CLINICAL

Osteosarcopenia: A new geriatric

syndrome
Ebrahim Bani Hassan, Gustavo Duque

I
Background n 2009, Binkley and Buehring drew absorptiometry (DXA) or bioelectrical
attention to a subgroup of frail, older impedance analysis (BIA) – and/or low
Longevity, the increase in the ageing patients with both osteoporosis and muscle function/strength for the diagnosis
population and a lifestyle of minimal sarcopenia,1 and described these patients of sarcopenia (Figure 1).
physical activity come with a hefty as being at higher risk of falls, fractures, There are no further criteria to define
price. Consequently, two diseases are
disability and frailty. This new syndrome, osteosarcopenia, other than a combination
increasingly becoming a concern for
originally denominated by the authors as of clinical and imaging criteria for low
the welfare of patients and the health
sarco-osteopenia, has evolved into the BMD (T-score <–1 standard deviation)
industry: osteoporosis and sarcopenia.
term osteosarcopenia. Since then, the and sarcopenia, as defined above. In
These conditions are usually interrelated
through several mechanisms and association between osteosarcopenia other terms, osteosarcopenia has been
metabolic pathways, and comprise a and poor outcomes in older people has defined as the presence of sarcopenia and
syndrome called osteosarcopenia. been well documented.2–4 Therefore, osteopenia or osteoporosis.2,3
identification of this syndrome and
Objectives implementation of an appropriate care Prevalence and importance
plan for these patients in clinical practice An estimated 66% of Australians
As patients with osteosarcopenia is pivotal. over 50 years of age reportedly have
represent an important subset of osteoporosis or osteopenia.7 More than
frail individuals at higher risk of Osteosarcopenia: 5.9% of men and 22.8% of women aged
institutionalisation, falls and fractures, A definition 50 years and older, and 12.9% of men
the aim of this review is to further
Osteoporosis is usually diagnosed and 42.5% of women aged 70 years and
familiarise general practitioners with
with a bone density scan. According older, have osteoporosis.7 In Australia,
osteosarcopenia as a new geriatric
to World Health Organization (WHO) more than 144,000 osteoporotic fractures
syndrome that requires early diagnosis
and effective therapeutic interventions. criteria, T-scores of bone mineral density occur every year, and the average cost of
(BMD) below –1 and –2.5 categorise the osteoporosis-associated or osteopenia-
Discussion patient as osteopenic and osteoporotic associated fractures is estimated at $3.36
respectively.5 By contrast, diagnosis of billion per year.
The most important aspects of sarcopenia requires a combination of The prevalence of sarcopenia in
osteosarcopenia are discussed here. clinical and imaging parameters. The Australians aged 65 years and older
These include pathogenesis, prevalence, European Working Group on Sarcopenia is estimated to be up to 6.4% in men
diagnostic criteria, management
in Older People (EWGSOP) defines and 9.3% in women.8 Patients with
and follow-up. Finally, the role of
sarcopenia as ‘a syndrome characterised sarcopenia are at least three times more
multidisciplinary clinics for the care
by progressive and generalised loss likely to have a fall in the next two years.9
of patients with osteosarcopenia is
of skeletal muscle mass and strength, Recent studies in Australian persons
discussed in brief.
with a risk of adverse outcomes such with previous history of falls reported
as physical disability, poor quality of that 40% of this high-risk population had
life and high mortality’.6 The working osteosarcopenia.2,3 Being female; having
group recommends using low muscle a history of osteoarthritis, oophorectomy
mass – measured by dual-energy X-ray or cancer; and impaired mobility were

© The Royal Australian College of General Practitioners 2017 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 849
 CLINICAL OSTEOSARCOPENIA: A NEW GERIATRIC SYNDROME

Older subject
(>65 years)

