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Acute Sarcopenia in Elderly with COVID-19: An Overlooked Problem


The coronavirus Disease-19 (COVID-19) pandemic was announced in March 2020 by World Health Organization (WHO). Studies showed that the elderly had higher morbidity and mortality rates. Acute sarcopenia in the elderly with COVID-19 is an overlooked problem. Inflammation, malnutrition, immobilization, a side effect of COVID-19 treatment, depression, and hormonal dysregulation contributed to acute sarcopenia in COVID-19, especially in the elderly. Muscle quantity can be assessed with different techniques such as imaging or anthropometric measurements in diagnosing sarcopenia. Imaging such as CT scan was widely used in multiple studies. Still, anthropometric measurements are more fit in developing countries because they are widely available, safe, do not require special skills, and fit in low-resources facilities. Muscle strength can be assessed with grip strength. Acute sarcopenia was associated with immune dysregulation and cytokine storm, length of stay and readmission, and ICU admission and mechanical ventilation. These will contribute to high mortality in sarcopenic elderly with COVID-19.


  1. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, Boirie Y, Cederholm T, Landi F, et al. Sarcopenia: European consensus on definition and diagnosis: Report of the European Working Group on Sarcopenia in Older People. Age Ageing. 2010 Jul 1;39(4):412–23.
  2. Fielding RA, Vellas B, Evans WJ, Bhasin S, Morley JE, Newman AB, et al. Sarcopenia: An Undiagnosed Condition in Older Adults. Current Consensus Definition: Prevalence, Etiology, and Consequences. International Working Group on Sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249–56.
  3. Chen L-K, Liu L-K, Woo J, Assantachai P, Auyeung T-W, Bahyah KS, et al. Sarcopenia in Asia: Consensus Report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014 Feb;15(2):95–101.
  4. Ali AM, Kunugi H. Screening for Sarcopenia (Physical Frailty) in the COVID-19 Era. Garcia-Rivas G, editor. Int J Endocrinol. 2021 May 21;2021:1–16.
  5. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019 Jan 1;48(1):16–31.
  6. Welch C, Greig C, Masud T, Wilson D, Jackson TA. COVID-19 and Acute Sarcopenia. Aging Dis. 2020;11(6):1345.
  7. Zhang X-M, Chen D, Xie X-H, Zhang J-E, Zeng Y, Cheng AS. Sarcopenia as a predictor of mortality among the critically ill in an intensive care unit: a systematic review and meta-analysis. BMC Geriatr. 2021 Dec;21(1):339.
  8. Weijs PJ, Looijaard WG, Dekker IM, Stapel SN, Girbes AR, Straaten H, et al. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Crit Care. 2014;18(1):R12.
  9. Kou H-W, Yeh C-H, Tsai H-I, Hsu C-C, Hsieh Y-C, Chen W-T, et al. Sarcopenia is an effective predictor of difficult-to-wean and mortality among critically ill surgical patients. Lazzeri C, editor. PLOS ONE. 2019 Aug 8;14(8):e0220699.
  10. Giraudo C, Librizzi G, Fichera G, Motta R, Balestro E, Calabrese F, et al. Reduced muscle mass as predictor of intensive care unit hospitalization in COVID-19 patients. Abete P, editor. PLOS ONE. 2021 Jun 17;16(6):e0253433.
  11. Corradi F, Isirdi A, Brusasco C, Santori G, Falcone M, Gargani L, et al. Low Diaphragm Muscle Mass Predicts Adverse Outcome in Patients Hospitalized for Covid-19 Pneumonia [Internet]. In Review; 2020 Aug [cited 2021 Aug 9]. Available from:
  12. Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss. GeroScience. 2020 Dec;42(6):1547–78.
  13. Lopez-Ruiz A, Kashani K. Assessment of muscle mass in critically ill patients: role of the sarcopenia index and images studies. Curr Opin Clin Nutr Metab Care. 2020 Sep;23(5):302–11.
