is documented, potential causes have to be considered. A more detailed discussion of the diagnosis and therapy of malnutrition is beyond the scope of this

Pharmacological Therapy

Testosterone has repeatedly been shown to increase muscle mass in elderly men and in most studies it also increased muscle strength.61 These effects did not correspond regularly with a benefit in functionality. To our knowledge, there are no studies that specifically addressed testosterone application in men who lived in nursing homes or long-term care. The relevance of the above-mentioned studies for the male nursing home population is uncertain and therefore there is no clear indication for

General Recommendations

Acute and chronic inflammatory conditions like infections of the urinary and respiratory tract, rheumatoid arthritis, or inflammatory bowel disease cause catabolic effects on muscle mass. Therefore, they should be treated resolutely in the elderly sarcopenic nursing home resident. In this context, it should also be reflected that corticosteroids may have negative effects on muscle mass and muscle strength and should be given only over a short period of time, if possible.

Hypo- and

Conclusion

Further studies on sarcopenia in nursing home inhabitants are necessary to clarify its impact on morbidity and mortality in this population. The optimal approach for successful intervention still needs to be evaluated. Apart from this, the creation of a widely accepted working definition in line with a standard diagnostic procedure for sarcopenia would be the first steps into the right direction of bringing this issue to relevance for those colleagues that care for nursing home patients.

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