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Editorial
SARC-F: A Simple Questionnaire to Rapidly Diagnose Sarcopenia
Theodore K. Malmstrom PhD
a
,
b
, John E. Morley MB, BCh
b
,
*
a
Department of Neurology and Psychiatry, Saint Louis University School of Medicine, St. Louis, MO
b
Division of Geriatric Medicine, Saint Louis University School of Medicine, St. Louis, MO
Sarcopenia was originally dened as an age-associated loss of
muscle mass.
1,2
Recently a number of European and international
groups have redened sarcopenia as being a decline in muscle
function (either walking speed or grip strength) associated with loss
of muscle mass.
3e5
This approach has been validated.
6,7
Sarcopenia
leads to disability, falls, and increased mortality.
8e16
Loss of muscle
strength and aerobic function are 2 of the hallmarks of frailty.
17e21
Sarcopenia has been linked to an increased prevalence of osteopo-
rosis, thus further increasing its propensity to produce hip
fractures.
22e27
Although osteoporosis has been classically diagnosed by
measuring bone mineral density, it has been recognized that
a number of other factors play into the role of diagnosing the
propensity to have a fracture.
28,29
This is particularly true in older
persons with diabetes mellitus who often have good bone mineral
density but weak bones, and this is coupled with an increase in
sarcopenia.
30e33
This has led to the concept that the questions
associated with the Fracture Risk Assessment Tool (FRAX) (www.shef.
ac.uk.FRAX) may be sufcient to screen for osteoporosis. Two studies
have conrmed that bone mineral density does not need to be
measured in most cases to make or exclude the diagnosis of osteo-
porosis.
34,35
As sarcopenia is much more denable by simple func-
tional questions, this led to the concept that a simple questionnaire
could be developed to diagnose sarcopenia and obviate the need for
the measurement of muscle mass.
The SARC-F questionnaire has been developed as a possible rapid
diagnostic test for sarcopenia.
36
There are 5 SARC-F components:
Strength, Assistance with walking, Rise from a chair, Climb stairs and
Falls (Table 1). The scores range from 0 to 10, with 0 to 2 points for
each component. Our preliminary studies have suggested that a score
equal to or greater than 4 is predictive of sarcopenia and poor
outcomes.
The ability to rapidly diagnose sarcopenia is important, as there is
increasing evidence that therapeutic interventions can improve
outcomes. Among successful therapeutic outcomes are resistance
exercise,
37e39
vitamin protein supplementation,
40e45
and possibly
testosterone.
46e48
References
1. Morley JE, Baumgartner RN, Roubenoff R, et al. Sarcopenia. J Lab Clin Med 2001;
137:231e243.
2. Bauer JM, Kaiser MJ, Sieber CC. Sarcopenia in nursing home residents. J Am Med
Dir Assoc 2008;9:545e551.
3. CruzeJentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus
on denition and diagnosis: Report of the European Working Group on Sar-
copenia in Older People. Age Ageing 2010;39:412e423.
4. Morley JE, Abbatecola AM, Argiles JM. Society on sarcopenia, Cachexia and
Wasting Disorders Trialist Workshop. Sarcopenia with limited mobility: An
international consensus. J Am Med Dir Assoc 2011;12:403e409.
5. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: An undiagnosed condition in
older adults. Current consensus denition: Prevalence, etiology, and conse-
quences. International Working Group on Sarcopenia. J Am Med Dir Assoc
2011;12:249e256.
6. Malmstrom TK, Miller DK, Herning MM, Morley JE, Low appendicular skeletal
muscle mass (ASM) with limited mobility and poor health outcomes in middle-
aged African Americans [published online ahead of print March 27, 2013].
J Cachexia Sarcopenia Muscle.
7. Patel HP, Syddall HE, Jameson K, et al. Prevalence of sarcopenia in community-
dwelling older people in the UK using the European Working Group on Sar-
copenia in Older People (EWGSOP) denition: Findings from the Hertfordshire
Cohort Study (HCS). Age Ageing 2013;42:378e384.
8. Roman D, Mahoney K, Mohamadi A. Sarcopenia: Whats in a name? J Am Med
Dir Assoc 2013;14:80e82.
9. Cesari M, Vellas B. Sarcopenia: A novel clinical condition or still a matter for
research? J Am Med Dir Assoc 2012;13:766e767.
10. Landi F, Liperoti R, Fusco D, et al. Sarcopenia and mortality among older
nursing home residents. J Am Med Dir Assoc 2012;13:121e126.
Table 1
SARC-F Screen for Sarcopenia
Component Question Scoring
Strength How much difculty do you
have in lifting and
carrying 10 pounds?
