Sarcopenia in older and elderly patients: clinical guidelines

List of Abbreviations

GS - geriatric syndrome

GH - growth hormone

ASMI - appendicular skeletal muscle mass index

IL-1 - interleukin-1

IL-6 - interleukin-6

BMI – body mass index

IGF-1 - insulin-like growth factor-1

CGA - comprehensive geriatric assessment

CrCl - creatinine clearance

FS - frailty syndrome

DM - diabetes mellitus

GFR – glomerular filtration rate

TGFβ - transforming growth factor beta 1

TSH — thyroid-stimulating hormone

TNF-α - tumor necrosis factor alpha

CKD - chronic kidney disease

COPD - chronic obstructive pulmonary disease

CHF – chronic heart failure

25(OH)D - 25-hydroxyvitamin D (calcidiol)

CKD-EPI - Chronic Kidney Disease Epidemiology Collaboration equation

DEXA - Dual-energy X-ray absorptiometry

EWGSOP2 - European Working Group on Sarcopenia for Older People 2

FRAX - Fracture risk assessment tool

Terms and Definitions

Autonomy – independence from outside help and the ability to make decisions independently.

Geriatric syndrome – a multifactorial age-associated clinical condition that impairs quality of life, increases the risk of adverse outcomes (death, dependence on outside help, readmissions, need for long-term care) and functional impairments. Unlike a traditional clinical syndrome, a geriatric syndrome is not a manifestation of a pathology in a single organ or body system, but reflects a complex of changes in multiple systems. The occurrence of one geriatric syndrome increases the risk of developing other geriatric syndromes. Geriatric syndromes include: frailty, dementia, delirium, depression, behavioral and psychological symptoms of dementia, osteoporosis, sarcopenia, functional impairment, reduced mobility, balance disorders, dizziness, orthostatic syndrome (orthostatic hypotension, orthostatic tachycardia with or without symptoms), sensory deficits (vision loss, hearing loss), urinary/fecal incontinence, constipation syndrome, malnutrition, dehydration, chronic pain syndrome.

Comprehensive geriatric assessment – a multidimensional interdisciplinary diagnostic process that includes assessment of physical and psycho-emotional status, functional capabilities, and identification of social problems in an older person, aimed at developing a treatment and monitoring plan to restore or maintain the patient's level of functional activity.

Elderly age – 60–74 years according to the 2012 World Health Organization age group classification.

Polypharmacy – the simultaneous prescription of 5 or more drug names to a patient, or more than 10 names during a course of treatment.

Polymorbidity (multimorbidity) – the presence of two or more chronic diseases in a single patient, regardless of the activity of each.

Sarcopenia – a progressive, age-associated, generalized, potentially reversible skeletal muscle disease associated with a high risk of adverse outcomes, including falls, fractures, disability, and death.

Confirmed sarcopenia – a diagnosis of sarcopenia is established based on low muscle strength and muscle mass values.

Severe sarcopenia – a diagnosis of sarcopenia is established, and additional assessment of physical performance using functional tests is required.

Frailty – a geriatric syndrome characterized by an age-associated decrease in physiological reserve and the functions of many body systems, leading to increased vulnerability of the older person to endo- and exogenous factors and a high risk of adverse health outcomes, loss of autonomy, and death. The frailty syndrome is closely related to other geriatric syndromes and polymorbidity, is potentially reversible, and influences patient management tactics. There are two models describing frailty, the phenotypic model, which includes five criteria (unintentional weight loss, low grip strength, increased fatigue, reduced walking speed, and low physical activity), and the deficit accumulation model, which involves assessing 40 to 70 deficits and calculating the frailty index.

Senile age – 75–89 years according to the 2012 World Health Organization age group classification.

Physical activity – any bodily movement produced by skeletal muscles that requires energy expenditure.

Physical performance – defined as objectively measured whole-body function related to locomotion.

Skeletal muscle function – determined by muscle strength and physical performance.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Sarcopenia is a progressive, age-associated, generalized, potentially reversible skeletal muscle disease associated with a high risk of adverse outcomes, including falls, fractures, disability, and death [1]. The development of sarcopenia is associated with a large number of factors, including aging, malnutrition, low physical activity, and the presence of chronic diseases [2]. Sarcopenia is also an important prognostic indicator of the likelihood of complications from existing diseases and patient survival [3].

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

Sarcopenia is a multi-etiological disease whose development is driven by multiple factors. These factors include both internal (genetic, hormonal, metabolic) and external (lifestyle, diet, physical activity) aspects. Factors closely associated with the risk of developing sarcopenia include:

• Advanced age;

• Underweight and obesity;

• Residence in long-term care facilities;

• Malnutrition;

• Bad habits (alcohol dependence, smoking);

• Low physical activity;

• Vitamin D deficiency (less than 20 ng/L);

• Multiple organ failure;

• Progression of chronic diseases: diabetes mellitus, arterial hypertension, chronic obstructive pulmonary disease, cerebrovascular diseases, acute cerebrovascular accident, liver cirrhosis, immunoinflammatory rheumatic diseases, malabsorption, inflammatory bowel diseases, malignant neoplasms;

• Prolonged uncontrolled intake of medicinal products belonging to the following groups: statins, glucocorticoids, loop diuretics.

Patient sex (specifically female sex) cannot currently be considered a factor closely associated with the risk of developing sarcopenia due to conflicting data in modern studies and publications [4, 5].

The pathogenetic mechanisms of sarcopenia development are quite diverse and complex. They are primarily driven by the aging process of the body as a whole and striated muscle tissue in particular. Maintaining muscle homeostasis depends on endogenous (endocrine, inflammatory, metabolic) and exogenous (physical exercise, nutrition) factors. Hormonal factors play an important role in the development and maintenance of muscle function throughout life, particularly testosterone, estrogens, growth hormone (GH), insulin, and insulin-like growth factor-1 (IGF-1), the synthesis of which decreases with age [6, 7].

Skeletal muscle aging is characterized by the loss of alpha-motor neurons and a decrease in the number of type I and type II muscle fibers, with the development of myofibrillar atrophy. Remodeling of skeletal muscle tissue via neuropathic, neurohormonal, and inflammatory pathways leads to a decrease in muscle cross-sectional area, volume, and regeneration rate. Degradation of the neuromuscular junction is characterized by impaired Schwann cell function, which contributes to ineffective reinnervation of muscle fibers with the gradual replacement of muscle mass by adipose and connective tissue [8, 9].

The progression of sarcopenia is also promoted by inadequate protein intake, which leads to a decrease in muscle protein synthesis. The quality of consumed protein is important. High-quality proteins containing 10 essential amino acids are potent stimulators of the mTOR (mammalian target of rapamycin) pathway, which regulates protein synthesis. With age, achieving a maximum anabolic response requires consuming a larger amount of protein than at a younger age. In addition, protein metabolism is affected by impaired absorption and increased protein breakdown, in which myostatin, a member of the TGFβ family, plays an active role [10-13].

Vitamin D and its active form, calcitriol, play a leading role in the regulation of metabolic processes in muscle tissue, exerting their effects through genomic and non-genomic mechanisms. Vitamin D has a direct effect on muscle cells by activating specific vitamin D receptors (VDR) present in skeletal muscles. These receptors are activated by calcitriol and regulate the expression of genes associated with muscle growth and function. Additionally, vitamin D suppresses the expression of pro-inflammatory cytokines (e.g., TNF-α and IL-6), exhibiting anti-inflammatory, antioxidant, and anti-apoptotic effects [14-17]. During aging, cells acquire a secretory phenotype that enhances the production of pro-inflammatory cytokines, such as IL-6, TNF-α, C-reactive protein (CRP), etc., leading to the development of low-grade chronic inflammation, which activates catabolic processes in muscle tissue [18].

Adipokines, hormones synthesized by both adipose and muscle tissue, play an important role in muscle tissue metabolism. On the one hand, muscles produce pro-inflammatory adipokines, such as leptin, resistin, and others, which disrupt myoblast differentiation and stimulate the synthesis of pro-inflammatory cytokines and transforming growth factor beta (TGF-β); on the other hand, anti-inflammatory adipokines—adiponectin and irisin—are synthesized, improving muscle protein metabolism and promoting the synthesis of anti-inflammatory cytokines [19-21].

The negative role of oxidative stress in the pathogenesis of sarcopenia is well known. With age, there is a decrease in mitochondrial function, as well as a decline in antioxidant systems, resulting in increased production of superoxide anions capable of damaging muscle cell DNA, oxidizing proteins and lipids, disrupting cellular signaling mechanisms, and ultimately activating apoptotic pathways. Furthermore, oxidative stress is interrelated with other pathogenetic factors of sarcopenia. For example, chronic inflammation frequently observed in older adults (so-called "inflammaging") enhances the production of reactive oxygen species through the activation of pro-inflammatory cytokines such as IL-6 and TNF-α [22-24]. In turn, impaired mitochondrial function contributes to the loss of skeletal muscle mass and strength in two ways: by increasing the accumulation of damaged proteins and by reducing the capacity of mitochondria to generate energy [25].

1.3 Epidemiology of the Disease or Condition

According to research data, the prevalence of sarcopenia varies across different countries worldwide: from 4.3% in the USA to 58% in Spain, and from 21.8% to 46.5% in European countries [26].

Studies conducted in the Russian Federation have shown that the prevalence of sarcopenia in the general older adult population ranged from 30 to 37% [27, 28].

The prevalence of sarcopenia directly depends on which international working group guidelines were used for diagnosis in the studies, varying from 9.9 to 40.4% [29].

The prevalence of sarcopenia depends on ethnicity, being lower in the USA, China, and Japan (4.3%, 9.0%, and 9.4%, respectively) compared to residents of Mexico and Spain (33.6% and 58%, respectively) [26].

Among community-dwelling older adults, the prevalence of sarcopenia ranges from 1% to 29%, whereas in institutionalized long-term care residents, it ranges from 14% to 33% [30].

The proportion of individuals suffering from sarcopenia increases with age, reaching 57.2% at 90 years and older [31].

It is worth noting that the prevalence of sarcopenia is higher in individuals suffering from circulatory system diseases (acute and chronic heart failure, strokes, arterial hypertension), type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, anemia, oncological diseases, autoimmune and rheumatic diseases, osteoporosis, and osteoarthritis [32-38, 267].

1.4 Features of Coding the Disease or Condition

M62.8 – Other specified disorders of muscle

1.5 Classification of the disease or condition

Several classifications of sarcopenia are used in clinical practice.

I. By form:

1. Primary sarcopenia, age-associated;

2. Secondary sarcopenia:

   – sarcopenia associated with reduced physical activity (sedentary lifestyle, prolonged immobilization, microgravity/absence of gravity);

   – sarcopenia associated with chronic non-communicable diseases (diseases of the cardiovascular system, lungs, liver, kidneys, brain, inflammatory diseases, endocrine disorders, malignant neoplasms);

   – sarcopenia associated with inadequate nutrition (insufficient dietary protein intake due to malabsorption, malnutrition, gastrointestinal disorders, or the use of medications provoking anorexia).

