Abbott has developed, in collaboration with a multidisciplinary group of healthcare professionals (HCPs), a Best Practice Consensus resource for maintaining muscle mass, strength and function pre- and post- falls and fractures in older adults.
It is designed to integrate with existing pathways (e.g. frailty and post-fall/fracture pathways) whilst offering practical guidance on screening, functional assessment, management strategies involving nutrition and exercise, monitoring, and education.
This article will provide a brief overview of the Best Practice Consensus and offer a dietitian’s perspective on its role in clinical practice.
Why is Maintaining Muscle Mass Important?
The Best Practice Consensus highlights that skeletal muscle helps us maintain physical movement and posture, and influences our metabolism. However, as we get older, we experience a progressive decline in skeletal muscle mass — a process that begins at around 40 years of age.
By 60-70 years, around 5-13% of people have an advanced loss of muscle mass, strength, and function (medically known as ‘sarcopenia’) (1). This rises to 11-50% of people older than 80 years of age (2).
Research has shown that loss of muscle mass is associated with increased:
● Wound healing time (2)
● Adverse health outcomes in people with certain diseases (i.e. cancer and chronic obstructive pulmonary disease). (4)
Screening and Assessment
The Best Practice Consensus recommends that HCPs should screen and assess:
● Adults aged over 65 years
● All patients who have already had a fall
● Anyone identified as being at high risk of falling
● Patients attending the Emergency Department (ED) as a result of a fall.
HCPs should use their clinical judgment along with validated screening tools to identify those at risk of falls and fractures. Specifically, patients should be asked about their food intake, appetite, weight, and daily activity levels. Suitable screening and assessment tools could include:
● Malnutrition Universal Screening Tool (‘MUST’) or other locally validated tools for nutrition risk screening (5)
● Electronic Frailty Index (verify using the Clinical Frailty Scale (CFS)) (6)
● The SARC-F tool to screen for sarcopenia. (7)
Assessing muscle strength and function at every opportunity is important to identify sarcopenia and monitor any deterioration. The Best Practice Consensus recognises that no single test is appropriate for all patients, however, the following validated tools and approaches may be useful:
● Timed Up and Go Test (8) – the time taken for a person to rise from a seated position, walk three metres unaided, return and sit down again.
● Sit-to-Stand Test (10) – a test used to determine the strength or leg muscles. It measures the amount of time taken for a person to rise from a seated position to standing with their arms folded. They are usually timed for five repetitions.
● Comprehensive Geriatric Assessment – a process used by HCPs to assess medical, psychosocial, and functional needs in older, frail people.
Early detection of older people who are at increased risk of falls and fractures enables us to intervene with appropriate, evidence-based strategies. It’s encouraging to see that the Consensus recognises the importance of nutritional screening (along with frailty and sarcopenia), as inadequate screening can lead to missed opportunities, which can have adverse effects on patient outcomes.
Nutritional Strategies to Maintain Muscle Mass and Function
The role of nutrition in helping to maintain muscle mass, strength and function is well established and is widely recognised within the Best Practice Consensus.
In addition to consuming a varied and healthy diet and staying hydrated, an adequate intake of protein, energy (calories), calcium and vitamin D, can help to maintain and restore muscle mass and function, even in frail elderly patients.
This section will explore the Consensus recommendations for specific nutrients in more detail.
Protein and Energy
The Best Practice Consensus states that older adults should consume enough energy or calories to maintain their weight. If an older person has unintentionally lost weight, is acutely unwell and/or has a low body mass index (BMI), they may require an increase in energy or calorie intake.
To help maintain muscle mass and strength, it’s recommended that older adults (aged 65 and older) should consume 1.0-1.2 g of protein per kg of body weight per day. This rises to 1.2-1.5g in older adults who are malnourished or at risk of malnutrition with acute/chronic illness, and up to 2g of protein per kg of body weight per day in older people with severe injury, illness or malnutrition (12).
Increases in protein and energy intake can be met through a food-based strategies by encouraging the older person to consume energy and protein-dense foods such as meat, poultry, fish, dairy, eggs, nuts, and seeds.
For those who struggle to meet their nutritional requirements through food alone, oral nutritional supplements have been shown to be beneficial in maintaining muscle mass in malnourished older people (13).
Vitamin D sourced from our diet, the action of sunlight exposure, and nutritional supplements,
have an important role in muscle strength and function as well as bone strength.