None ¼0
Some ¼1
A lot or unable ¼2
Assistance in
walking
How much difculty do you
have walking across a room?
None ¼0
Some ¼1
A lot, use aids, or
unable ¼2
Rise from a chair How much difculty do you
have transferring from
a chair or bed?
None ¼0
Some ¼1
A lot or unable without
help ¼2
Climb stairs How much difculty do you
have climbing a ight
of 10 stairs?
None ¼0
Some ¼1
A lot or unable ¼2
Falls How many times have you
fallen in the past year?
None ¼0
1e3 falls ¼1
4 or more falls ¼2
The authors declare no conicts of interest.
* Address correspondence to John E. Morley, MB, BCh, Division of Geriatric
Medicine, Saint Louis University School of Medicine, 1402 S. Grand Boulevard,
M238, St. Louis, MO 63104.
E-mail address: morley@slu.edu (J.E. Morley).
JAMDA
journal homepage: www.jamda.com
1525-8610/$ - see front matter Copyright Ó2013 - American Medical Directors Association, Inc.
http://dx.doi.org/10.1016/j.jamda.2013.05.018
JAMDA 14 (2013) 531e532
11. Neyens JC, van Haastregt JC, Dijcks BP, et al. Effectiveness and imple-
mentation aspects of interventions for preventing falls in elderly people in
long-term care facilities: A systematic review of RCTs. J Am Med Dir Assoc
2011;12:410e425.
12. Choi M, Hector M. Effectiveness of intervention programs in preventing falls: A
systematic review of recent 10 years and meta-analysis. J Am Med Dir Assoc
2012;13:188.e13e188.e21.
13. Morley JE, Rolland Y, Tolson D, Vellas B. Increasing awareness of the factors
producing falls: The mini falls assessment. J Am Med Dir Assoc 2012;13:87e90.
14. Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: Are they
preventable? J Am Med Dir Assoc 2006;7:S53eS58. 52.
15. Rapp K, Becker C, Cameron ID, et al. Epidemiology of falls in residential aged
care: Analysis of more than 70,000 falls from residents of Bavarian nursing
homes. J Am Med Dir Assoc 2012;13:187.e1e187.e6.
16. Arango-Lopera VE, Arroyo P, Gutiérrez-Robledo LM, et al. Mortality as an
adverse outcome of sarcopenia. J Nutr Health Aging 2013;17:259e262.
17. Rougé Bugat ME, Cestac P, Oustric S, et al. Detecting frailty in primary care: A
major challenge for primary care physicians. J Am Med Dir Assoc 2012;13:
669e672.
18. Abellan van Kan G, Rolland YM, Morley JE, Vellas B. Frailty: Toward a clinical
denition. J Am Med Dir Assoc 2008;9:71e72.
19. Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: A call to action.
J Am Med Dir Assoc 2013;14:392 e397.
20. Peters LL, Boter H, Buskens E, Slaets JP. Measurement properties of the Gro-
ningen Frailty Indicator in home-dwelling and institutionalized elderly people.
J Am Med Dir Assoc 2012;13:546e551.
21. Gobbens RJ, van Assen MA, Luijkx KG, et al. Determinants of frailty. J Am Med
Dir Assoc 2010;11:356e364.
22. Sjoblom S, Suuronen J, Rikkonen T, et al. Relationship between postmenopausal
osteoporosis and the components of clinical sarcopenia. Maturitas 2013;75:
175e180.
23. Cederholm T, CruzeJentoft AJ, Maggi S. Sarcopenia and fragility fractures. Eur J
Phys Rehabil Med 2013;49:111e117.
24. Miyakoshi N, Hongo M, Mizutani Y, Shimada Y. Prevalence of sarcopenia in
Japanese women with osteopenia and osteoporosis [published online ahead of
print March 21, 2013]. J Bone Miner Metab.
25. Morley JE. Falls and fractures. J Am Med Dir Assoc 2007;8:276e278.
26. Kaji H. Linkage between muscle and bone: Common catabolic signals resulting
in osteoporosis and sarcopenia. Curr Opin Clin Nutr Metab Care 2013;16:
272e277.
27. Morley JE. Frailty, falls, and fractures. J Am Med Dir Assoc 2013;14:149e151.
28. Morley JE. Osteoporosis and fragility fractures. J Am Med Dir Assoc 2011;12:
389e392.
29. Martinez-Reig M, Ahmad L, Duque G. The orthogeriatrics model of care:
Systematic review of predictors of institutionalization and mortality in post-
hip fracture patients and evidence for interventions. J Am Med Dir Assoc
2012;13:770e777.