Measure gait
speed

>0.8 m/s ≤0.8 m/s

Measure grip strength Measure muscle mass

Risk of
No sarcopenia
sarcopenia No sarcopenia Sarcopenia
men: >30 kg
men: <30 kg
women: >20 kg BIA BIA
women: <20 kg
men: ≥10.76 kg/m2 Sarcopenia
women: ≥6.76 kg/m2 men: ≤8.50 kg/m2
women: ≤5.75 kg/m2
DXA (ALM/H2)
Presarcopenia
men: >7.26 kg/m2
men: 8.51–10.75 kg/m2
women: >5.45 kg/m2
women: 5.76–6.75 kg/m2

DXA (ALM/H2)
men: <7.26 kg/m2
women: <5.45 kg/m2

Figure 1. A suggested algorithm for the diagnosis of sarcopenia6,13

ALM/H2, appendicular lean muscle mass/height (derived from DXA whole body exam); BIA, bioelectrical impedance analysis; DXA, dual energy X-ray absorptiometry

risk factors for osteosarcopenia in the to gain or regain volume and strength. and possibly nervous crosstalk. Any
Australian cohort.3 Regarding poor In addition to acting as an endocrine alterations in this crosstalk could affect
outcomes, patients with osteosarcopenia organ for bone mass maintenance, all three tissues simultaneously.13
have a higher prevalence of disability, strong musculature minimises the risk Furthermore, atrophied muscle and
falls and fractures (especially if they are of fractures by sustaining better balance bone are usually replaced by adipose
obese),10,11 and higher mortality risk.4 and minimising falls, while also partially tissue.13,14 Significant fat infiltration
Box 1 lists the most common risk factors absorbing/dissipating forces associated into the muscles and bone marrow in
for osteosarcopenia, which should be with falls. patients with osteosarcopenia highlights
identified in clinical practice. In addition, these tissues not only react the possible involvement of lipotoxicity
to endocrine stimulation, they produce and local inflammation in age-associated
Pathophysiology and hormones that affect the metabolism and osteosarcopenia.13,14 This further
pathogenesis activities of the other tissues.12 Bone, complicates the crosstalk between
Bone, muscle and associated muscle and adipose tissues are known to muscle, bone and fat, which are the
tissues (eg tendons, ligaments) need communicate with each other, and help three most abundant components of the
weight‑bearing to avoid atrophy, and sustain homeostasis through a hormonal connective tissue.

850 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 © The Royal Australian College of General Practitioners 2017
 OSTEOSARCOPENIA: A NEW GERIATRIC SYNDROME CLINICAL