II. By the ratio between adipose tissue and muscle mass:

Type 1 – associated with a high body fat content (more than 38% in women and more than 27% in men) with a reduction in skeletal muscle mass;

Type 2 – characterized by a reduction in skeletal muscle mass with normal or reduced body fat content.

III. By disease duration:

– acute sarcopenia (duration up to 6 months);

– chronic sarcopenia (duration over 6 months) [1].

1.6 Clinical presentation of the disease or condition

Patients may present with a number of non-specific signs and symptoms indicating the possible presence of sarcopenia or an increased risk of its development. The most significant signs of sarcopenia are difficulties in performing certain activities that require muscle strength and endurance [1]. These activities include:

1. Lifting and carrying loads:

• Patients may experience difficulty lifting and holding objects weighing 4-5 kg or more. This may manifest as weakness in the arms, tremor, or rapid fatigability [39, 40].

2. Indoor walking:

• Noticeable slowing of walking speed, instability, the need for an assistive device (e.g., a cane or walker), or frequent stops to rest [39, 40].

3. Rising from a bed or chair:

• Difficulty getting up from a bed or chair, the need to push off with the hands or use additional aids (e.g., armrests) [39, 40].

4. Stair climbing:

• Difficulty climbing a single flight of stairs, including the need to rest halfway, shortness of breath, or pronounced fatigue [39, 40].

5. History of falls:

• Presence or increased frequency of fall episodes associated with loss of balance, leg weakness, or decreased motor coordination [39, 40].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnostic criteria for sarcopenia are:

1. reduced muscle strength;

2. reduced muscle mass.

A diagnosis of sarcopenia is confirmed based on low values of muscle strength and muscle mass. To determine the severity of sarcopenia, physical performance is assessed. Meanwhile, low muscle strength is a powerful predictor of functional limitations, poor quality of life, and mortality.

In 2018, the second European Working Group on Sarcopenia in Older People (EWGSOP2) updated the diagnostic criteria for sarcopenia, defining probable, confirmed, and severe sarcopenia. Muscle strength became the primary diagnostic component for detecting sarcopenia, as it best reflects skeletal muscle function, while muscle mass confirms the presence of sarcopenia. Furthermore, reduced physical performance indicates severe sarcopenia [1].

To date, there is no single algorithm for diagnosing sarcopenia. When muscle mass cannot be determined in practical work, the term probable sarcopenia can be used based on characteristic complaints and identified reduced muscle strength. From the perspective of the specialized EWGSOP2 expert group, identifying probable sarcopenia is sufficient to initiate therapeutic interventions for sarcopenia.

Based on these facts, in real clinical practice, sarcopenia should be diagnosed when a patient presents with complaints characteristic of sarcopenia and exhibits reduced muscle strength.

2.1 Complaints and Anamnesis

Patients with sarcopenia may not voice complaints, considering their symptoms to be a natural manifestation of aging.

For a more structured collection of complaints, one should purposefully inquire about the presence of the following symptoms: increased fatigue, muscle weakness, difficulty performing certain activities (e.g., walking on flat ground, rising from a chair, climbing stairs), and the number of falls over the past year [41, 42, 43, 268]. These complaints are not specific to sarcopenia, but they fall into the category of "characteristic" signs of sarcopenia.

Comments: sarcopenia is one of the most unfavorable geriatric syndromes regarding patient prognosis. The presence of sarcopenia is associated with a more severe course of chronic non-communicable diseases, a high risk of falls and fractures, and a high rate of disability. Identifying sarcopenia is crucial for determining the prognosis, management tactics, duration, and quality of life of the patient [44].

Comments: the criterion for unintentional weight loss is a body weight decrease > 5% within the preceding 6 months or > 10% over a period of more than 6 months. Weight loss is closely associated with the presence of malnutrition and frailty syndrome in patients aged 60 years and older, the course of which is often accompanied by the development of sarcopenia. In elderly and senile patients, any weight loss is associated with the development and/or progression of sarcopenia, malnutrition, bone mass loss, and increased mortality [46].

2.2 Physical Examination

Comments: body mass index (BMI) is an indicator that allows assessing the degree of correspondence between a person's weight and height. BMI = body mass/height² (kg/m²). Reference BMI values:

• < 18.5 kg/m² — underweight;

• 18.5–24.9 kg/m² — normal body weight;

• 25–29.9 kg/m² — overweight;

• ≥ 30 kg/m² — obesity.

The development of sarcopenia is most likely at low BMI values. However, the presence of normal weight, overweight, or obesity in a patient does not exclude the risks of developing sarcopenia.

A decrease in calf volume (circumference less than 31 cm for both sexes) is a sign of reduced muscle mass [269].

Comments: as part of sarcopenia screening, handgrip dynamometry parameters and/or the results of the 5-times sit-to-stand test are evaluated (Appendix B).

Chronic non-communicable diseases (CNCDs) are accompanied by systemic inflammation, oxidative stress, hormonal changes, inadequate nutrition, and low physical activity, which in turn accelerates the process of muscle tissue and function loss. The presence of sarcopenia worsens the prognosis of such patients, is associated with a more severe course of the disease, decreased exercise tolerance, an increased risk of CNCD decompensation, and increases the rate of disability.

Comments: identification of FS determines the health and life prognosis for an elderly patient, their management tactics, and the need for outside assistance and care. FS screening at the primary healthcare level has proven effective in preventing the decline in functional status of elderly and senile patients [58, 59]. The use of short validated (in a specific country) questionnaires aimed at identifying the main signs of FS and key GS is an international practice for identifying FS that has proven its effectiveness. FS screening is carried out using the "Age is No Obstacle" scale (Appendix G1), based on the results of which the patient is referred to a geriatrician.

Comments: when assessing risk factors for falls, one should be guided by the clinical guidelines of the Russian Ministry of Health "Falls in elderly and senile patients".

Comment: examination, management, and follow-up of patients with osteoporosis are carried out based on the clinical guidelines "Osteoporosis".

Comments: since the main intervention strategy for sarcopenia is increasing dietary protein intake, active detection of malnutrition plays a crucial role in patient management tactics. When malnutrition or the risk of its development is detected, the examination and management of the patient are carried out taking into account the clinical guidelines "Malnutrition in elderly and senile patients", posted in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

Comments: chronic musculoskeletal pain in patients aged 60 years and older is considered in relation to the development and progression of sarcopenia. On the one hand, pain itself can reduce patient activity, exacerbating sarcopenia; on the other hand, pathogenetic changes in muscles during sarcopenia (primarily the inflammatory cascade) can worsen degenerative changes in cartilage and bone tissue [74, 75].

Comments: The patient's social status is partially assessed by all members of the multidisciplinary team, but the most comprehensive assessment is performed by a medical social worker. When assessing social status, data on educational level, occupation, marital status, living arrangements, whom the patient turns to for help when needed are clarified, home safety is evaluated, and signs of neglect, self-neglect, and elder abuse are identified.

2.3 Laboratory Diagnostics

Comments: Anemia is a common condition in older adults and elderly individuals, associated with an increased risk of developing sarcopenia. The WHO diagnostic criterion for anemia is a hemoglobin (Hb) level of less than 130 g/L in men and less than 120 g/L in non-pregnant women. Even mild anemia increases mortality risk, elevates morbidity, and reduces patients' quality of life.

Comments: Iron is one of the key trace elements maintaining normal muscle tissue function. Iron is a component of myoglobin and is also required as a cofactor for electron transfer by all complexes of the mitochondrial electron transport chain, ensuring energy metabolism in myocytes. Muscle tissue contains up to 15% of all body iron and is one of the most energy-demanding tissues in the body. Iron deficiency and anemia lead to reduced muscle aerobic capacity, muscle strength, muscle mass, and muscle function [319-324].

Comments: A decrease in serum total protein and albumin concentrations in patients with frailty syndrome is a sign of protein-energy malnutrition and undernutrition. Low total protein and albumin levels serve as serological markers of sarcopenia.

Comments: If these values deviate from the reference ranges, a diagnostic workup must be conducted to identify conditions that may cause secondary sarcopenia.

Comments: Blood CRP levels are a strong independent prognostic marker of sarcopenia, impaired mobility, and reduced activities of daily living.

Comments: Blood 25-OH vitamin D levels are a strong independent diagnostic and prognostic marker of sarcopenia [83, 94-104]. Vitamin D deficiency corresponds to a 25(OH)D3 concentration < 20 ng/mL (50 nmol/L), vitamin D insufficiency to 25(OH)D3 from 20 to 30 ng/mL (50 to 75 nmol/L), and sufficiency to > 30 ng/mL (75 nmol/L). The recommended target level of 25(OH)D3 when correcting vitamin D deficiency is 30–60 ng/mL (75–150 nmol/L) [105].

Comments: Due to the potential risk of developing hypercalcemia/hypercalciuria, these medications may only be prescribed under medical monitoring of blood calcium levels and, in some cases, urinary calcium levels (provided glomerular filtration rate is normal).

Comments: Levels of TSH, free thyroxine (FT4), and free triiodothyronine (FT3) are associated with indices of muscle mass and function. Both hypothyroidism and hyperthyroidism can contribute to the development of sarcopenia by altering muscle protein synthesis and breakdown, as well as increasing oxidative stress.

Comments: In addition to calculating eGFR using the CKD-EPI equation, it is advisable to calculate creatinine clearance using the Cockcroft-Gault formula, as the prescribing information for many drugs uses this parameter for dose adjustment. Calculating eGFR using cystatin C concentration via the CKD-EPI Cystatin C equation is appropriate in clinical settings where the accuracy of creatinine-based eGFR is compromised [109, 110, 111].

2.4 Instrumental Diagnostics

Comments: Handgrip dynamometry should be performed in all older and elderly patients to assess hand muscle strength for the diagnosis of sarcopenia. The procedure [271] is described in Appendix G5. Dynamometry is performed using an electronic or hydraulic/mechanical dynamometer. To obtain more accurate results, it is recommended to take three measurements of muscle strength on both the right and left hand. The rest interval between trials is approximately 1 minute. The maximum muscle strength value of the stronger hand can be used to evaluate the results. Dynamometry cut-off values indicating reduced muscle strength to diagnose sarcopenia are < 16 kg in women and < 27 kg in men.

Comments: The Short Physical Performance Battery (Appendix G6) is performed in accordance with the clinical guidelines on "Frailty" published in the electronic rubricator of clinical guidelines of the Russian Ministry of Health.

Lower extremity muscle strength is assessed using the 5-time sit-to-stand test [115].

The 4-meter gait speed test is used to determine the severity of sarcopenia and predict adverse events. A gait speed < 0.8 m/s is an unfavorable prognostic indicator. Conversely, a gait speed ≥ 1 m/s is considered the target gait speed [116, 117].

Balance is assessed using the following tests: feet together, semi-tandem, and tandem stance. Decreased muscle strength and function impair balance maintenance, increasing the risk of falls and adverse outcomes [64, 118].