Certain groups are at increased risk of vitamin D deficiency. This includes (14):
● Older people aged 65 and over
● Those who have low or no exposure to the sun (e.g. those who are housebound or in care homes)
● People with darker skin.
All adults should consume a daily 10 microgram (400 IU) vitamin D supplement, particularly during autumn and winter months (15). Older people who have suffered a fracture or report symptoms such as bone or muscle pain, impaired wound healing or difficulty climbing stairs should have their vitamin D status checked. If a deficiency is detected, higher dosage supplementation may be required.
Getting enough calcium is important for strong bones and muscle function. Adults in the UK should aim to consume 700 mg/day (16). For older adults with poor appetite, deficiencies and/or reduced absorption of nutrients, oral nutritional supplements or calcium supplements may be recommended to meet their requirements.
HMB stands for ß-hydroxy-ß-methylbutyrate; a metabolite of the amino acid leucine.
It stimulates protein synthesis and helps to prevent protein breakdown. Research shows that HMB has a role in the management of sarcopenia and frailty (17).
Some oral nutritional supplements are fortified with higher levels of HMB than those found in foods (HMB is only found in foods in insignificant amounts) to help preserve muscle mass. It’s recommended that people avoid the use of over-the-counter HMB tablets as these may vary in terms of dose and quality.
It’s encouraging to see that the Consensus document incorporates food-based strategies, whilst recognising that oral nutritional supplements may be helpful for those unable to meet their nutritional requirements through diet alone. HMB and its potential role in the management of sarcopenia and frailty is an interesting and evolving area.
Exercising to Maintain Muscle Mass and Function
The Best Practice Consensus states that regular exercise that challenges and improves balance and builds strength can help to prevent falls. For frail older adults, even chair-based exercises may be beneficial in improving muscle strength (although there is no evidence that they prevent falls).
They state that getting around three hours of exercise per week on an ongoing basis is important for preventing falls in older people. An exercise prescription should challenge balance and build strength, whilst taking into account an individual’s expectations, preferences, and previous exercise experience.
The resource recognises that exercise is not a short term intervention and adherence is essential, with regular monitoring to assess progress.
The resource makes it clear that reducing the risk of falls and fractures requires a multi-faceted approach that combines adequate nutrition with appropriate physical activity. Offering exercise programmes as a ‘prescription’ could help to promote long-term adherence. It would be useful to learn more about which HCPs would be best-placed to prescribe the exercise and whether there is a role for group sessions.
Ongoing Clinical/Functional Monitoring
The Best Practice Consensus recommends that HCPs regularly monitor and review a patient’s weight, strength, and function through repeat screening and assessment.
They state that triggers for re-assessment should include:
● Attending Accident & Emergency
● Changes in medication
● Changes in care (i.e. moving to care home)
● Referral to social services for care and/or adaptions
Where appropriate, HCPs are encouraged to follow appropriate guidelines and promote self-awareness and self-monitoring amongst patients to increase compliance.
Ongoing monitoring helps to ensure that interventions remain clinically indicated. Some older patients could struggle with the self-monitoring aspect, so other options would need to be available (i.e. frequent follow-ups). Ideally, clinical data should be stored on an online patient record system which is accessible by all HCPs; this would streamline the monitoring process.
The Best Practice Consensus recommends that HCPs should work as part of a multidisciplinary team (MDT) to educate all team members about the importance of exercise combined with good nutrition as a gold-standard approach for maintaining muscle strength and function. One suggestion is that HCPs could develop a directory of local services to ensure all stakeholders are aware of and know how to access suitable resources.
Working as part of an MDT when addressing sarcopenia, falls and fractures is key. Dietitians are best-placed to advise patients on diet and nutrition; dietitian-led talks to patients identified as being at ‘high risk’ of falls and fractures could be useful. These talks could run collaboratively with other HCPs (i.e. Physiotherapists) to offer an all-encompassing approach to optimising muscle mass and function in older age. Patients could undergo individual screening and monitoring using the validated tools mentioned above at each session.
Evidence-based interventions such as nutrition are often overlooked in falls/hip fracture pathways, resulting in patients who are too weak to exercise due to low energy and/or poor nutritional status. The Best Practice Consensus recognises that the combination of exercise plus appropriate nutrition is considered the gold standard for maintaining muscle strength and function. It provides clear, concise and evidence-based information for HCPs which could be implemented in a clinical setting and integrated within existing pathways.