Box 1. Risk factors for in Australia.15 Most DXA machines in been proven to be of benefit in patients
osteosarcopenia13,20 Australia include a body composition with sarcopenia. Angiotensin converting
analysis function. However, GPs should enzyme inhibitors (eg enalapril), which
Osteoporosis
specify this request when referring the might work by preventing mitochondrial
Maternal history of hip fracture patient for a DXA test. This additional decline and improving endothelial function
Sarcopenia analysis could incur an extra charge, which and muscle metabolism, are still in the
is not covered by Medicare Australia. experimental phase.17 Anti-myostatin
Low albumin Muscle function, however, is measured therapies, which target myostatin – a
Stroke
by estimation of strength and function potent inhibitor of skeletal muscle growth
Hyperlipidaemia
using a combination of techniques, such – and prevent muscle loss due to ageing
Osteoporosis and sarcopenia as gait speed – which can be easily have shown limited efficacy;18 however,
measured in general practice – and grip new modalities of these drugs are under
Older age
strength using a dynamometer, following clinical trial and are expected to be
Female
well established protocols and cut-off available in a few years’ time.
High alcohol intake
Oral glucocorticoids values (Figure 1).6 In some instances,
people who are frail, older and have poor Osteosarcopenia in clinical
Menopause (females)
Low protein intake mobility cannot ambulate or attend a DXA practice
Low BMI facility. In those cases, BIA might be a Osteoporosis and sarcopenia are
Current smoking useful, low-cost alternative, which can be chronically deteriorating conditions.
Low dietary calcium combined with grip strength to make the Therefore, regular follow-up and education
Low serum vitamin D diagnosis of sarcopenia. Although less of patients are paramount for successful
Hypogonadism (in men) accurate than high-quality BIA machines, management. Falls and bone metabolic
Hyperparathyroidism but as a very low-cost and accessible clinics, which are run by geriatricians and
Obesity alternative, body composition is also endocrinologists respectively, have the
Rheumatoid arthritis included in many commonly available limitations of being fragmented models of
Living in residential aged-care facilities
weighing scales that show percentages care that evaluate and treat bone health
Chronic kidney disease
of fat, muscle and water. Nevertheless, and sarcopenia separately. Therefore, an
Low mobility and function
the European Consensus agreed that, important part of the osteosarcopenia
even in the absence of imaging or BIA, follow-up involves referring high-risk
clinical parameters (gait velocity and grip patients – those with multiple risk factors
How to diagnose strength) are reliable enough to diagnose for osteoporosis and sarcopenia, or patients
sarcopenia in clinical practice.6 who have suffered falls and fractures – to
osteosarcopenia?
specialised multidisciplinary clinics, such
A previous history of falls and/or fractures Prevention and treatment as falls and fractures clinics, which are
in older people should alert general recommendations usually run by geriatricians together with a
practitioners (GPs) to the presence of Regarding primary prevention, no study has multidisciplinary team. These specialised
osteosarcopenia. Common clinical signs looked at interventions with a combined clinics, which offer a combined model
of osteoporosis include kyphosis and impact on bone and muscle that could be of bone health and falls prevention, may
decreased height because of pathological implemented prior to the development constitute the future gold standard of
fractures of the vertebrae after middle age. of osteosarcopenia. After identification care in this population.19 In cases where
Muscle weakness, falls and decreasing of osteosarcopenia, secondary causes specialised clinics and services are not
function could indicate sarcopenia. of sarcopenia and osteoporosis should
However, in many cases, osteosarcopenia be identified and treated (Box 2). This
is asymptomatic until a catastrophic should be followed by implementation of Box 2. Recommended tests to
identify secondary causes of
fracture occurs, which is the rationale for evidence-based preventive and therapeutic
osteosarcopenia21
regular assessment of bone and muscle interventions that are effective for
mass and function in older people with risk osteoporosis and sarcopenia (Table 1).15,16 25(OH) vitamin D
factors for this disease (Box 1). Regarding pharmacological treatment Calcium
Parathyroid hormone
For economic and logistic reasons, the for osteosarcopenia, the effectiveness of
Creatinine/estimated glomerular filtration rate
most cost-effective diagnostic method for osteoporosis drugs in preventing fractures
Albumin
sarcopenia is DXA, which already has clear is well documented. By contrast, there
Serum testosterone in men
indications for diagnosis of osteoporosis is no pharmacological therapy that has

© The Royal Australian College of General Practitioners 2017 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 851
 CLINICAL OSTEOSARCOPENIA: A NEW GERIATRIC SYNDROME

available, the patient could still benefit from Table 1. Preventive and therapeutic interventions for osteosarcopenia15,16,22,23
being assessed by a physiotherapist or
Intervention Recommendation
exercise physiologist, while also attending
community health centres, which are Healthy lifestyle Smoking cessation, alcohol restriction
widely available in Australia and often run Physical activity Resistance and balance training at least twice a week for not less
exercise programs specifically designed than 30 minutes per session
for people who are frail and older.
Vitamin D and calcium Particularly in those with low vitamin D levels (ie <50 ng/mL).
In addition, follow-up with DXA scans The target is to maintain it above 75 ng/ml to assure anti-fall and
is recommended every two years for anti‑fracture efficacy22
low-risk patients and once a year for Dietary calcium should be encouraged, with a target of 1.2 g/day
high-risk patients.15 As changes in muscle Pharmacological Should be initiated in all patients with bone mineral density (BMD)
mass occur more rapidly than changes treatment for T‑score <–2.5 standard deviation (SD) or in patients on corticosteroids
in BMD, annual evaluation of lean mass osteoporosis (7.5 mg/day for longer than three months and a BMD T‑score <–1.5
by DXA, combined with a regular clinical SD).15,16 This includes first-line treatments such as bisphosphonates
(alendronate, risedronate and zoledronic acid), or RANKL antagonist
assessment of muscle strength and
(denosumab). Teriparatide (bone anabolic) should be considered in
function, is recommended. high-risk patients who fracture while on anti-resorptives for longer
than 12 months, and have a history of a BMD T‑score <–3 SD15
Discussion and conclusion
Protein intake In addition to dietary protein, high-quality protein supplementation
Osteosarcopenia is an ever-increasing (up to 2 g/kg/day in patients with normal renal function and a
global health concern. Similarly to most maximum of 1.2 g/kg/day in patients with renal impairment),
medical conditions, the primary aim especially combined with exercise, consistently improves muscle
should be to prevent the occurrence function and strength23