Comments: bioelectrical impedance analysis is based on measuring the electrical resistance of body tissues. It allows for the evaluation of key body composition parameters, such as muscle mass, adipose tissue, and total body water content. The appendicular skeletal muscle mass index (ASMI) is calculated as the ratio of limb muscle mass to height squared (kg/m²). This parameter is used to standardize data and compare it with normative values.

2.5 Other Procedures

Comments: achieving mobility is often impossible without the use of orthopedic devices and minor assistive technologies. In patients with toe deformities, wearing traditional footwear without orthopedic appliances causes pain, which limits mobility (patients stop leaving the house), potentially leading to sarcopenia. Special devices and footwear that facilitate their use should be recommended, and the strategy for expanding mobility should be coordinated with an orthopedic surgeon. Patients with a fear of falling ( and/or a history of falls) severely restrict their mobility; appropriate walking aids (canes, walkers, specialized footwear) should be selected for them to reduce the risk of falls.

Comments: identification of frailty syndrome in sarcopenia determines the prognosis for the health and life of an elderly patient, their management tactics, and the need for assistance and care. Screening for frailty in patients with diagnosed sarcopenia at the primary care level has proven effective in preventing the decline of functional status in older and geriatric patients. When patients aged 60 and older seek medical care, signs indicating the potential presence of frailty syndrome or an increased risk of its development should be actively identified, especially in individuals with sarcopenia. The use of short, country-validated questionnaires aimed at identifying the main signs of frailty and key geriatric syndromes is a screening practice that has proven effective in many countries. In Russia, the "Age Is No Obstacle" questionnaire has been developed and validated (Appendix G1). A score of 5 or more on the "Age Is No Obstacle" questionnaire requires referring the patient to a geriatric office.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative

3.1.1 Non-pharmacological therapy

Comments: combining physical exercise and nutrition is an effective intervention for improving muscle health in sarcopenia, among older adults at risk for sarcopenia or at risk of/with malnutrition. Combining increased protein intake and any type of physical exercise increases both muscle mass and muscle strength. Furthermore, the combination of increased protein intake and any physical exercise has a stronger effect in preventing the loss of muscle mass and lower extremity strength in older adults at risk of sarcopenia and frailty compared to physical exercise alone.

Comments: patients with sarcopenia and their caregivers need to be educated on the necessity of correcting the protein component in their diet and performing strength exercises for the treatment of sarcopenia. Increasing patients' awareness of the causes and methods of correcting sarcopenia can dispel any misconceptions about sarcopenia as an inevitable consequence of aging and improve adherence to prescribed interventions.

Comment: for older adults aged 65 years and older, physical activity yields greater health benefits in accordance with the 2020 WHO Guidelines. It is recommended that individuals aged 65 years and older incorporate aerobic physical activity: at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity, or an equivalent combination of both throughout the week, along with muscle-strengthening activities involving major muscle groups on two or more days per week. Resistance training plays a leading role in increasing skeletal muscle mass and improving their function (increasing muscle strength and physical performance). Research results demonstrate that anaerobic physical (resistance) exercises performed for ≥ 3 months have a positive effect on muscle mass, strength, and walking speed in older adults. A 3-month course of anaerobic training in older men results in a 6–9% increase in the cross-sectional area of the quadriceps femoris muscle. In addition, performing an adequate amount of resistance exercises is associated with a greater increase in lean muscle mass, the main component of which is muscle tissue. It has been established that with an additional repetition—10 repetitions of an anaerobic exercise performed in one set—it is possible to achieve an increase in lean muscle mass by 0.5 kg.

A reduction in the plasma levels of subclinical chronic inflammation factors in elderly patients has been demonstrated following a course of resistance training. At the same time, resistance training should progressively increase in exercise intensity and include a sufficient number of repetitions to induce a training effect.

Sample anaerobic exercise regimen: at least 2 times per week, including exercises aimed at increasing lower limb muscle strength through squats or leg presses, knee flexion, calf raises, wall push-ups, arm curls with dumbbells and/or resistance bands; exercise intensity should progressively increase from 40–60% to 70–85% of 1 repetition maximum (1RM), consisting of 6–12 repetitions of each exercise in 1–3 sets, with rest intervals between sets ranging from 6 to 120 seconds; the preferred interval (rest) between workouts should be at least 48 hours. Meanwhile, in some patients with sarcopenia who present with lower muscle strength, training may begin at a lower intensity (e.g., 30–60% of 1RM) compared to those with higher baseline strength.

Training programs must be designed by qualified specialists (physicians in physical therapy and sports medicine / exercise therapy specialists). The training program must be regularly reviewed and adjusted depending on the patient's progress and changes in their clinical status.

Comment: elderly and senile patients with sarcopenia who do not have acute diseases or exacerbations of chronic conditions require an increased daily protein intake of up to 1.5 g/kg of body weight per day. This is due to the development of "anabolic resistance" resulting from slower digestion and assimilation of protein after a meal, which is an important factor in reducing muscle protein synthesis. Protein intake can be increased either by dietary modification or by using dietary supplements with a specific set of nutrients. Furthermore, consuming whole foods, as opposed to isolated amino acids, confers greater benefits. The foods richest in protein include fish, legumes, meat, and eggs.

It is advisable to consume protein up to 1.5–2.0 g/kg/day for patients suffering from acute or chronic diseases, and to increase protein intake up to 2.0 g/kg per day for patients with severe illness and malnutrition. It is desirable to increase protein intake to 1.0–1.5 g/kg of body weight per day for patients with frailty syndrome for the treatment and prevention of sarcopenia, provided that the eGFR is not less than 30 mL/min/1.73 m². Some studies suggest a threshold value of 25–30 g of protein per meal, whereas others propose 0.4 g/kg of protein per meal. At the same time, it is preferable for older adults to distribute protein intake evenly into 25–30 g portions three times a day to optimize the rate of muscle protein synthesis.

The International Working Group on Sarcopenia has emphasized the need for a comprehensive approach to the nutrition of older adults—that is, not relying solely on adequate protein intake, but also including healthy fats/omega-3 fatty acids and sufficient fluid intake in the diet, as well as evaluating the quality of consumed calories and taking into account the impact of medications on nutrient utilization.

Comment: protein supplements have shown benefits in improving muscle strength; however, when combined with physical exercise, they demonstrated a significant improvement in muscle mass, strength, and physical functioning in elderly patients with sarcopenia.

Comments: loneliness and social isolation are major factors contributing to ineffective treatment and progression of sarcopenia. Patients should be encouraged to contact social service centers for leisure organization and enhancement of social activity.

Comments: coordinated actions of a multidisciplinary team contribute to personalized muscle health management, the implementation of protein-enriched nutrition, and rehabilitation nutrition; furthermore, the frequency of sarcopenia assessment increases. Lifestyle, biological, and psychosocial factors affecting muscle health must also be identified and monitored by various healthcare professionals.

Comments: core activities aimed at reducing the risk of falls should include: consultations with specialists (geriatrician, ophthalmologist, otolaryngologist, urologist, gynecologist) to correct sensory deficits, geriatric syndromes, and urinary tract disorders; adjusting furniture to a comfortable height (beds, armchairs, toilets, etc.); ensuring furniture stability; installing handrails, especially in restrooms and bathrooms; using non-slip floor coverings; choosing non-traumatic floor coverings (e.g., fitted carpet); eliminating thresholds wherever possible; adequate, but not overly bright lighting; and high-contrast markings on stairs and steps.

3.1.2 Pharmacotherapy

Currently, there is no convincing evidence regarding the role of pharmacological agents in slowing the progression of sarcopenia. However, considering the well-established pathogenetically driven role of insulin resistance, dyslipidemia, obesity, inflammatory diseases, hypogonadism, iron deficiency, vitamin B12 deficiency, vitamin D3 deficiency, and a number of other age-associated conditions, an individualized patient management plan must be developed, taking into account the correction of these conditions and the achievement of target control parameters. Only vitamin D supplements and their analogs have demonstrated the most compelling evidence regarding efficacy and safety in patients with sarcopenia.

When choosing the pharmacotherapy strategy for sarcopenia, clinicians take into account not only the presence of chronic and/or acute diseases, but also geriatric syndromes—especially frailty—the results of functional status assessments, and the presence of psychoemotional disorders and social problems in elderly and senile patients.

Comment: vitamin D deficiency corresponds to a 25(OH)D3 concentration of < 20 ng/mL (< 50 nmol/L), insufficiency to 25(OH)D3 from 20 to 30 ng/mL (from 50 to 75 nmol/L), and an adequate level is 30-100 ng/mL (75-250 nmol/L). In the treatment of vitamin D deficiency/insufficiency, preference is given to medicinal products of the native form of D3 (cholecalciferol**), which have comparatively greater efficacy in achieving and maintaining target serum 25(OH)D values [334, 335]. Cholecalciferol** (vitamin D) supplementation at a dose of 800–1000 IU/day is associated with a lower risk of falls among the elderly and has a beneficial effect on fall prevention in populations receiving daily doses, whereas intermittent cholecalciferol** administration has no preventive effect [276]. High doses of cholecalciferol** (> 1000 IU/day) increase the risk of falls compared to a dose of 800-1000 IU/day of cholecalciferol**. Calcium preparations increase the positive effect of cholecalciferol** on fall prevention, whereas calcium monotherapy is less effective than cholecalciferol** monotherapy. Rarer dosing regimens of once a month or once every 3 months increase the risk of falls. Oral administration of native forms of vitamin D₃ (cholecalciferol**) helps increase muscle strength and physical performance, and reduces the frequency of falls and fractures [276]. High doses of cholecalciferol** lead to high serum 25(OH)D concentrations, and at values above 40-45 ng/mL (100-112.5 nmol/L), the risk of falls in elderly individuals increases. Obesity reduces the efficacy of cholecalciferol** therapy by diminishing the increase in 25(OH)D levels by approximately 15 ng/mL.

Long-term therapy with antiepileptic drugs leads to a decrease in serum cholecalciferol** concentration. These patients require higher doses to maintain adequate blood 25(OH)D levels. Long-term therapy with high doses of glucocorticoids H02AB is accompanied by the development of Cushing's syndrome and requires an increase in the cholecalciferol** dose throughout the high-dose therapy period to maintain adequate blood 25(OH)D levels. To correct vitamin D deficiency and insufficiency in patients with sarcopenia in the presence of CKD, standard doses of cholecalciferol** are used in treatment, contributing to an increase in serum 25(OH)D concentration, a reduction in the risk of falls and fractures and all-cause mortality. This therapy is not accompanied by the development of hypercalcemia, but leads to a significant increase in blood phosphorus. Concomitant intake of whey protein and cholecalciferol** may increase appendicular muscle mass in patients with sarcopenia, improve muscle strength, and enhance physical performance [100, 162, 163, 164, 165, 167-189].

Comments: active vitamin D metabolites have demonstrated greater efficacy compared to cholecalciferol** in reducing the risk of falls, especially in patients with decreased GFR (< 65 mL/min) [279]. Alfacalcidol** has been shown to increase muscle strength in elderly individuals, while co-administration with calcium preparations did not result in an additional effect on muscle strength [278]. The positive effect of alfacalcidol** on muscle strength and skeletal muscle function does not depend on serum 25(OH)D levels [280].