  14. Gan JM, Kho J, Akhunbay-Fudge M, Choo HM, Wright M, Batt F, et al. Atypical presentation of COVID-19 in hospitalised older adults. Ir J Med Sci 1971 -. 2021 May;190(2):469–74.
  15. Singhal S, Kumar P, Singh S, Saha S, Dey AB. Clinical features and outcomes of COVID-19 in older adults: a systematic review and meta-analysis. BMC Geriatr. 2021 Dec;21(1):321.
  16. Puthucheary ZA, Rawal J, McPhail M, Connolly B, Ratnayake G, Chan P, et al. Acute Skeletal Muscle Wasting in Critical Illness. JAMA. 2013 Oct 16;310(15):1591.
  17. Wierdsma NJ, Kruizenga HM, Konings LAML, Krebbers D, Jorissen JRMC, Joosten M-HI, et al. Poor nutritional status, risk of sarcopenia and nutrition related complaints are prevalent in COVID-19 patients during and after hospital admission. Clin Nutr ESPEN. 2021 Jun;43:369–76.
  18. Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of 10 Days of Bed Rest on Skeletal Muscle in Healthy Older Adults. JAMA. 2007 Apr 25;297(16):1769.
  19. Paddon-Jones D, Sheffield-Moore M, Cree MG, Hewlings SJ, Aarsland A, Wolfe RR, et al. Atrophy and Impaired Muscle Protein Synthesis during Prolonged Inactivity and Stress. J Clin Endocrinol Metab. 2006 Dec 1;91(12):4836–41.
  20. Szlejf C, Suemoto CK, Brunoni AR, Viana MC, Moreno AB, Matos SMA, et al. Depression is Associated With Sarcopenia Due to Low Muscle Strength: Results From the ELSA-Brasil Study. J Am Med Dir Assoc. 2019 Dec;20(12):1641–6.
  21. Bartleson JM, Radenkovic D, Covarrubias AJ, Furman D, Winer DA, Verdin E. SARS-CoV-2, COVID-19 and the aging immune system. Nat Aging. 2021 Sep;1(9):769–82.
  22. Schiaffino S, Albano D, Cozzi A, Messina C, Arioli R, Bnà C, et al. CT-derived Chest Muscle Metrics for Outcome Prediction in Patients with COVID-19. Radiology. 2021 Aug;300(2):E328–36.
  23. Kim J-W, Yoon JS, Kim EJ, Hong H-L, Kwon HH, Jung CY, et al. Prognostic Implication of Baseline Sarcopenia for Length of Hospital Stay and Survival in Patients With Coronavirus Disease 2019. Newman AB, editor. J Gerontol Ser A. 2021 Jul 13;76(8):e110–6.
  24. Derstine BA, Holcombe SA, Ross BE, Wang NC, Su GL, Wang SC. Skeletal muscle cutoff values for sarcopenia diagnosis using T10 to L5 measurements in a healthy US population. Sci Rep. 2018 Jul 27;8(1):11369.
  25. Tuzun S, Keles A, Okutan D, Yildiran T, Palamar D. Assessment of musculoskeletal pain, fatigue and grip strength in hospitalized patients with COVID-19. Eur J Phys Rehabil Med [Internet]. 2021 Sep [cited 2021 Sep 22];57(4). Available from:
  26. Nakanishi R, Oki E, Sasaki S, Hirose K, Jogo T, Edahiro K, et al. Sarcopenia is an independent predictor of complications after colorectal cancer surgery. Surg Today. 2018 Feb;48(2):151–7.
  27. Yang M, Hu X, Wang H, Zhang L, Hao Q, Dong B. Sarcopenia predicts readmission and mortality in elderly patients in acute care wards: a prospective study. J Cachexia Sarcopenia Muscle. 2017 Apr;8(2):251–8.
