Grades are shown as the source states them. ICFSR 2018 grades its recommendations with GRADE (strong or conditional, with the certainty of evidence), shown beside its statements; where it found too little evidence it made no recommendation. EWGSOP2 and GLIS are expert consensus and are not graded. The Asian Working Group for Sarcopenia 2019 update could not be read under an open licence and is listed as further reading.
Key recommendations
Sarcopenia is a progressive, generalised disease of skeletal muscle (muscle failure) that raises the risk of falls, fractures, physical disability and death. It is common in older age but can begin earlier in life.
Abstract; Sarcopenia: operational definitionEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Low muscle strength is the main criterion. Low strength alone means probable sarcopenia; low muscle quantity or quality as well confirms the diagnosis; and low physical performance on top of both makes it severe.
Sarcopenia: operational definition; Table 1European Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Follow the Find–Assess–Confirm–Severity pathway: find cases with the SARC-F questionnaire or clinical suspicion, assess strength with grip strength or the chair stand test, confirm with a measure of muscle quantity, and grade severity with a test of physical performance.
Practical algorithm; Summary and call-to-actionEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Screen adults aged 65 and over for sarcopenia opportunistically — once a year, or after a major health event such as a fall needing hospital admission — using gait speed or the SARC-F questionnaire.
Conditional; low certaintyRecommendations 1A and 1BInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Prescribe progressive resistance-based (strength) training as the first-line treatment; it improves muscle strength, muscle mass and physical function.
Strong; moderate certaintyRecommendation 3AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Do not use medicines as first-line treatment. The evidence is too limited to recommend anabolic hormones such as testosterone, or any of the drugs under development.
No recommendation; very low certaintyRecommendations 6A and 7AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Diagnosis
Suspect sarcopenia and test further when a person reports falls, feeling weak, walking slowly, difficulty rising from a chair, or weight loss or muscle wasting.
Finding sarcopenia casesEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
The SARC-F is a five-item self-report of difficulty with strength, walking, rising from a chair and climbing stairs, and of falls. Its sensitivity for low muscle strength is low to moderate and its specificity very high, so it mainly picks up more severe cases.
Finding sarcopenia casesEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Low muscle strength: grip strength under 27 kg in men or under 16 kg in women, measured with a calibrated hand-held dynamometer, or taking more than 15 seconds to rise five times from a chair without using the arms.
Table 3; Muscle strengthEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Low muscle quantity: appendicular skeletal muscle mass under 20 kg in men or under 15 kg in women, or under 7.0 kg/m² in men and 5.5 kg/m² in women when divided by height squared.
Table 3European Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Low physical performance, which marks severe sarcopenia: usual gait speed of 0.8 m/s or less, a Short Physical Performance Battery score of 8 or less, a Timed Up and Go of 20 seconds or more, or not completing a 400 m walk or taking 6 minutes or more.
Table 3European Working Group on Sarcopenia in Older People (EWGSOP2) 2019
The EWGSOP2 cut-off points are rounded values set about two standard deviations below the mean of healthy young European adults. Gait speed and strength depend on body size, so use regional normative data where they exist.
Defining cut-off points for sarcopenia testsEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Diagnose with an objective measurement tool using any published consensus definition. The Asian Working Group for Sarcopenia definition gives cut-off points for older adults from or descended from South-East Asia.
Conditional; moderate certaintyRecommendation 2AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Use gait speed and grip strength to measure physical performance and muscle strength when diagnosing sarcopenia.
Strong; moderate certaintyRecommendation 2CInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Grip strength is a diagnostic test rather than a screening test; most of the primary care doctors who reviewed the guideline preferred not to measure it in their clinics.
Recommendation 1BInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Before attributing low strength to sarcopenia, consider other causes such as depression, stroke, balance disorders and peripheral vascular disease.
Figure 1 (footnote)European Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Sarcopenia is primary when ageing is the only evident cause, and secondary when disease (especially inflammatory conditions such as cancer or organ failure), inactivity, or too little energy or protein contributes. It is acute when present for less than 6 months, usually after an illness or injury, and chronic after that.
Primary and secondary sarcopenia; Acute and chronic sarcopeniaEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Investigations
Use DXA to measure lean mass when confirming the diagnosis. If DXA, CT and MRI are not available, use clinical judgement to assess muscle mass.
Conditional; low certaintyRecommendation 2BInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
DXA results differ between makes of scanner and are affected by hydration, and whether to adjust muscle mass for body size (by height squared, weight or BMI) is still debated.
Muscle quantityEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
DXA measures lean body mass rather than muscle itself and can misclassify people with a lot of water or fibrous tissue; whether it adds to the prediction of falls, fractures or poor mobility is uncertain.
Recommendation 2BInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Bioelectrical impedance (BIA) is cheap and portable but estimates muscle mass from equations derived in particular populations; the recommended Sergi equation comes from older Europeans, so allow for age and ethnicity.