At the same time, when 25(OH)D deficiency is established, compensation of native vitamin D deficiency is an obligatory stage of treatment and is carried out, inter alia, in patients with end-stage renal disease [313] and diabetic nephropathy [314]. It must be remembered that active vitamin D metabolites and their analogues are not detected in significant amounts when examining serum vitamin D concentrations due to their structural differences from cholecalciferol** and their rapid degradation. The prescription of active vitamin D metabolites (alfacalcidol**, calcitriol**) and their analogues is possible in patients with sarcopenia and a high risk of falls only when a vitamin D metabolism disorder is established according to the absolute and relative indications given in Table 2.

Active vitamin D metabolites and their analogues should also be prescribed with caution simultaneously with native vitamin D preparations containing a cholecalciferol** dose higher than the prophylactic dose (more than 800–1000 IU per day) [315].

It is known that in the presence of hypoparathyroidism, average therapeutic doses of calcitriol** are 0.25-2.0 mcg/day, and for alfacalcidol** - 1.0-4.0 mcg/day. To maintain blood calcium levels within the target range in hypoparathyroidism, titration of vitamin D and its derivative doses is necessary, dividing the total drug dose into 2-3 administrations. Dose titration is usually performed in steps of 0.5 (or 0.25) mcg for alfacalcidol** and 0.25 mcg for calcitriol** [316]. A larger dose adjustment step may be required in cases of marked hypo-/hypercalcemia. The preferred time interval for adjusting doses of vitamin D and its derivatives (alfacalcidol**, calcitriol**) in hypoparathyroidism is 2-3 days, due to their pharmacokinetics and, consequently, an adequate assessment of the implemented changes. In cases of asymptomatic presentation and moderate fluctuations in calcaemia parameters, laboratory evaluation of the adequacy of the adjusted doses can be performed after 7-10 days. Evaluating the clinical efficacy of the selected therapy and achieving stable calcaemia values may take about 2-3 months, especially for patients with a high requirement for vitamin D and its derivatives.

Comments: in Russia, routine clinical practice holds a persistent belief in the efficacy of medications with anabolic effects, but study results have not demonstrated sustained efficacy of these medications.

No effect on muscle mass and skeletal muscle function was found during the administration of ACE inhibitors and ARBs.

The efficacy of testosterone use in clinical studies for increasing muscle mass or function varies depending on the patients included, duration of use, dose, and methods for assessing components of sarcopenia.

The use of estrogens in clinical studies did not contribute to an increase in muscle mass or an improvement in skeletal muscle function in elderly individuals.

3.1.3 Other treatment

Comments: a single-center prospective comparative study showed that the use of a bioactive concentrate of small marine fish over 2 months of follow-up resulted in a significantly greater increase in upper extremity muscle strength. Additionally, the intervention group showed a clinically significant reduction in time to complete the "Timed Up and Go" test, and an increased walking speed compared to the control group.

Comments: in a single-center prospective comparative study, the use of the combination product in patients with osteoarthritis and chronic pain syndrome was associated with a 76% reduction in WOMAC pain scores (p = 0.04) and a 74% reduction in Visual Analog Scale pain scores (p < 0.05), as well as improved functional parameters (walking speed + 12%, Timed Up and Go test time - 42%).

Comments: the combination of resveratrol and physical exercise may represent a more effective strategy for reversing sarcopenia than exercise alone. Furthermore, the combination of training and resveratrol demonstrated safety and good tolerability.

Comments: in a randomized, double-blind, placebo-controlled study in elderly individuals with frailty syndrome and decreased muscle strength, a 10-week course of levocarnitine at a dose of 1.5 g/day led to a significant improvement in frailty index and handgrip strength compared to the placebo group. Levocarnitine supplementation demonstrated a favorable effect on functional status and fatigue in elderly individuals with sarcopenia and frailty.

Comments: by reducing fiber damage and the inflammatory response, Traumeel S helps patients with sarcopenia better tolerate strength training and recover muscle function faster. Less muscle fiber damage and attenuated inflammation allow for an earlier return to training, thereby increasing the total training stimulus, which is critical for combating atrophy. The reduction in ICAM-1 and neutrophils means less secondary tissue destruction and oxidative stress—factors that exacerbate sarcopenia. In RCTs, Traumeel S significantly reduced pain and swelling: up to 65–85% of participants achieved pain-free mobility by days 8–10, and the efficacy of the drug was comparable to diclofenac with better tolerability.

Comments: whole-body vibration (WBV) training programs for 12 weeks showed improved muscle strength and tone in elderly individuals [281-282].

The method of muscle electrical stimulation (ES) can be an additional training option to improve muscle function and strength in patients with sarcopenia during a 4-week rehabilitation program. ES provides improved skeletal muscle function with additional potential health benefits for patients with sarcopenia suffering from heart disease and orthopedic conditions [283-285].

It has also been shown that the ES method can be used in elderly individuals with sarcopenia who may not be able to perform regular physical activity, by modulating similar exercise-related factors [285]. Progressive training on stabilometric platforms can improve skeletal muscle mass and function. The dynamic antigravity postural system ensures postural stability and enhances proprioceptive, vestibular, and visual sensitivities, reducing the risk of falls in the elderly [286-287].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

Patients with sarcopenia, including those who have undergone acute illness or surgery, as well as individuals with secondary sarcopenia, require longer rehabilitation due to a decreased level of functional activity. Rehabilitation can be carried out in a rehabilitation center or department (if a geriatric rehabilitation specialist is available) or a geriatric department after receiving specialized or high-tech medical care.

For the effective correction of progressive loss of muscle mass and its function in sarcopenia, it is necessary to use personalized and effective strategies for prevention, early-stage diagnosis, and medical rehabilitation complexes [224].

The goal of rehabilitation in sarcopenia is to minimize the loss of muscle mass and function, which is achieved by increasing physical activity, ensuring adequate nutrition, and providing a set of non-pharmacological interventions to improve the functional status of patients [226].

Comment: obesity exacerbates the course of sarcopenia, promotes fat infiltration of muscles, and impairs physical function [250–253]. A Korean national study (2008–2009) involving 2,264 elderly patients revealed a sarcopenia prevalence of approximately 12% and sarcopenic obesity in about 2/3 of cases. Moderate and high physical activity reduced the risk of sarcopenia and sarcopenic obesity in men (38–74%); in women, only high activity reduced the likelihood of sarcopenic obesity [254].

Comment: osteoporotic fractures are known to be associated with a significant decrease in muscle strength, low sarcopenic index values, as well as a decrease in fat mass and percentage, indicating an increased risk of developing sarcopenia [261].

A study by Marchenkova L.A. et al. (2024) investigated the efficacy of comprehensive rehabilitation after hip arthroplasty in patients with femoral neck fracture against the background of osteoporosis. The program included: supervised dynamic exercises under the guidance of an exercise therapy instructor, training on an interactive treadmill with biofeedback, specialized hip muscle strength training, and pulsed laser therapy of the hip joint (infrared range, 80 Hz, 20 W). After 12 days, there was an increase in the total Harris score (p = 0.034) and maximum hip extension strength (p = 0.041), an increase in walking speed and improvement in walking biomechanics—an increase in the right step length after 12 days (p = 0.036) and a reduction in step width after 60 days (p = 0.22), rapid regression of pain syndrome, improved physical functioning, increased lower limb muscle strength, and improved basic motor and coordination abilities [262]. 5.

Comment: the clinical benefits of balneotherapy in patients with musculoskeletal diseases are due to its ability to reduce serum levels of pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), which leads to a decrease in pain syndrome and improved functional capabilities [255-260].

5. Prevention and Dispensary Observation

Prevention of sarcopenia includes measures aimed at maintaining skeletal muscle mass and function, preventing falls in healthy older and elderly individuals, as well as preventing falls and fractures in individuals with diagnosed sarcopenia.

Comments: non-pharmacological approaches, including physical exercise, diet, and lifestyle changes, can help prevent sarcopenia. Traditional exercise methods, including strength training and aerobic exercise, have a positive effect on muscle strength, physical performance, and muscle mass in healthy elderly individuals [274, 288-289]. Lack of physical activity is an important factor in the development of sarcopenia [290]. To prevent falls and improve coordination, balance exercise programs, resistance exercises, as well as yoga and tai chi are indicated [291].

Protein intake of 0.8 g/kg of body weight/day will help slow down bone mass loss and reduce the risk of proximal femur fractures [292].

Individual balance training exercises and resistance exercises are preferred over group classes [293]. Progressive training on stabilometric platforms can improve skeletal muscle mass and function. The dynamic antigravity postural system ensures postural stability and increases proprioceptive, vestibular, and visual sensitivities, reducing the risk of falls in elderly individuals [286-295]. Physical therapy, such as electromyostimulation and whole-body vibration, can be an important component of training to improve muscle function for the prevention of falls and fractures [221, 282, 285].

For preventive purposes, it is advisable to conduct group and individual educational programs for elderly and senile patients living at home in order to prevent the development and progression of sarcopenia. Health education for young and elderly people using 4–6 minute videos on sarcopenia and its risk factors has a positive effect on the development of sarcopenia. Video recordings of 30-minute physical exercises help improve muscle strength in both men and women. Raising awareness about sarcopenia and its prevention has a positive effect in elderly individuals [263-266].

When providing preventive counseling to elderly and senile individuals, it is necessary to take into account age-related features of correcting risk factors for chronic non-communicable diseases and the high likelihood of polypharmacy. It is necessary to orient the patient not only toward eliminating the symptoms of existing chronic diseases, but also toward healthy longevity and an active lifestyle. All patients should be counseled on regular physical activity, nutrition, clinical and psychological training, organizing a safe home environment, and medication intake rules.

6. Organization of Medical Care

The attending physician for a patient with sarcopenia is a general practitioner (district physician) (general practitioner (family doctor)). Indications for a consultation with a geriatrician are listed in section 2.5.

Indications for hospitalization in a medical organization

For the majority of patients with sarcopenia, in the event of an exacerbation of chronic diseases, it is preferable to provide medical care at home, provided that the necessary volume of diagnostic and therapeutic care can be ensured. If there are difficulties associated with conducting the necessary examinations and selecting therapy in a home setting, it is recommended to consider hospitalizing the patient with sarcopenia in a department matching the profile of the underlying disease.

Indications for patient hospitalization in the geriatric department

An indication for patient hospitalization in a geriatric department is the combination of sarcopenia and frailty syndrome.

Referral of a patient with sarcopenia and frailty syndrome for hospitalization in a geriatric department is carried out by a general practitioner (district physician), general practitioner (family doctor), geriatrician, or other specialist doctors.

Indications for patient discharge from a medical organization

1) Completion of examination, treatment, and rehabilitation regarding the underlying disease that caused hospitalization.

2) Improvement in the functional activity level of the patient with sarcopenia or substantiation of the impossibility of improvement.