  28. Cosquéric G, Sebag A, Ducolombier C, Thomas C, Piette F, Weill-Engerer S. Sarcopenia is predictive of nosocomial infection in care of the elderly. Br J Nutr. 2006 Nov;96(5):895–901.
  29. Fuentes E, Fuentes M, Alarcón M, Palomo I. Immune System Dysfunction in the Elderly. An Acad Bras Ciênc. 2017 Mar;89(1):285–99.
  30. Meloche C, Azam T, Anderson E, Shadid H, Berlin H, Pan M, et al. Biomarkers of inflammation and outcomes of patients hospitalized for COVID-19: The international study of inflammation in COVID-19. J Am Coll Cardiol. 2021 May;77(18):3030.
  31. van Paassen J, Vos JS, Hoekstra EM, Neumann KMI, Boot PC, Arbous SM. Corticosteroid use in COVID-19 patients: a systematic review and meta-analysis on clinical outcomes. Crit Care. 2020 Dec;24(1):696.
  32. Piotrowicz K, Gąsowski J. Risk Factors for Frailty and Cardiovascular Diseases: Are They the Same? In: Veronese N, editor. Frailty and Cardiovascular Diseases [Internet]. Cham: Springer International Publishing; 2020 [cited 2021 Aug 19]. p. 39–50. (Advances in Experimental Medicine and Biology; vol. 1216). Available from:
  33. Ali AM, Kunugi H. Physical Frailty/Sarcopenia as a Key Predisposing Factor to Coronavirus Disease 2019 (COVID-19) and Its Complications in Older Adults. BioMed. 2021 Jul 29;1(1):11–40.
  34. Piotrowicz K, Gąsowski J, Michel J-P, Veronese N. Post-COVID-19 acute sarcopenia: physiopathology and management. Aging Clin Exp Res [Internet]. 2021 Jul 30 [cited 2021 Aug 9]; Available from:
  35. Franceschi C, Garagnani P, Parini P, Giuliani C, Santoro A. Inflammaging: a new immune–metabolic viewpoint for age-related diseases. Nat Rev Endocrinol. 2018 Oct;14(10):576–90.
  36. Nelke C, Dziewas R, Minnerup J, Meuth SG, Ruck T. Skeletal muscle as potential central link between sarcopenia and immune senescence. EBioMedicine. 2019 Nov;49:381–8.
  37. Merino J, Joshi AD, Nguyen LH, Leeming ER, Mazidi M, Drew DA, et al. Diet quality and risk and severity of COVID-19: a prospective cohort study. Gut. 2021 Nov;70(11):2096–104.
  38. Cox NJ, Morrison L, Ibrahim K, Robinson SM, Sayer AA, Roberts HC. New horizons in appetite and the anorexia of ageing. Age Ageing. 2020 Jul 1;49(4):526–34.
  39. Yoshida M, Tsuga K. Sarcopenia and Mastication. Curr Oral Health Rep. 2020 Jun;7(2):179–87.
  40. Batsis JA, Villareal DT. Sarcopenic obesity in older adults: aetiology, epidemiology and treatment strategies. Nat Rev Endocrinol. 2018 Sep;14(9):513–37.
  41. Wilkinson TJ, Yates T, Baker LA, Zaccardi F, Smith AC. Sarcopenic obesity and the risk of hospitalisation or death from COVID-19: findings from UK Biobank [Internet]. Epidemiology; 2021 Mar [cited 2021 Aug 9]. Available from:
  42. Kostoglou-Athanassiou I, Pantazi E, Kontogiannis S, Kousouris D, Mavropoulos I, Athanassiou P. Vitamin D in acutely ill patients. J Int Med Res. 2018 Oct;46(10):4246–57.
  43. Ceglia L. Vitamin D and its role in skeletal muscle: Curr Opin Clin Nutr Metab Care. 2009 Nov;12(6):628–33.
  44. Aryana IGPS, Hapsari AAAR, Kuswardhani RAT. Myokine Regulation as Marker of Sarcopenia in Elderly. Mol Cell Biomed Sci. 2018 Sep 1;2(2):38.