Muscle quantityEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Where no other method is available, a calf circumference under 31 cm can stand in for low muscle mass.
Muscle quantityEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
CT and MRI are the reference standards for muscle mass but are costly and lack agreed cut-off points; CT at the third lumbar vertebra is used to find low muscle mass in cancer, intensive care and liver disease.
Muscle quantity; Lumbar 3rd vertebra imaging by computed tomographyEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Measure usual walking speed over 4 m with a stopwatch or electronic timing. The Short Physical Performance Battery takes at least 10 minutes, so it is used more in research.
Physical performanceEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Muscle ultrasound is reliable for measuring muscle size in older adults and can also show muscle quality, and is starting to be used at the bedside.
Ultrasound assessment of muscleEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Treatment
Resistance training works muscles against external load — dumbbells, free weights, elastic bands or body weight. Prescribe it with progression in intensity and volume, aim it at function, and match it to the person's goals; consider referral to a physiotherapist or exercise physiologist, or to group classes.
Strong; moderate certaintyRecommendation 3AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Consider protein supplementation or a protein-rich diet, combined with exercise rather than on its own, and discuss adequate energy and protein intake.
Conditional; low to very low certaintyRecommendations 4A–4CInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
There is not enough evidence to recommend vitamin D to treat sarcopenia. If 25-hydroxyvitamin D is below 20 ng/mL, decide on supplementation on clinical grounds, considering other conditions that may benefit.
No recommendation; very low certaintyRecommendation 5AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Evidence for leucine or its metabolite HMB in older adults with sarcopenia is very limited.
Recommendation 4AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
A practical combined plan: referral for resistance-based exercise, protein supplementation, and education about physical activity and adequate energy and protein, drawn up as an individual plan by an inter-professional team.
Combined treatment plansInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Beyond exercise and nutrition, base further treatment on the person's other illnesses and medicines.
Recommendation 7AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Important geriatric considerations
Sarcopenia and physical frailty overlap — low grip strength and slow gait feature in both, and weight loss contributes to both — but frailty is a broader syndrome across many body systems, to which sarcopenia contributes.
FrailtyEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Low muscle mass is also part of malnutrition, from low intake, poor absorption or high requirements (as in cancer or organ failure); unlike sarcopenia, malnutrition usually reduces fat mass too.
Malnutrition-associated sarcopeniaEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Obesity worsens sarcopenia: it increases fat within muscle, lowers physical function and raises mortality. Sarcopenic obesity is a distinct condition whose definition is still being developed.
Sarcopenic obesityEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Physical performance tests may not be possible in people with dementia or gait or balance disorders.
Physical performanceEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
After 50, leg muscle mass falls by about 1–2% and strength by 1.5–5% a year. Prevention runs across life: build muscle when young, maintain it in midlife and limit its loss in older age.
Time courseEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Older people consulted for the guideline did not want costly scans to diagnose muscle loss, and were more willing to join an exercise programme when they already had difficulty functioning than for prevention; cost, transport and lack of support were barriers.
Recommendations 2B and 3AInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Refer anyone who screens positive for assessment to confirm the diagnosis.
Conditional; low certaintyRecommendation 1CInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Muscle imaging with DXA, MRI or CT in specialist care is suggested for people at high risk of adverse outcomes.
Practical algorithmEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Red flags
Muscle wasting with weight loss can reflect a systemic disease such as cancer or organ failure, or malnutrition, rather than ageing; look for the cause.
Primary and secondary sarcopenia; Malnutrition-associated sarcopeniaEuropean Working Group on Sarcopenia in Older People (EWGSOP2) 2019
Recent updates
A 2024 global consensus (GLIS) defines sarcopenia conceptually as low muscle mass together with low muscle strength, with muscle-specific strength as a third component. It treats impaired physical performance as an outcome of sarcopenia rather than part of its definition, and does not include severity grades.
Table 2; Table 3; DiscussionGlobal Leadership Initiative in Sarcopenia (GLIS) 2024
GLIS has not yet set an operational definition with measures and cut-off points; that is its next step.
DiscussionGlobal Leadership Initiative in Sarcopenia (GLIS) 2024
Sarcopenia has a code in ICD-10-CM, the clinical modification used in some countries such as Australia and the United States; as of 2024 the WHO had not yet included it in its own ICD.
IntroductionGlobal Leadership Initiative in Sarcopenia (GLIS) 2024
The ICD-10-CM code for sarcopenia is M62.84, in use since 2016.
IntroductionInternational Conference on Sarcopenia and Frailty Research (ICFSR) task force 2018
Outcomes agreed in the 2024 consensus: sarcopenia increases the risk of impaired physical performance, walking and transfer limitations, falls, fractures, loss of basic and instrumental activities of daily living, hospital and care-home admission, poor quality of life and death.
Table 2Global Leadership Initiative in Sarcopenia (GLIS) 2024