of osteosarcopenia rather than treat it.

Its complex and multifactorial nature
requires multifaceted treatment and In conclusion, it is vital to increase 2. Huo YR, Suriyaarachchi P, Gomez F, et al.
Phenotype of osteosarcopenia in older
prevention strategies. the general knowledge about individuals with a history of falling. J Am Med Dir
A healthy lifestyle and regular exercise osteosarcopenia among patients and Assoc 2015;16(4):290–95.
(ie strength, balance) are the first-line medical professionals, particularly GPs 3. Huo YR, Suriyaarachchi P, Gomez F, et al.
Comprehensive nutritional status in sarco-
prevention and treatment choices for as the sentinels of disease prevention, osteoporotic older fallers. J Nutr Health Aging
osteosarcopenia; however, although control, and treatment. 2015;19(4):474–80.
essential, second-line and third-line 4. Pasco JA, Mohebbi M, Holloway KL,
Authors Brennan-Olsen SL, Hyde NK, Kotowicz MA.
measures are commonly required. Parallel Musculoskeletal decline and mortality:
Ebrahim Bani Hassan DVM, DVSc, PhD, Research
to pharmacological intervention, patients Fellow, Australian Institute for Musculoskeletal
Prospective data from the Geelong Osteoporosis
Study. J Cachexia Sarcopenia Muscle
should receive pragmatic instructions Science (AIMSS), the University of Melbourne 2017;8(3):482–89.
about adjunct therapy and prevention of and Western Health, St. Albans, Vic; Department
5. World Health Organization. WHO scientific group
of Medicine, Western Health, yhe University of
falls and fractures. In summary, GPs are on the assessment of osteoporosis at primary
Melbourne, St Albans, Vic
health care level. Geneva: WHO, 2007.
encouraged to: Gustavo Duque MD, PhD, FRACP, Geriatrician,
6. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al.
• assess for sarcopenia and osteoporosis Professor and Chair of Medicine, Department Sarcopenia: European consensus on definition
of Medicine, Melbourne Medical School and and diagnosis: Report of the European Working
in older people Western Health; Director, Australian Institute for Group on Sarcopenia in Older People. Age
• document low bone/muscle mass by Musculoskeletal Science (AIMSS), St Albans, Vic. Ageing 2010;39(4):412–23.
DXA and low muscle function/strength [email protected]
7. Watts JJ, Abimanyi-Ochom J, Sanders KM.
• consider patients with osteosarcopenia Competing interests: None. Osteoporosis costing all Australians: A new
Provenance and peer review: Not commissioned, burden of disease analysis – 2012 to 2022.
to be at much greater risk for falls, Glebe, NSW: Osteoporosis Australia, 2013.
externally peer reviewed.
fractures, disability and frailty, Available at www.osteoporosis.org.au/sites/
Acknowledgements default/files/files/burden%20of%20disease%20
compared with patients with
analysis%202012-2022%20(1).pdf [Accessed 3
osteoporosis or sarcopenia alone The authors are grateful to Dr Hossein Kalantar October 2017].
and Dr Aida Karimpour for proofreading this
• exclude secondary causes manuscript, and for bringing their GP perspective
8. Yu S, Appleton S, Adams R, et al. The impact of
low muscle mass definition on the prevalence of
• initiate evidence-based interventions of its content.
sarcopenia in older Australians. BioMed Res Int
(ie exercise, nutritional supplements, 2014;2014:361790.
References
pharmacotherapy) 9. Landi F, Liperoti R, Russo A, et al. Sarcopenia
1. Binkley N, Buehring B. Beyond FRAX: It’s time as a risk factor for falls in elderly individuals:
• refer high-risk patients to specialised to consider ‘sarco-osteopenia’. J Clin Densitom Results from the ilSIRENTE study. Clin Nutr
clinics, where available. 2009;12(4):413–16. 2012;31(5):652–58.