  45. Annweiler C, Beaudenon M, Simon R, Guenet M, Otekpo M, Célarier T, et al. Vitamin D supplementation prior to or during COVID-19 associated with better 3-month survival in geriatric patients: Extension phase of the GERIA-COVID study. J Steroid Biochem Mol Biol. 2021 Oct;213:105958.
  46. Abodonya AM, Abdelbasset WK, Awad EA, Elalfy IE, Salem HA, Elsayed SH. Inspiratory muscle training for recovered COVID-19 patients after weaning from mechanical ventilation: A pilot control clinical study. Medicine (Baltimore). 2021 Apr 2;100(13):e25339.
  47. Zha L, Xu X, Wang D, Qiao G, Zhuang W, Huang S. Modified rehabilitation exercises for mild cases of COVID-19. Ann Palliat Med. 2020 Sep;9(5):3100–6.
  48. Arentson-Lantz EJ, English KL, Paddon-Jones D, Fry CS. Fourteen days of bed rest induces a decline in satellite cell content and robust atrophy of skeletal muscle fibers in middle-aged adults. J Appl Physiol. 2016 Apr 15;120(8):965–75.
  49. Brooks NE, Myburgh KH. Skeletal muscle wasting with disuse atrophy is multi-dimensional: the response and interaction of myonuclei, satellite cells and signaling pathways. Front Physiol [Internet]. 2014 Mar 17 [cited 2021 Dec 23];5. Available from:
  50. Foletta VC, White LJ, Larsen AE, Léger B, Russell AP. The role and regulation of MAFbx/atrogin-1 and MuRF1 in skeletal muscle atrophy. Pflüg Arch - Eur J Physiol. 2011 Mar;461(3):325–35.
  51. Bodine SC, Stitt TN, Gonzalez M, Kline WO, Stover GL, Bauerlein R, et al. Akt/mTOR pathway is a crucial regulator of skeletal muscle hypertrophy and can prevent muscle atrophy in vivo. Nat Cell Biol. 2001 Nov;3(11):1014–9.
  52. Sacheck JM, Ohtsuka A, McLary SC, Goldberg AL. IGF-I stimulates muscle growth by suppressing protein breakdown and expression of atrophy-related ubiquitin ligases, atrogin-1 and MuRF1. Am J Physiol-Endocrinol Metab. 2004 Oct;287(4):E591–601.
  53. McPherron AC, Lawler AM, Lee S-J. Regulation of skeletal muscle mass in mice by a new TGF-p superfamily member. Nature. 1997 May;387(6628):83–90.
  54. Bellelli G, Zambon A, Volpato S, Abete P, Bianchi L, Bo M, et al. The association between delirium and sarcopenia in older adult patients admitted to acute geriatrics units: Results from the GLISTEN multicenter observational study. Clin Nutr. 2018 Oct;37(5):1498–504.
  55. Zucchelli A, Manzoni F, Morandi A, Di Santo S, Rossi E, Valsecchi MG, et al. The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017. Aging Clin Exp Res [Internet]. 2021 Aug 20 [cited 2021 Sep 22]; Available from:
  56. Bueno-Notivol J, Gracia-García P, Olaya B, Lasheras I, López-Antón R, Santabárbara J. Prevalence of depression during the COVID-19 outbreak: A meta-analysis of community-based studies. Int J Clin Health Psychol. 2021 Jan;21(1):100196.
  57. Wang Y, Yang Y, Ren L, Shao Y, Tao W, Dai X. Preexisting Mental Disorders Increase the Risk of COVID-19 Infection and Associated Mortality. Front Public Health. 2021 Aug 9;9:684112.
