Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – resistance training

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ACUTE
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all patients
1st line – 

resistance training

Prescribe resistance training first line to improve muscle strength, skeletal muscle mass, and physical function in all patients with confirmed sarcopenia.[2][9][62]

  • Resistance training refers to physical activity using external resistance, such as dumbbells, free weights, elastic therapy bands, and the body weight itself.[2] It is recommended as a safe and effective form of exercise for preventing the loss of muscle mass and strength, and even increasing it in older adults.[63][64][65]

For optimal ageing and maintaining functional capability in an older adult, recommend resistance training 2-3 times per week. This could include 1-3 sets of 8-12 repetitions of an exercise, such as lifting free weights, bench presses, or knee extensions/curls.[9]

  • Some patients may need to start with a cautious and possibly supervised programme, using body weight alone as the source of resistance.

  • Simple elastic bands that come in a range of resistances may also be a useful way of introducing resistance in people not yet able to manage free weights.

Advice on exercise should be individualised to the patient, with reference to the intended outcomes, and with a personal plan for the frequency, duration, and intensity of exercise.[9]

Studies have compared low- versus high-resistance training intensities in older adults. Superior increases in muscle strength were observed when participants were trained with higher intensities (~80% one-repetition maximum) as opposed to lower intensities (<60% one-repetition maximum).[66][67][68] In addition, it has been shown that mean muscle strength increases with high-resistance training intensities after 18 weeks: by 29% (+31.6 kg) for leg press, 33% (+12.1 kg) for knee extension, 24% (+9.83 kg) for chest press, and 25% (+10.6 kg) for lateral pulldown.[64]

Resistance exercise has been shown to increase muscle protein synthesis, which increases muscle mass in the long term. It is a key technique for minimising muscle wasting in the older population and even improving muscle mass.[59] Regular resistance exercise increases the size and cross-sectional area of muscle fibres. These changes have been observed in particular in fast-twitch (types IIa and IIx) rather than in slow-twitch fibres (type I).[69] Several studies have shown that increased muscle protein synthesis and muscle fibre size improve force-generating ability, muscle quality, and physical performance.[59]

Plus – protein intake

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ACUTE
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all patients
Plus – 

protein intake

Treatment recommended for ALL patients in selected patient group

Recommend a protein-rich diet (or consider protein supplementation, where needed) for patients with sarcopenia.[2] This should be combined with a physical activity intervention.[2]

  • Protein intake is a major factor in improving muscle mass and strength. The absolute amount of protein intake should remain the same throughout ageing to preserve lean tissue mass and prevent the development of sarcopenia. Protein supplementation alone (without resistance exercise) has not been proven to increase muscle strength or physical performance in older people with sarcopenia. Meta-analyses and consensus statements support advice to combine a protein intervention with a physical activity; however, the International Conference on Frailty and Sarcopenia Research (ICFSR) states that its recommendation is based on low certainty of evidence.[2][6][40][57][58][70] Protein intake is more likely to lead to increased lean mass when combined with exercise.

The FAO/WHO/UNU Expert Consultation on Protein and Amino Acid Requirements in Human Nutrition 2007 recommends dietary protein allowances of 0.8 g/kg of body weight for adults regardless of age.[71] However, other evidence suggests that consuming a higher amount of protein (1.2 g/kg of body weight) is needed to achieve maximal muscle protein synthesis (MPS) following a meal.[11][72] This is based on evidence that older adults have anabolic resistance to protein (amino acids) compared with their younger counterparts and achieve lower MPS rates following a standard amino acid bolus.[73] To overcome this resistance, each meal should contain 25-30 g of protein.[74]

A well-balanced protein intake is essential for supporting optimal MPS throughout the day. To achieve this, include protein-rich foods in every meal, including breakfast, lunch, and dinner. Some evidence suggests that evenly distributing protein intake across meals helps sustain MPS and overall protein utilisation.[75] For example, during breakfast, incorporating protein sources such as eggs, yoghurt, or dairy products can provide a solid foundation of protein intake, and during lunch and dinner, including around 200 g of lean meat or fish. These animal protein sources are rich in essential amino acids, crucial for muscle repair and growth. Additionally, consider plant-based protein sources such as lentils and whole grains, which provide a well-rounded amino acid profile in addition to high amounts of fibre. 