7. Additional Information

The mechanisms of sarcopenia continue to be actively studied, and it is already clear that there is no universal mechanism for the age-related loss of muscle mass quantity and quality. Sarcopenia is a multifactorial syndrome with a complex interdisciplinary pathogenesis. According to modern concepts, muscle tissue acts as one of the most significant human endocrine organs, as it produces a large amount of biologically active substances, hormonoids, and special cytokines (myokines). The latter are cellular regulators of growth and breakdown and support the function of muscle mitochondria; accordingly, both mitochondrial dysfunction (characteristic of all age-associated diseases) and sarcopenia exacerbate each other and form a vicious circle of progressive functional insufficiency in elderly patient groups. Therefore, it is so important to conduct mass screening and detect sarcopenia as early as possible in the modern population.

Data from the UK Biobank, containing information on 499,046 patients, demonstrate that patients with multimorbidity have almost twice the probability of sarcopenia compared to those without a combination of multiple diseases (OR 1.96 [95% CI: 1.91, 2.02]) [296].

A number of studies emphasize the high prevalence of sarcopenia in patients with cardiovascular diseases, type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic liver diseases, musculoskeletal system diseases, endocrine and neurological diseases, and ophthalmological pathology [296-300]. The association between sarcopenia and chronic non-communicable diseases is unfavorable and worsens the prognosis in elderly patients. Presumably, achieving compensation for concomitant pathology will help improve the condition of the muscular system.

Sarcopenia can be a significant risk factor for frequent hospitalizations of elderly individuals [301]. Sarcopenia is a multifactorial disease of elderly and senile individuals who have already established multiple chronic comorbid diseases and identified complications with varying degrees of impaired body functions. This combination leads to a restriction of motor activity in elderly patients and, accordingly, to repeated hospitalizations and restricted patient activity, which in turn exacerbates the manifestations of sarcopenia.

One of the main manifestations of sarcopenia is falls, which are frequently accompanied by injuries of varying severity, which also leads to repeated and prolonged hospitalizations. In addition, sarcopenia is considered a predictor of future fractures in elderly individuals, which increases the risk of subsequent (repeated) hospitalizations as well.

It should be noted that sarcopenia is associated with human cognitive functions, so early detection of this disease will reduce the risk of cognitive impairment in clinical practice [302].

Taking into account its multifactorial nature and combined comorbidity, sarcopenia increases the risk of all-cause mortality by 3.6 times in elderly and senile individuals [303].

Elderly patients with DM are at a higher risk of developing geriatric syndromes, including sarcopenia, which is known to be characterized by a progressive and generalized loss of muscle mass and strength [304-305]. DM accelerates the decline in muscle mass and strength due to hyperglycemia, the progression of diabetes complications, concomitant obesity, insulin resistance, and the activation of inflammatory cytokines [306-308]. The combination of excess weight and reduced muscle mass and/or strength has been defined as "sarcopenic obesity" [309]. These pathological conditions associated with alterations in muscle tissue "quality" in turn contribute significantly to the perpetuation of insulin resistance and exacerbate glycemic control impairments by reducing glucose uptake by muscles. An important risk factor for the development and progression of sarcopenia in T2D is chronic hyperglycemia. Hyperglycemia accelerates the loss of muscle mass, while an increase in the concentration of advanced glycation end products contributes to a reduction in muscle strength. Thus, accumulating in skeletal muscles and cartilage, advanced glycation end products reduce their elasticity in patients with diabetes. It has been established that high levels of glycation end products are associated with poorer handgrip dynamometry performance and low walking speed in elderly individuals [304]. Therefore, efforts should be made to achieve target glycemic goals. Hyperglycemia-related weight loss can lead to the loss of both muscle mass and muscle strength. Additionally, weight loss may be driven by decreased appetite and adherence to low-calorie diets. Certain medications used in diabetes (e.g., GLP-1 receptor agonists) can affect not only fat mass but also muscle mass [294]. When prescribing drugs that affect body weight, physical exercise should be recommended to counteract the loss of muscle mass.

Sex-specific features of the alteration and preservation of muscle mass in the body are well known. Thus, testosterone is a potent mitochondrial protector, and its age-related deficiency leads to mitochondrial dysfunction in Leydig cells, which is considered one of the key molecular mechanisms of late-onset hypogonadism, the prevalence of which reaches 20% in men over 60 years of age and increases to 50% after 80 years. Lower testosterone concentrations are associated with a decrease in both skeletal muscle mass and strength.

A similar trend is observed in postmenopausal women. There is a positive correlation between the reduction in muscle mass and estrogen levels. Furthermore, estrogen may exert a direct anabolic effect on muscle fibers, as skeletal muscle cell membranes contain beta-estrogen receptors.

Low levels of sex hormones are significantly associated with obesity and insulin resistance through the mechanisms of sarcopenia (deficiency in the quantity and quality of skeletal muscles), since glucose utilization occurs primarily in muscle tissue.

Criteria for Evaluating the Quality of Medical Care

References

Appendix A1. Working Group Composition

1. Tkacheva O.N. – Corresponding Member of the Russian Academy of Sciences, D.Sc. (Medicine), Professor, Director of the Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Head of the Department of Aging Diseases, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, President of the Russian Association of Gerontologists and Geriatricians.

2. Lila A.M. – Corresponding Member of the Russian Academy of Sciences, D.Sc. (Medicine), Professor, Honored Doctor of the Russian Federation, Director of the V.A. Nasonova Research Institute of Rheumatology.

3. Zubareva N.N. – D.Sc. (Economics), Associate Professor, Director of the National Medical Research Center for Rehabilitation and Balneology of the Russian Ministry of Health, President of the National Association of Experts in Health Resort Treatment.

4. Tтельян В.А. – Academician of the Russian Academy of Sciences, D.Sc. (Medicine), Professor, Scientific Advisor of the Federal Research Center of Nutrition, Biotechnology and Food Safety, Head of the Department of Food Hygiene and Toxicology at the Institute of Professional Education, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Union of Dietitians, Nutritionists and Food Industry Specialists.

5. Kotovskaya Yu.V. – D.Sc. (Medicine), Professor, Deputy Director for Science, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

6. Runikhina N.K. – D.Sc. (Medicine), Deputy Director for Geriatrics, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

7. Naumov A.V. – D.Sc. (Medicine), Head of the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

8. Dudinskaya E.N. – D.Sc. (Medicine), Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Head of the Laboratory of Age-Related Metabolic and Endocrine Disorders, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

9. Khovasova N.O. – D.Sc. (Medicine), Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Senior Researcher at the Laboratory of Musculoskeletal Diseases, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

10. Sharashkina N.V. – D.Sc. (Medicine), Associate Professor at the Department of Aging Diseases, Faculty of Continuous Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Head of the Laboratory of General Geriatrics, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

11. Safonova Yu.A. – D.Sc. (Medicine), Professor at the E.S. Pushkova Department of Geriatrics, Propaedeutics and Nursing Management, North-Western State Medical University named after I.I. Mechnikov of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

12. Guryeva I.V. – D.Sc. (Medicine), Professor, Professor at the Department of Endocrinology, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Head of the Scientific and Practical Sector for Rehabilitation and Prevention of Disability Caused by Endocrine Pathology, Federal Center for Rehabilitation of the Disabled of the Ministry of Labor of Russia, Moscow, Member of the Russian Association of Gerontologists and Geriatricians.

13. Starodubova A.V. – D.Sc. (Medicine), Associate Professor, Deputy Director for Research and Clinical Work, Federal Research Center of Nutrition, Biotechnology and Food Safety, Professor at the Department of Faculty Therapy, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Professor at the Department of Dietetics and Nutrition, Russian Medical Academy of Continuous Professional Education of the Russian Ministry of Health, Member of the Union of Dietitians, Nutritionists and Food Industry Specialists.

14. Onuchina Yu.S. – Ph.D. (Medicine), Assistant Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Researcher at the Laboratory of Age-Related Endocrine and Metabolic Disorders, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

15. Machekhina Lyubov Viktorovna – Ph.D. (Medicine), Associate Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Head of the Laboratory of Aging Biomarkers, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

16. Ostapenko V.S. – Ph.D. (Medicine), Head of the Geriatrics Department, Russian Gerontology Clinical Research Center (Structural Unit), Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Assistant Professor at the Department of Aging Diseases, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Russian Association of Gerontologists and Geriatricians.

17. Apkhanova T.V. – D.Sc. (Medicine), Chief Researcher at the Department of Physiotherapy and Reflexology, National Medical Research Center for Rehabilitation and Balneology of the Ministry of Health of the Russian Federation, Member of the National Association of Experts in Health Resort Treatment.

18. Konchugova T.V. – D.Sc. (Medicine), Professor, Head of the Educational Center, Chief Researcher at the Department of Physiotherapy and Reflexology, National Medical Research Center for Rehabilitation and Balneology of the Ministry of Health of the Russian Federation, Member of the National Association of Experts in Health Resort Treatment.

19. Marchenkova L.A. – D.Sc. (Medicine), Associate Professor, Head of the Research Management Department, Chief Researcher at the Department of Somatic Rehabilitation, Reproductive Health and Active Longevity, National Medical Research Center for Rehabilitation and Balneology of the Ministry of Health of the Russian Federation, Member of the National Association of Experts in Health Resort Treatment.

20. Zotkin E.G. – D.Sc. (Medicine), First Deputy Director of the V.A. Nasonova Research Institute of Rheumatology, Member of the Association of Rheumatologists of Russia.

21. Toroptsova N.V. – D.Sc. (Medicine), Head of the Laboratory of Osteoporosis, V.A. Nasonova Research Institute of Rheumatology, Member of the All-Russian Public Organization "Association of Rheumatologists of Russia".

22. Taskina Elena Alexandrovna – Ph.D. (Medicine), Head of the Laboratory of Osteoarthritis, V.A. Nasonova Research Institute of Rheumatology, Member of the All-Russian Public Organization "Association of Rheumatologists of Russia".

All members of the Working Group have confirmed that they have no financial support or conflicts of interest to disclose.

Appendix A2. Methodology for Developing Clinical Guidelines

The clinical guidelines were developed by expert specialists of the Russian Association of Gerontologists and Geriatricians.

This version of the clinical guidelines is based on the following resources and documents:

- Makris UE, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014;312(8):825–836. doi:10.1001/jama.2014.9405

- The International Association for the Study of Pain, https://www.iasp-pain.org/GlobalYear/PaininOlderPersons

- P. Schofield. The Assessment of Pain in Older People: UK National Guidelines, Age and Ageing, Volume 47, Issue suppl_1, March 2018, Pages i1–i22, https://doi.org/10.1093/ageing/afx192

- Abdulla A, Adams N, Bone M et al. Guidance on the management of pain in older people. Age and ageing 2013; 42: i1–i57. March 2013.

- Hadjistavropoulos T, Herr K, Turk DC, Fine PG, Dworkin RH, Helme R, et al. An interdisciplinary expert consensus statement on assessment of pain in older persons. Clin J Pain 2007.23(1):1-43

Sources for recent updates included journal publications in reputable peer-reviewed journals indexed in Russian and international citation databases.