852 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 © The Royal Australian College of General Practitioners 2017
 OSTEOSARCOPENIA: A NEW GERIATRIC SYNDROME CLINICAL

10. Scott D, Chandrasekara SD, Laslett LL, 19. Gomez F, Curcio CL, Suriyaarachchi P,
Cicuttini F, Ebeling PR, Jones G. Associations of Demontiero O, Duque G. Differing approaches to
sarcopenic obesity and dynapenic obesity with falls and fracture prevention between Australia
bone mineral density and incident fractures over and Colombia. Clin Interv Aging 2013;8:61–67.
5–10 years in community-dwelling older adults. 20. Pérez-López FR, Ara I. Fragility fracture risk
Calcif Tissue Int 2016;99(1):30–42. and skeletal muscle function. Climacteric
11. Huo YR, Suriyaarachchi P, Gomez F, et al. 2016;19(1):37–41.
Phenotype of sarcopenic obesity in older 21. Johnson K, Suriyaarachchi P, Kakkat M, et al.
individuals with a history of falling. Arch Gerontol Yield and cost-effectiveness of laboratory testing
Geriatr 2016;65:255–59. to identify metabolic contributors to falls and
12. Kawao N, Kaji H. Interactions between muscle fractures in older persons. Arch Osteoporos
tissues and bone metabolism. J Cell Biochem 2015;10:226.
2015;116(5):687–95. 22. Duque G, Daly RM, Sanders K, Kiel DP.
13. Hirschfeld HP, Kinsella R, Duque G. Vitamin D, bones and muscle: Myth versus
Osteosarcopenia: Where bone, muscle, and reality. Australas J Ageing 2017;36 Suppl 1:8–13.
fat collide. Osteoporos Int 2017 [Epub ahead of 23. Phu S, Boersma D, Duque G. Exercise and
publication]. sarcopenia. J Clin Densitom 2015;18(4):488–92.
14. Demontiero O, Boersma D, Suriyaarachchi P,
Duque G. Clinical outcomes of impaired muscle
and bone interactions. Clinic Rev Bone Miner
Metab 2014;12(2):86–92.
15. The Royal Australian College of General
Practitioners. Osteoporosis prevention, diagnosis
and management in postmenopausal women
and men over 50 years of age. Melbourne:
RACGP, 2010. Available at www.racgp.org.
au/your-practice/guidelines/musculoskeletal/
osteoporosis [Accessed 3 October 2017].
16. Duque G. Osteoporosis in older persons: Current
pharmacotherapy and future directions. Expert
Opin Pharmacother 2013;14(14):1949–58.
17. Burton LA, McMurdo ME, Struthers AD.
Mineralocorticoid antagonism: A novel way to
treat sarcopenia and physical impairment in older
people? Clin Endocrinol 2011;75(6):725–29.
18. Becker C, Lord SR, Studenski SA, et al. Myostatin
antibody (LY2495655) in older weak fallers: A
proof-of-concept, randomised, phase 2 trial.
Lancet Diabetes Endocrinol 2015;3(12):948–57.

© The Royal Australian College of General Practitioners 2017 REPRINTED FROM AFP VOL.46, NO.11, NOVEMBER 2017 853