A systematic review of randomised clinical trials of 6-52 weeks' duration showed that dietary protein supplementation significantly enhanced changes in muscle strength and size during prolonged resistance exercise training in healthy adults. However, older age reduced the efficacy of this effect.[76]

Consider discussing in general with the patient the importance of an adequate calorie intake as well as protein intake, along with general nutritional advice (e.g., eating non-processed foods in preference to processed foods).[2]

  • Any dietary interventions should be in combination with appropriate physical exercise programmes.[2]

  • Healthy dietary habits are a cornerstone of healthy ageing as they contribute to maintenance of body integrity and function. However, ageing may alter energy and nutrient requirements with deleterious consequences if adjustments in food intake are not made. Ageing is associated with loss of lean body mass, especially muscle mass, a metabolically active tissue, and therefore its loss leads to a decrease in the basal metabolic rate, which represents 60% to 70% of our daily energy expenditure.[77]

Advise patients to consider their overall food intake to maintain a healthy weight at older age to prevent loss of lean mass and the development of frailty, in which malnutrition plays a key role.

Consider – aerobic exercise

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all patients
Consider – 

aerobic exercise

Additional treatment recommended for SOME patients in selected patient group

Consider aerobic exercise as a helpful adjunct to resistance exercise. It is important for maintaining overall health but is not an alternative to resistance training. Resistance training is the preferred option for managing sarcopenia.[2][9]

  • Many older adults require balance training before aerobic exercise can be undertaken.[9] One aspect that needs consideration is safe mobility and self-confidence prior to embarking on an exercise programme or regular physical activity.[78] Having a trainer or physiotherapist is a form of reassurance and will help to ensure that the movement is done properly. This may be helpful to increase adherence or decrease any initial fear of movement. Once established, the patient may be able to continue the programme without supervision.

Evidence-based exercise programmes used to improve mobility that may be suitable for vulnerable older adults include:

  • Otago Exercise Programme[79]

  • Vivifrail[9]

  • Lifestyle-integrated Functional Exercise-Programme (LiFE).[80]

Aerobic exercise is usually achieved via two types of training:

  • Continuous training - the patient is asked to walk, run, cycle, or complete any distance with the same intensity

  • Interval training - the patient is asked to complete any distance by changing the intensity several times during the workout. Sometimes referred to as high-intensity interval training (HIIT).

Both aerobic training types have been shown to improve metabolic control and cardiovascular function by increasing adenosine triphosphate (ATP) production in the mitochondria of skeletal muscle. Additionally, aerobic exercise reduces the expression of catabolic genes, improves muscle protein synthesis, induces mitochondrial biogenesis and dynamics, and restores mitochondrial metabolism.[81][82][83]

One study showed that cycle training boosted muscular size and strength in people as young as 20 and as old as 74 years.[84] Overall, aerobic exercise (continuous or HIIT) appears to promote muscular hypertrophy and strength while improving mitochondrial content and expression, albeit not to the same extent as resistance training. Because of the marked loss of muscle mass and strength in the older population, aerobic exercise (continuous exercise or HIIT) should be supplemented with resistance training with a focus on lower limbs in order to improve functional capacity.

For optimal ageing and maintaining functional capability in an older adult, recommend a 20-60 minute session of aerobic training 3-7 times per week.[9] This would ideally be in addition to resistance training, but would still be beneficial on its own.

In practice, it can be difficult to ask older adults to adhere to moderate or vigorous activity programmes, such as those proposed by current guidelines. However, walking is an activity amenable to most older adults, with considerable health benefits, and should not be overlooked as a possible activity to recommend.[85]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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