Target audience for these clinical guidelines:

1. Geriatrician.

2. General practitioner / Physician.

3. General practitioner (family physician).

4. Neurologist.

5. Cardiologist.

6. Nephrologist.

7. Gastroenterologist.

8. Rheumatologist.

9. Physical and rehabilitation medicine physician.

10. Physiotherapist.

Table 1. Scale for assessing levels of evidence (LE) for diagnostic methods (diagnostic interventions)

Table 2. Levels of Evidence (LoE) grading scale for prevention, treatment, and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitation interventions)

Table 3. Scale for assessing the levels of recommendation persuasiveness (LRP) for prevention, diagnostic, treatment and medical rehabilitation methods, including those based on natural therapeutic factors (preventive, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

Table 1. Treatment regimens for vitamin D deficiency and insufficiency.

(Dosage form: film-coated tablets or capsules)

Table 2. Indications for prescribing active vitamin D metabolites (alphacalcidol**, calcitriol**) and their analogues

Table 3. Oral enteral nutrition (sip feeds).

Related Documents

1. Order of the Ministry of Health of the Russian Federation No. 38n dated January 29, 2016, "On Approval of the Procedure for Providing Medical Care in the Profile of 'Geriatrics'."

2. Order of the Russian Ministry of Health No. 1067n dated December 20, 2019, "On Amendments to the Procedure for Providing Medical Care in the Profile of 'Geriatrics', Approved by Order of the Russian Ministry of Health No. 38n dated January 29, 2016."

3. Clinical Guidelines KR 613 "Frailty."

4. Clinical Guidelines "Falls in Older and Elderly Patients."

5. Clinical Guidelines "Chronic Pain in Older and Elderly Patients."

6. Pharmacotherapy in Older and Elderly Persons / D.A. Syчев, O.N. Tкачева, Yu.V. Kotovskaya, I.P. Malaya. – M.: KONGRESSKHIM LLC Publishing House – 2024. – 124 p.

7. Sarcopenia: revised European consensus on definition and diagnosis / A. J. Cruz-Jentoft, G. Bahat, J. Bauer [et al.] // Age and Ageing. — 2019. — Vol. 48, N 1. — P. 16–31]

8. Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia / L.-K. Chen, L.-K. Liu, M. J. Woo [et al.] // J. Am. Med. Dir. Assoc. — 2014. — Vol. 15, N 2. — P. 95–101.

9. Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia / R. A. Fielding, B. Vellas, W. J. Evans [et al.] // J. Am. Med. Dir. Assoc. — 2011. — Vol. 12, N 4. — P. 249–256.

10. The FNIH sarcopenia project: rationale, study description, conference recommendations, and final estimates / S. A. Studenski, K. W. Peters, D. E. Alley [et al.] // J. Gerontol. ABiol. Sci. Med. Sci. — 2014. — Vol. 69, N 5. — P. 547–558].

11. Kirk B, Zanker J, Bani Hassan E, Bird S, Brennan-Olsen S, Duque G. Sarcopenia Definitions and Outcomes Consortium (SDOC) Criteria are Strongly Associated With Malnutrition, Depression, Falls, and Fractures in High-Risk Older Persons. JAmMedDirAssoc. 2021 Apr;22(4):741-745].

12. Chew S. T. H. et al. Singapore multidisciplinary consensus recommendations on muscle health in older adults: assessment and multimodal targeted intervention across the continuum of care // BMC Geriatrics. – 2021. – Vol. 21. – No. 1. – P. 314.

13. Dent E. et al. International clinical practice guidelines for sarcopenia (ICFSR): screening, diagnosis and management // The Journal of Nutrition, Health & Aging. – 2018. – Vol. 22. – P. 1148-1161]

14. Zanker J. et al. Consensus guidelines for sarcopenia prevention, diagnosis and management in Australia and New Zealand // Journal of Cachexia, Sarcopenia and Muscle. – 2023. – Vol. 14. – No. 1. – P. 142-156

15. C. Beaudart, Y. Rolland, A. J. Cruz Jentoft et.al. Assessment of Muscle Function and Physical Performance in Daily Clinical Practice. A position paper endorsed by the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Calcifed Tissue International (2019) 105:1–14 https://doi.org/10.1007/s00223-019-00545-w

16. Bhasin S. et al. Sarcopenia definition: the position statements of the sarcopenia definition and outcomes consortium // Journal of the American Geriatrics Society. – 2020. – Vol. 68. – No. 7. – P. 1410-1418

17. Kirk B. et al. The Conceptual Definition of Sarcopenia: Delphi Consensus from the Global Leadership Initiative in Sarcopenia (GLIS) //Age and ageing. – 2024.

Appendix B. Physician Action Algorithms

* Interventions

Appendix C. Patient Information

It is known that starting from the age of 30, a gradual loss of muscle mass occurs in humans, with approximately 8% of muscle lost per decade of life. At age over 70, muscle tissue loss increases to 15% for each subsequent decade. Ultimately, by age 80, a person may lose more than half of their muscle mass.

The reduction in the quantity and quality of muscle mass in elderly patients due to age-related changes leads to a decrease in glucose uptake by muscles and impaired glycemic control. In turn, "poor" glycemic control accelerates the decline in muscle mass quantity and quality, which can lead to the development of such a formidable geriatric syndrome as sarcopenia. Inadequate physical activity against the background of muscle mass loss is also a factor in the development of sarcopenia.

Sarcopenia (from Greek *sarco* – "flesh", *penia* – "loss") is an age-associated or age-related muscle disease characterized by a decrease not only in the quantity and quality of muscle mass, but also in muscle strength and function.

Why is sarcopenia dangerous? Loss of muscle mass and strength is a significant risk factor for fractures in elderly patients. This occurs because sarcopenia negatively affects the ability to maintain balance during walking and movement, thereby creating a risk of falls, contributing to a decrease in walking speed, and impairing self-care in daily life.

When sarcopenia is combined with other age-related diseases, its impact can be even more pronounced. For example, the presence of osteoporosis (a disease in which bones become fragile and break easily) combined with sarcopenia additionally and significantly increases the risk of falls and fractures.

You can independently assess whether you have probable sarcopenia using a simple handgrip dynamometer test (Figure 2). To do this, take the dynamometer in your hand, extend your arm to the side at shoulder level, and squeeze the dynamometer as hard as possible. Two measurements must be taken on each hand and the best result recorded. Approximate normal handgrip dynamometry values for elderly individuals are > 27 kg for men and > 16 kg for women.

Currently, there is no officially approved medicinal product for the treatment of sarcopenia.

The main methods for preventing and influencing sarcopenia are optimal protein intake, vitamin D supplementation, and physical exercise. Physical exertion helps increase muscle strength and ensure muscle mass gain, making it the simplest and most accessible method for alleviating the patient's condition.

Any muscular contraction requires energy. Our muscles consist of bundles of muscle fibers. When the nervous system issues a command, these fibers contract and work is performed—a person lifts weights or moves their body in space. Muscle fibers can receive "fuel" through two types of metabolism (or energy expenditure): aerobic or anaerobic.

The aerobic mechanism occurs when a lot of oxygen is required to produce energy, and the energy substrates are glucose, fatty acids, and glucose metabolites such as ketone bodies and lactic acid. When energy synthesis involves oxygen, our heart rate increases and reaches up to 70% of its maximum value. To determine your upper heart rate limit, subtract your age from 220. For example, if you are 30 years old, your maximum heart rate is 190 beats per minute. Aerobic exercise consists of rhythmic, repetitive, or continuous movements of the same large muscle groups lasting at least 5 minutes. These include: walking, swimming, yoga, cycling, skiing, ice skating and rollerblading, brisk running, dancing, stationary cycling, and treadmill exercise.

The anaerobic mechanism (or oxygen-free mechanism) is when muscle activity uses energy stored by the body, consuming a high amount of glucose and little oxygen. Under these conditions, muscle fibers are capable of performing significant work, but not for very long because they fatigue quickly and require a lot of energy. Anaerobic loads are characterized by short duration and high intensity. Anaerobic or strength training aims to increase muscle mass and strength through weightlifting or resistance to muscle movement. During anaerobic physical activity, the release of counter-regulatory hormones increases significantly, which in patients with diabetes mellitus can, on the one hand, lead to a pronounced increase in blood glucose levels, while on the other hand increasing cellular sensitivity to insulin, which can promote muscle mass growth.

Human muscles are bundles of muscle fibers, some of which use aerobic metabolism while others use anaerobic metabolism. Therefore, aerobic and anaerobic exercises should be alternated every other day. "Aerobic exercise saves our lives by preventing heart attacks, while anaerobic exercise makes life more worthwhile by strengthening bones and joints" (K. Crowley). Anaerobic and anaerobic-aerobic types of physical activity are beneficial for elderly patients with diabetes mellitus, because physical training increases the number of "glucose transporters" inside cells. This occurs not only in muscle cells, but also in the liver. Improving impaired metabolism helps improve the quality of muscle mass and, accordingly, its function, which is especially important in older patients.

Thus, physical activity is an important component of the prevention and treatment of sarcopenia. Physical activity is just as beneficial for the older age group as it is for the young.

What do you need to know before starting physical exercise?

Many patients do not undertake any significant physical activity for years, aside from routine daily activities. Intensive physical activity cannot be recommended to all patients without exception, as comorbid conditions may limit the capacity for significant physical exertion. Every patient should discuss their capabilities with a physician.

Nevertheless, we can provide some general recommendations regarding physical activity for patients with sarcopenia:

1. The most acceptable and safe exercise program consists of light, followed by moderate-intensity physical exercises. If a person is starting "from scratch," their duration should gradually increase from 5–10 to 45–60 minutes.

2. The regularity of physical exercise is important. It must be undertaken at least 3 times a week; only in this case can a positive effect be expected. The benefits of physical exercise fade very quickly in the event of prolonged pauses.

3. During periods of physical exertion, monitoring one's own condition is of particular importance.

4. It must be taken into account that significant routine physical exertion may occur in many people outside of fitness and sports activities—for example, major house cleaning or garden work. These loads also require careful monitoring.

Precautions regarding physical exercise:

1. Caution is necessary in the presence of comorbid conditions (coronary artery disease, arterial hypertension, diabetes mellitus), as well as complications of diabetes. Inadequate physical exertion can worsen the condition of patients with these problems. Consult your doctor before starting physical exercise.

2. Any unpleasant sensations during physical exertion are a warning sign: pain and palpitations, headache, dizziness, shortness of breath. They should not be pushed through. You must stop the workout and, if necessary, consult a physician.

3. Footwear must be as comfortable as possible, and a thorough inspection of the feet before and especially after exercise is essential to avoid accidental chafing or injury.

4. If you have diabetes mellitus and are receiving insulin or sulfonylurea glucose-lowering drugs such as glibenclamide, gliclazide, glimepiride, and similar medications that stimulate insulin production, it is very important to remember that physical activity can lead to a drop in blood sugar or hypoglycemia. This condition can occur both during exertion and several hours afterwards. Therefore, when engaging in physical activity, it is necessary to carry easily digestible carbohydrates (sugar, fruit juice) to treat potential hypoglycemia. Consult your doctor before starting physical exercise.