30. Migdal A, Yarandi SS, Smiley D, Umpierrez GE. Update on diabetes in the elderly
and in nursing home residents. J Am Med Dir Assoc 2011;12:627e632.e2.
31. Morley JE. Diabetes mellitus: The times they are aechanging.J Am Med Dir
Assoc 2012;13:574e575.
32. Leenders M, Verdijk LB, van der Hoeven L, et al. Patients with type 2
diabetes show a greater decline in muscle mass, muscle strength, and
functional capacity with aging. J Am Med Dir Assoc 2013;14:585e592.
33. Sinclair A, Morley JE, RodriguezeMañas L, et al. Diabetes mellitus in older
people: Position statement on behalf of the International Association of
Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for
Older People (EDWPOP), and the International Task Force of Experts in Dia-
betes. J Am Med Dir Assoc 2012;13:497e502.
34. Kanis JA, McCloskey E, Johansson H, et al. FRAX(Ò) with and without bone
mineral density. Calcif Tissue Int 2012;90:1e13.
35. Leslie WD, Lix LM, Langsetmo L, et al. Construction of a FRAXÒmodel for the
assessment of fracture probability in Canada and implications for treatment.
Osteoporos Int 2011;22:817e827.
36. Malmstrom TK, Morley JE. Sarcopenia: The target population. J Frailty Aging
2013;2:55e56.
37. Yamada M, Arai H, Sonoda T, Aoyama T. Community-based exercise program is
cost-effective by preventing care and disability in Japanese frail older adults.
J Am Med Dir Assoc 2012;13:507e511.
38. Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive
resistance training and targeted multidisciplinary treatment of frailty on
mortality and nursing home admissions after hip fracture: A randomized
controlled trial. J Am Med Dir Assoc 2012;13:24e30.
39. Valenzuela T. Efcacy of progressive resistance training interventions in older
adults in nursing homes: A systematic review. J Am Med Dir Assoc 2012;13:
418e428.
40. Demontiero O, Herrmann M, Duque G. Supplementation with vitamin D and
calcium in long-term care residents. J Am Med Dir Assoc 2011;12:190e194.
41. McKinney JD, Bailey BA, Garrett LH, et al. Relationship between vitamin D
status and ICU outcomes in veterans. J Am Med Dir Assoc 2011;12:208e211.
42. Mithal A, Bonjour JP, Boonen S, et al, IOF CSA Nutrition Working Group. Impact
of nutrition on muscle mass, strength, and performance in older adults.
Osteoporos Int 2013;24:1555e1566.
43. Morley JE, Argiles JM, Evans WJ, et al. Society for Sarcopenia, Cachexia, and
Wasting Disease. Nutritional recommendations for the management of sarco-
penia. J Am Med Dir Assoc 2010;11:391e396.
44. Tieland M, van de Rest O, Dirks ML, et al. Protein supplementation improves
physical performance in frail elderly people: A randomized, double-blind,
placebo-controlled trial. J Am Med Dir Assoc 2012;13:720e726.
45. Tieland M, Kirks ML, van der Zwaluw N, et al. Protein supplementation
increases muscle mass gain during prolonged resistance-type exercise training
in frail elderly people: A randomized, double-blind, placebo-controlled trial.
J Am Med Dir Assoc 2012;13:713e719.
46. Morley JE. Anabolic steroids and frailty. J Am Med Dir Assoc 2010;11:533e536.
47. Wittert GA, Chapman IM, Haren MT, et al. Oral testosterone supplementation
increases muscle and decreases fat mass in healthy elderly males with low-
normal gonadal status. J Gerontol A Biol Sci Med Sci 2003;58:618e625.
48. Morley JE. Androgens and aging. Maturitas 2001;38:61e71.
Editorial / JAMDA 14 (2013) 531e532532
... This scale was developed by Malmstrom in 2013 [48] and was translated into a Chinese version by Xiaoying Wang in 2018 [49]. The scale comprised 5 items: "When you carry and lift 10 pounds, how many difficulties do you have? ...
... (None = 0, 1-3 falls = 1, 4 or more falls = 2)". These items were used respectively to describe each of the following five components which include strength, assistance with walking, rising from a chair, climbing stairs, and falls [48]. The scale has a total score of 0-10 points. ...
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... This five-item questionnaire assesses strength, walking assistance, rising from a chair, climbing stairs, and falls, scoring from 0 to 10 points. A score equal to or greater than 4 is predictive of sarcopenia and poor outcomes [48]. However, clinicians should be aware that this score has high specificity, but low sensitivity. ...
