Sarcopenia and deconditioning

Clarify whether the problem is chronic loss of reserve or an acute change. Ask baseline transfers, stairs, walking distance, shopping, carrying, falls and recovery after recent illness. Collateral may reveal that a person previously walked outdoors but has stayed in bed since admission. Sudden or asymmetric change requires acute neurological or medical investigation, not a sarcopenia label.

EWGSOP2 places low muscle strength at the centre: low strength makes sarcopenia probable, low muscle quantity or quality confirms it, and low physical performance indicates severe sarcopenia. This sequence is clinically useful because strength predicts function and can be tested at the bedside, while muscle mass measurement may require specialist equipment.

Use SARC-F to case-find where appropriate, but do not let a reassuring questionnaire override observed difficulty rising, repeated falls or evident wasting. Measure handgrip with a calibrated dynamometer when feasible, or use a five-times chair-rise test with arms crossed if safe. Record protocol, chair height, pain and encouragement. Inability to attempt is itself important but may reflect pain or balance as well as strength.

Confirm reduced muscle quantity when it affects diagnostic or treatment certainty. DXA-derived appendicular lean mass is a reference clinical method; validated bioelectrical impedance is more accessible but changes with hydration and device equations. CT or MRI muscle measures may be available from existing imaging but are not routine screening. Avoid diagnosing from body weight or calf appearance alone.

Assess physical performance with gait speed, SPPB or Timed Up and Go, using consistent aid and conditions. Also examine muscle pattern, tone, reflexes, sensation, joints and cardiorespiratory reserve. Screen cognition, mood, vision, orthostatic symptoms and fear. A performance score describes current function; it does not identify whether the limiting mechanism is muscle, pain, breathlessness or comprehension.

Investigate secondary causes from history and examination. Common first tests include FBC, renal and electrolytes, liver, CRP or ESR when inflammation is suspected, thyroid, glucose or HbA1c, calcium and vitamin D context. Add CK for myalgia or rapid proximal weakness, B12 for neuropathy, coeliac or malignancy tests for weight loss and organ-specific assessment. Review glucocorticoids, sedatives and interacting medicines.

Exercise is the core treatment. Use progressive resistance training for major muscle groups two or more times weekly, starting at a safe achievable load and increasing resistance or repetitions as adaptation occurs. Add challenging balance, gait and task practice and aerobic activity matched to capacity. After acute illness, short frequent mobilisation may begin the route but should progress beyond low-load movement.

Nutrition supports, rather than substitutes for, training. Estimate energy and protein with a dietitian when frailty, weight loss or organ disease is present. Many older adults require roughly 1.0 to 1.2 g protein/kg/day, and 1.2 to 1.5 g/kg/day may be considered during acute or chronic illness when clinically appropriate. Distribute high-quality protein across meals; address dentition, swallowing, shopping, cooking and assistance.

In advanced CKD, severe liver disease or metabolic instability, generic high-protein advice can be harmful or infeasible; agree targets with the relevant dietitian and team. Correct vitamin D deficiency and other micronutrient deficiency but do not present supplementation as a stand-alone muscle treatment. Oral nutritional supplements are used when food-first measures cannot meet assessed needs, with intake and weight monitored.

Hospital practice can either preserve or remove function. Encourage normal clothing, meals in a chair, independent washing and toileting, safe corridor walking and access to glasses, hearing aids and walking aid. Remove catheters and monitors when no longer needed and manage pain, delirium, posture and sleep. Set a mobility plan visible to the team and carers.

Review outcomes that matter: chair rise, walking range, falls, ADLs, fatigue and participation, together with weight and intake. If progress stalls, reconsider disease activity, exercise dose, pain, mood, adherence, transport and carer feasibility. A discharge destination should not become permanent merely because rehabilitation was delayed.