EXERCISE PROGRAM [309]

The exercises presented below consist of 4 groups: balance exercises, strength exercises for the arms and legs, foot exercises, and flexibility exercises. It is recommended to start the first training sessions under the supervision of a physical therapy instructor, who will help select exercises taking into account your individual characteristics.

The best results are achieved by performing the exercises 3 times a week. Optimally, perform 3 sets of 8 to 12 repetitions of each exercise, taking a rest pause of about 2 minutes between them.

BALANCE EXERCISES

Initially, these exercises are performed with the hands resting on a table, chair, wall, or another stable object. As soon as you become confident in performing the exercises with hand support, you can switch to single-finger support, and then abandon support altogether (though you should still perform the exercise near an object you can grab in case of a loss of balance). If you are stable while performing the exercises, you can try performing them with your eyes closed (with or without support).

Exercise 1. Plantar flexion.

1. Starting position: standing, holding onto a table or the back of a chair to maintain balance.

2. Slowly rise up onto your toes as high as you can (INHALE).

3. Hold this position for 1–2 seconds.

4. Slowly lower yourself back onto your heels over 3 seconds (EXHALE).

Exercise 2. Knee flexion.

1. Starting position: standing, holding onto a table or the back of a chair to maintain balance.

2. Slowly bend one leg at the knee without flexing it at the hip joint (INHALE).

3. Hold this position for 1–2 seconds.

4. Slowly lower the leg to the floor into the starting position (EXHALE).

5. Repeat the exercise with the other leg.

Exercise 3. Hip flexion.

1. Starting position: standing, holding onto a table or the back of a chair to maintain balance.

2. Slowly bend one leg at the knee toward your chest, without leaning your torso or flexing the other leg at the hip joint (INHALE).

3. Hold this position for 1–2 seconds.

4. Slowly lower the leg to the floor into the starting position (EXHALE).

5. Repeat the exercise with the other leg.

Exercise 4. Lateral leg abduction.

1. Starting position: standing, holding onto a table or the back of a chair to maintain balance. The back and knees must be straight during the exercise.

2. Slowly move one leg out to the side by 15–30 cm (INHALE).

3. Hold this position for 1–2 seconds.

4. Slowly lower the leg to the floor into the starting position (EXHALE).

5. Repeat the exercise with the other leg.

Exercise 5. Hip extension (straight leg swing backward).

1. Starting position: standing, 30–45 cm away from a table or the back of a chair.

2. Flex your hips and hold onto the table or the back of the chair.

3. Slowly lift one straight leg backward (INHALE).

4. Hold this position for 1–2 seconds.

5. Slowly lower the leg to the floor into the starting position (EXHALE).

6. Repeat the exercise with the other leg.

Exercise 6. Knee extension.

1. Starting position: sitting. Place a bolster under your knees if necessary (feet should lightly touch the floor).

2. Place your hands on your knees or at the sides of the chair.

3. Slowly lift one leg and extend it in front of you, parallel to the floor, to straighten it at the knee joint.

4. Pull your toes toward yourself.

5. Hold this position for 1–2 seconds.

6. Slowly (over 3–5 seconds) lower the leg to the starting position.

7. Repeat the exercise with the other leg.

Exercise 7. Tandem walking ("heel-to-toe" walking).

1. Starting position: standing, with one foot placed in front of the other, the heel of one foot touching the toes of the other.

2. Imagine a straight line.

3. Take 8–15 steps straight forward, alternating your feet. Then take 8–15 steps backward.

4. Repeat the exercise.

Exercise 8. Figure-eight walking (walking with directional changes).

1. Starting position: standing. Place any 2 objects at a short distance apart.

2. Mentally trace a figure-eight between 2 objects.

3. Start walking in a figure-eight pattern between the 2 objects.

4. Walk the figure-eight pattern twice.

5. Rest and then repeat the exercise.

Exercise 9. Walking with tossing a ball upwards.

1. Starting position: standing, with arms slightly bent in front of you as if holding a ball.

2. Begin walking, imitating the arm motion of tossing a ball up and catching it. If you do not experience dizziness, loss of step tempo, or instability, you may proceed to perform the exercise with a real ball.

3. Walk forward and backward for 10–15 steps, trying to toss and catch the imaginary or real ball.

4. Rest for a minute, then repeat the exercise.

Exercise 10. Toe and heel walking.

1. Starting position: standing. During the exercise, you may hold onto a wall or handrail (as shown in the figure).

2. Walk on your toes counting to 10.

3. Stop, count to 10, turn around.

4. Walk on your heels counting to 10.

5. Rest for a minute, then repeat the exercise.

Exercise 11. Walking "over an obstacle".

1. Starting position: standing. Place a small "obstacle" 15 cm high on the floor, such as a shoebox. During the exercise, you may hold onto a wall or chair.

2. Place the "obstacle" (box) in front of you.

3. Step over the "obstacle".

4. Turn around and step over it again.

5. Repeat the exercise 10–15 times.

6. Rest for a minute, then repeat the exercise another 10 times.

Exercise 12. Standing up from a chair.

1. Starting position: sitting on a chair. You can place a pillow against the backrest to support your back.

2. Sitting on the edge of the chair, lean back (back and shoulders remain straight, knees bent, feet pressed to the floor). (EXHALE).

3. Then sit up straight, trying not to use your hands for assistance. (INHALE). The goal is not to use them at all, if possible.

4. Slowly stand up from the chair, ideally without using your hands. Slowly sit back down.

5. Keep your back and shoulders straight while performing the exercise.

STRENGTH EXERCISES FOR ARMS AND LEGS

Exercise 1. For arm muscles, using a resistance band (option 1).

1. Starting position: sitting on a chair.

2. Hold the ends of the resistance band.

3. Stretch the band at chest level and move your arms out to the sides, fully straightening them (INHALE).

4. Initiate the stretching movement from your shoulder blades, trying to squeeze them together.

5. Relax the band and bring your arms together at chest level (EXHALE).

6. Repeat the exercise.

Exercise 1. For arm muscles, using a resistance band (option 2).

1. Starting position: sitting on a chair.

2. Hold the ends of the resistance band.

3. Begin moving your arms apart diagonally from each other — one upwards, the other downwards (INHALE).

4. Bring your arms together (EXHALE).

5. Repeat the exercise.

Exercise 2. "Towel wringing".

1. Starting position: standing.

2. Hold a towel with both hands.

3. Begin gradually twisting it (as if wringing out water) as hard as you can.

4. Repeat the exercise.

Exercise 3. "Ball squeezing".

1. Starting position: standing.

2. Take a rubber or stress ball that fits completely in your hand.

3. Slowly squeeze the ball as hard as possible, hold for 3–5 seconds.

4. Slowly release your hand.

5. Repeat the exercise.

Exercise 4. Biceps curls with dumbbells.

1. Starting position: sitting (easy option) or standing (advanced option).

2. Feet on the floor, shoulders relaxed, back straight, stomach pulled in.

3. Hold dumbbells or other objects weighing 0.5–1.5 kg (e.g., water bottles) in your hands.

4. Rest your hands with dumbbells on your thighs with palms facing up. Keep your elbows pressed to your body.

5. Bend your arms with dumbbells until your wrists almost touch your shoulders (INHALE). Hold at the top for 1–2 seconds, slowly lower your arms (EXHALE).

6. Repeat the exercise.

Exercise 5. For lower extremity muscles, using a resistance band.

You will need a rubber resistance band that allows you to perform the exercise 30 times without stopping, while feeling "muscle fatigue" at the end.

1. Starting position: sitting on a chair, feet together.

2. Place the band around your legs just above the knees.

3. Move your knees apart as far as possible, overcoming the resistance of the band (INHALE).

4. Bring your knees together (EXHALE).

5. Repeat the exercise.

FOOT EXERCISES

Exercise 1. Feet on the floor.

Starting position: sitting on a chair.

a. Foot pressed to the floor. Alternately (or simultaneously) flex and extend the toes of your right and left foot.

b. Foot pressed to the floor. Alternately (or simultaneously) raise and lower the toes of the right and left foot. Make circular motions.

c. The foot remains on the floor. Alternately (or simultaneously) raise and lower the heels of the right and left foot, make circular motions. Raise your heels, move them apart, bring them together.

Exercise 2. With marbles.

1. Starting position: sitting on a chair, back straight, feet flat on the floor.

2. Place an empty bowl in front of you and a container with marbles (20 marbles will be enough to start).

3. Using only your toes, pick up one marble at a time and transfer it to the empty bowl.

4. Repeat the exercise with the other leg.

(image source: https://pikabu.ru/story/vsego_2_uprazhneniya_i_ploskostopie_vas_ne_pobespokoit_6299200)

Exercise 3. With a towel.

The exercise can be performed with each foot in turn or both at once.

1. Starting position: sitting on a chair. Place a towel on the floor.

2. Place your feet on the near edge of the towel.

3. Using your toes, scrunch the towel towards you, trying not to lift your heel off the floor.

(image source: https://lifehacker.ru/uprazhneniya-ot-ploskostopiya-kak-ukrepit-svod-stopy).

FLEXIBILITY EXERCISES

Exercise 1. Neck muscle stretching.

1. Starting position: standing, feet shoulder-width apart, knees slightly bent. Or starting position: sitting on a chair, back straight, feet pressed to the floor.

2. Relax your shoulders and tilt your head towards your right shoulder. Hold this position for 5 seconds.

3. Then tilt your head to the left shoulder. Hold this position for 5 seconds.

4. Repeat the exercise 2–3 times.

Exercise 2. Stretching the shoulder and upper-posterior chest muscles.

1. Starting position: sitting on the edge of a chair, arms down.

2. Pull your arms back, try to hold onto the back of the chair.

3. Straighten your shoulders and, without taking your hands off the back of the chair, lean forward until a slight tension appears in the arm muscles.

4. Hold this position for 10 seconds.

5. Then relax for about 5 seconds, keeping your hands on the back of the chair.

6. Repeat the exercise 2–3 times.

Exercise 3. Thigh muscle stretching.

1. Starting position: lying on the floor, on your right side.

2. Rest your head on a pillow or your arm.

3. Bend your upper (left) leg at the knee.

4. Grab your left heel with your left hand and pull slightly to feel a stretch in the anterior thigh. If you cannot reach your foot, simply bend your knee and reach with your fingers toward your buttocks.

5. Hold this position for 10–30 seconds.

6. Smoothly release the foot while straightening the leg.

7. Roll over to the other side and repeat the exercise.

8. Perform 3–5 sets on each side.

Exercise 4. Calf muscle stretching.

The exercise is performed without shoes.

1. Starting position: sitting on the edge of a chair, lean back against its backrest, using a pillow for back support. Extend your legs forward so that your weight rests only on your heels.

2. Pull your toes toward yourself.

3. Point your toes away from you.

4. Hold this position. You should feel a stretch in the ankle joints. If this does not happen, lift your heels slightly off the floor while performing the exercise.