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Purpose: The aim of the study was to determine the relationship between the components of clinical sarcopenia and osteoporosis in postmenopausal women. Methods: A population-based cohort of 590 Finnish postmenopausal women (mean age 67.9; range 65-72) was selected from the Osteoporosis Fracture Prevention (OSTPRE-FPS) study in 2002. Bone mineral density (BMD) and lean tissue mass were assessed by dual X-ray absorptiometry (DXA). The study sample was divided into three categories according to the WHO BMD classification: normal, osteopenia and osteoporosis. The study sample was divided into non-sarcopenic, presarcopenic, sarcopenic and non-classified groups according to quartiles of RSMI i.e. relative skeletal muscle index (appendicular muscle mass (kg)/square of height (m)), hand grip strength (kPa) and walking speed. Results: In logistic regression analysis sarcopenic women had 12.9 times higher odds of having osteoporosis (p ≤ 0.001, OR=12.9; 95% CI=3.1-53.5) in comparison to non-sarcopenic women. In comparison to women in the highest grip strength quartile, women within the lowest quartile had 11.7 times higher odds of having osteoporosis (p=0.001, OR=11.7; 2.6-53.4). Sarcopenic women had 2.7 times higher odds of having fractures than their non-sarcopenic counterparts (p=0.005, OR=2.732; 1.4-5.5). Sarcopenic women had also 2.1 times higher risk of falls during the preceding 12 months compared to non-sarcopenic women (p=0.021, OR=2.1; 1.1-3.9). Adjustment for age, body mass index (BMI), physical activity and hormone therapy (HT) did not significantly alter these results. Conclusions: The components of clinical sarcopenia are strongly associated with osteoporosis. Grip strength is the most significant measurement to reveal the association between sarcopenia and osteoporosis, falls and fractures.
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Sarcopenia, a reduction in muscle mass and muscle function, is considered one of the hallmarks of the aging process. Current views consider sarcopenia as the consequence of multiple medical, behavioural and environmental factors that characterize aged individuals. Likewise bone fragility is known to depend on several pathogenetic mechanisms leading to bone mass loss and reduction of bone strength. Muscle weakness, fear of falls, falls and subsequent fractures are associated to concurrent sarcopenia and osteoporosis and lead to restricted mobility, loss of autonomy and reduced life expectancy. The skeletal and the muscular organ systems are tightly intertwined: the strongest mechanical forces applied to bones are, indeed, those created by muscle contractions that condition bone density, strength, and microarchitecture. Not surprising, therefore, the decrease in muscle strength leads to lower bone strength. The degenerative processes leading to osteoporosis and sarcopenia show many common pathogenic pathways, like the sensitivity to reduced anabolic hormone secretion, increased inflammatory cytokine activity and reduced physical activity. Thus they may also respond to the same kind of treatments. Basic is life-style interventions related to exercise and nutrition. Sufficient vitamin D levels are of importance for both bone and muscle, primarily provided by sun exposure at younger age, and by supplementation at older age. Resistance training several times per week is crucial, and to be effective adequate access to energy and proteins is necessary.
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Background: The loss of muscle mass with aging reduces muscle strength, impairs functional capacity, and increases the risk of developing chronic metabolic disease. It has been suggested that the development of type 2 diabetes results in a more rapid decline in muscle mass, strength, and functional capacity. Objective: To investigate the impact of type 2 diabetes on muscle mass, strength, and functional capacity in an older population. Methods: Muscle mass (DXA and muscle biopsies), strength (1-repetition maximum), functional capacity (sit-to-stand test and handgrip strength), and reaction time performance (computer task) were compared between 60 older men with type 2 diabetes (71 ± 1 years) and 32 age-matched normoglycemic controls (70 ± 1 years). Data were analyzed using ANCOVA to adjust for several potential confounders. Results: Leg lean mass and appendicular skeletal muscle mass were significantly lower in older men with type 2 diabetes (19.1 ± 0.3 and 25.9 ± 0.4 kg, respectively) compared with normoglycemic controls (19.7 ± 0.3 and 26.7 ± 0.5 kg, respectively). Additionally, leg extension strength was significantly lower in the group with type 2 diabetes (84 ± 2 vs 91 ± 2 kg, respectively). In agreement, functional performance was impaired in the men with type 2 diabetes, with longer sit-to-stand time (9.1 ± 0.4 vs 7.8 ± 0.3 seconds) and lower handgrip strength (39.5 ± 5.8 vs 44.6 ± 6.1 kg) when compared with normoglycemic controls. However, muscle fiber size and reaction time performance did not differ between groups. Conclusion: Older patients with type 2 diabetes show an accelerated decline in leg lean mass, muscle strength, and functional capacity when compared with normoglycemic controls. Exercise intervention programs should be individualized to specifically target muscle mass, strength, and functional capacity in the older population with type 2 diabetes.