The presented exercises will help strengthen the arm and leg muscles, improve coordination and balance, thereby reducing the risk of falls, increasing physical tone, and consequently improving the well-being and quality of life of a patient with sarcopenia.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

APPENDIX G1. "Age is Not an Obstacle" Questionnaire

Russian name: “Age is No Obstacle” questionnaire.

Original name: “Age is No Obstacle” questionnaire.

Source: Tkacheva O.N., Runikhina N.K., Ostapenko V.S., Sharashkina N.V., Mkhitaryan E.A., Onuchina Yu.S., Lysenkov S.N. Validation of the screening questionnaire for frailty syndrome in outpatient practice // ADVANCES IN GERONTOLOGY, 2017, Vol. 30, No. 2, pp. 236-242.

Type (underline):

- rating scale;

- index;

- questionnaire;

- other.

Purpose: screening for frailty syndrome.

Content (template):

The “Age is No Obstacle” questionnaire was developed and validated for frailty screening. It includes 7 questions concerning weight loss, sensory deficits, falls, symptoms of depression and cognitive impairment, urinary incontinence, and decreased mobility. The questionnaire can be filled out by a nurse or non-medical personnel (e.g., volunteers), as well as by the patient themselves. For each positive answer, the patient scores 1 point, and for a negative answer, 0 points. The maximum score on the questionnaire is seven.

* This refers to unintentional weight loss. If the patient lost weight intentionally — through a special diet or regular physical activity, no point is awarded. 1 point is awarded for each positive answer.

Key (interpretation):

• 1–2 points – no frailty;

• 3–4 points – pre-frailty;

• 5 or more points – probable senile asthenia.

Appendix G2. Fracture Risk Assessment using FRAX

Russian title: FRAX – Fracture Risk Assessment Tool.

Original title (if applicable): FRAX ® - Fracture Risk Assessment Tool.

Source (official developer website, validation publication):

https://www.sheffield.ac.uk/FRAX/tool.aspx?lang=rsLesnyak, Olga M. et al. “Epidemiology of fracture in the Russian Federation and the development of a FRAX model.” ArchivesofOsteoporosis 7 (2012): 67-73.

Type: rating scale.

Purpose: assessment of fracture risk.

Content:

To calculate the 10-year probability of fracture using bone mineral density, please answer the following questions.

Questionnaire:

Key (interpretation):

Fracture risk assessment result in the orange zone: dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is recommended. If osteoporosis is detected (T-score < -2.5), anti-osteoporotic therapy is indicated without re-assessing fracture risk.

Fracture risk assessment result in the red zone: dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is not indicated; the patient unequivocally requires anti-osteoporotic therapy.

Fracture risk assessment result in the green zone: dual-energy X-ray absorptiometry (DXA) of the lumbar spine and proximal femur is not indicated; the patient does not require anti-osteoporotic therapy.

Notes:

For clinical risk factors, answer "yes" or "no". If a field is left blank, the default answer is "no".

Risk factor notes

Previous fracture. A special situation applies to a previous vertebral fracture. If a fracture was detected only on imaging (morphometric vertebral fracture), it is considered a previous fracture. However, a prior clinically overt vertebral fracture, along with a hip fracture, is a particularly strong risk factor. Therefore, in this case, the calculated fracture probability may be artificially underestimated. Additionally, the calculated fracture probability will be artificially underestimated in patients with multiple prior fractures.

Smoking, alcohol, glucocorticoids. These risk factors are likely dose-dependent. This is not accounted for in the model, and average values are assumed in the calculation. Clinical judgment should be applied for very low or very high doses.

Rheumatoid arthritis. A documented diagnosis of rheumatoid arthritis is taken into account.

Bone mineral density. DXA densitometry data of the femoral neck are used.

Appendix G3. Mini Nutritional Assessment

Russian title: Mini Nutritional Assessment.

Original title (if applicable): Mini Nutritional Assessment, MNA.

Source (official developer website, validation publication):

Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC; MNA-International Group. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. 2009

Type: scale.

Purpose: screening for malnutrition in elderly and senile patients.

Content (template):

It is necessary to complete the screening part (from item "A" to item "E") and sum up the obtained points. If the result is less than 12 points, continue the assessment by adding the subsequent points to the sum of the screening part.

Total score: ___________/30

Interpretation of results (full scale from A to T):

> 23.5 points – normal nutritional status

17–23.5 points – risk of malnutrition

< 17 points – malnutrition

APPENDIX G4. Digital rating (numerical rank) pain scale

Russian title: Numeric Rating Scale for pain.

Original title: Numeric Rating Scale.

Source: Bijur, P.E., Latimer, C.T. and Gallagher, E.J. (2003), Validation of a Verbally Administered Numerical Rating Scale of Acute Pain for Use in the Emergency Department. Academic Emergency Medicine, 10: 390-392. doi:10.1111/j.1553-2712.2003.tb01355.x

Type (underline):

• rating scale

• index

• questionnaire

• other

Purpose: assessment of pain intensity.

Content (template):

The scale consists of a sequential series of numbers from 0 to 10. Patients are asked to rate their pain intensity using numbers: 0 – no pain, 5 – moderate pain, and 10 – worst pain imaginable.

Key (interpretation):

APPENDIX G5. DYNAMOMETRY

Original title: Handgrip strength testing.

Source: American Society of Hand Therapists (ASHT) protocol of 1992 (updated in 2015).

Roberts, Helen C., et al. "A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach." Age and ageing 40.4 (2011): 423-429.

Type: strength index.

Purpose: measurement of grip strength.

Content (template):

Dynamometry procedure

Dynamometry is performed using an electronic or mechanical dynamometer. Before starting, ensure the dynamometer is calibrated in accordance with the manufacturer's instructions to guarantee measurement accuracy. The patient should be in a sitting position with the arm supported on a horizontal surface, the shoulder in a neutral position, the elbow flexed at 90 degrees, and the wrist in palmar flexion at an angle of 0 to 30°. Ask the patient to hold the dynamometer so that the handle rests comfortably in the palm and fits snugly against the fingers [271]. Squeeze the dynamometer with maximum force for approximately 3–5 seconds. To obtain more accurate results, it is recommended to measure muscle strength three times on both the right and left hands. The rest time between sets is about 1 minute. To evaluate the results, the maximum muscle strength value of the stronger hand is used.

Key (interpretation):

Criteria for low grip strength according to gender and body mass index

APPENDIX G6. Methodology for the Short Physical Performance Battery and Interpretation of Results

Russian title: Short Physical Performance Battery.

Original title: Short Physical Performance Battery (SPPB).

Source: nia.nih.gov/research/labs/leps/short-physical-performance-battery-sppb

Short Physical Performance Battery (SPPB)

Assessing Physical Performance in the Older Patient

Type:

- assessment scale: lower extremity function in older adults.

Purpose: evaluation of physical performance in elderly patients.

Content (template):

1. Balance assessment

The examining nurse explains to the patient: This test consists of three parts. In the first part, you must try to maintain your balance in three different positions. I will first describe and then demonstrate each of these positions.

A. Side-by-side stand

Now I will show you the first position (demonstrate). I need you to stand in this position with your feet together for 10 seconds. You may use your arms to balance, bend your knees, or move your body to maintain your balance, but try not to move your feet or hold onto anything. Try to remain in this position for 10 seconds until you hear the command 'stop'.

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something for support.

B. Semi-tandem stand

The examining nurse: now, I will show you the second position (demonstrate). You need to stand for 10 seconds with one foot placed forward so that the toe of one foot is alongside the heel or instep of the other foot, and the inner surfaces of both feet are touching. You may place either foot forward, whichever is more comfortable for you. You may use your arms to balance, bend your knees, or move your body to maintain your balance, but try not to move your feet or hold onto anything. Remain in this position until you hear the command 'Stop'.

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something for support, and say: 'Stop'.

C. Tandem stand

The examining nurse: now, I ask you to assume the third position. (Demonstrate). Stand with the heel of one foot directly in front of and touching the toes of the other foot. Stand like this for 10 seconds. You may put either foot forward, whichever is most comfortable for you. You may use your arms to balance, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to remain in this position until you hear the command 'Stop'.

As soon as the nurse sees that the patient is standing independently (without support), she starts the stopwatch. Stop the stopwatch after 10 seconds, or as soon as the patient changes foot position or touches something for support, and say: 'Stop'.

2. 4-meter gait speed test

Required distance: about 6 meters (corridor, room). Measure a distance of 4 meters from the 'Start' mark. The patient should be able to continue moving for a few more steps past the finish line so as not to slow down prematurely due to an obstacle. The test is performed in the shoes the patient normally wears.

The examining nurse: This test is necessary for us to see how you usually walk. Start here (the patient's feet are at the 'Start' mark). If you use a cane (or any other assistive device) and feel that you need it to walk this distance, you may use it. You should walk without stopping at your normal pace, as if you were walking down a hallway or outside. I will show you what I mean.

Demonstrate. Look forward and, maintaining an upright posture, walk at a normal pace to and past the finish line.

You will need to walk this distance three times. I will be right beside you. We will not talk while you are walking, but I will be there to support you so you do not fall.

The patient should stand without support at the starting line so that the toes of both feet touch the line or slightly cross it, standing at a comfortable distance from each other.

The first attempt is a practice run. During the second and third attempts, the time in seconds taken by the patient to walk 4 meters is measured. The best result is recorded.

3. Chair stands

Preparation: single chair stand. Chair without armrests.

The examining nurse: 'With this test, we will check the strength of your legs. Let me show you what you will do.'

Demonstrate and explain the procedure while sitting on a chair opposite the patient.

First, fold your arms across your chest or abdomen and sit so that your feet are flat on the floor. Then stand up while keeping your arms folded across your chest or abdomen.

If the patient cannot perform a single chair stand without using their arms, the 5-repetition chair stand test is not performed.

Test performance: five-repetition chair stand.

The examining nurse: please, now stand up five times in a row without stopping, as fast as you can. After each rise, you need to sit down and then stand up again. Your arms must be folded across your chest or abdomen. I will time the exercise.

The time taken by the patient to rise from the chair 5 times without using their arms is recorded. After the patient stands up for the fifth time (final position), stop the stopwatch.

Stop the test in the following cases:

- If the patient stands up using their arms.

- After one minute if the patient has not completed the test by that time.

- At your discretion, if necessary to ensure patient safety.

If the patient stops before completing 5 stands and appears fatigued, clarify by asking: 'Can you continue?' If the patient says 'Yes', continue the test. If the patient says 'No', stop and check the time on the stopwatch.

Key (interpretation):

Interpretation of Short Physical Performance Battery results

Points are awarded for each stage of the test (Fig. 1) and summed up. If the patient scores 10–12 points, there is no frailty; 8–9 points indicate prefrailty; 7 points or less indicate frailty. A score of 1 point or less in the balance test, and/or 5 seconds or more in the gait speed test, and/or 1 point or less in the 5-repetition chair stand test indicates a high risk of falls.

Figure 1. Short Physical Performance Battery