  58. Kim NH, Kim HS, Eun CR, Seo JA, Cho HJ, Kim SG, et al. Depression Is Associated with Sarcopenia, Not Central Obesity, in Elderly Korean Men. J Am Geriatr Soc. 2011 Nov;59(11):2062–8.
  59. Pasco JA, Williams LJ, Jacka FN, Stupka N, Brennan-Olsen SL, Holloway KL, et al. Sarcopenia and the Common Mental Disorders: a Potential Regulatory Role of Skeletal Muscle on Brain Function? Curr Osteoporos Rep. 2015 Oct;13(5):351–7.
  60. Batista MA, Calvo-Fortes F, Silveira-Nunes G, Camatta GC, Speziali E, Turroni S, et al. Inflammaging in Endemic Areas for Infectious Diseases. Front Immunol. 2020 Nov 12;11:579972.
  61. Dalle S, Rossmeislova L, Koppo K. The Role of Inflammation in Age-Related Sarcopenia. Front Physiol. 2017;8:1045.
  62. Oikawa SY, Holloway TM, Phillips SM. The Impact of Step Reduction on Muscle Health in Aging: Protein and Exercise as Countermeasures. Front Nutr. 2019 May 24;6:75.
  63. Ramirez J, Guarner F, Bustos Fernandez L, Maruy A, Sdepanian VL, Cohen H. Antibiotics as Major Disruptors of Gut Microbiota. Front Cell Infect Microbiol. 2020 Nov 24;10:572912.
  64. Ahmed S, Leurent B, Sampson EL. Risk factors for incident delirium among older people in acute hospital medical units: a systematic review and meta-analysis. Age Ageing. 2014 May;43(3):326–33.
  65. Sakuma K, Yamaguchi A. The recent understanding of the neurotrophin’s role in skeletal muscle adaptation. J Biomed Biotechnol. 2011;2011:201696.
  66. Chevrel G, Hohlfeld R, Sendtner M. The role of neurotrophins in muscle under physiological and pathological conditions. Muscle Nerve. 2006 Apr;33(4):462–76.
  67. Berk M, Williams LJ, Jacka FN, O’Neil A, Pasco JA, Moylan S, et al. So depression is an inflammatory disease, but where does the inflammation come from? BMC Med. 2013 Dec;11(1):200.
  68. Leonard B, Maes M. Mechanistic explanations how cell-mediated immune activation, inflammation and oxidative and nitrosative stress pathways and their sequels and concomitants play a role in the pathophysiology of unipolar depression. Neurosci Biobehav Rev. 2012 Feb;36(2):764–85.
  69. Horstman AM, Dillon EL, Urban RJ, Sheffield-Moore M. The role of androgens and estrogens on healthy aging and longevity. J Gerontol A Biol Sci Med Sci. 2012 Nov;67(11):1140–52.
  70. Kim YJ, Tamadon A, Park HT, Kim H, Ku S-Y. The role of sex steroid hormones in the pathophysiology and treatment of sarcopenia. Osteoporos Sarcopenia. 2016 Sep;2(3):140–55.
  71. Cummings D, Merriam G. Age-Related Changes in Growth Hormone Secretion: Should the Somatopause Be Treated? Semin Reprod Med. 1999 Dec;17(04):311–25.
  72. Lombardi G, Tauchmanova L, Di Somma C, Musella T, Rota F, Savanelli MC, et al. Somatopause: dismetabolic and bone effects. J Endocrinol Invest. 2005;28(10 Suppl):36–42.
  73. de Luca C, Olefsky JM. Inflammation and insulin resistance. FEBS Lett. 2008 Jan 9;582(1):97–105.
  74. Yudkin JS. Adipose tissue, insulin action and vascular disease: inflammatory signals. Int J Obes. 2003 Dec;27(S3):S25–8.
  75. Ye Q, Wang B, Mao J. The pathogenesis and treatment of the `Cytokine Storm’ in COVID-19. J Infect. 2020 Jun;80(6):607–13.

How to Cite

I Gusti Putu Suka Aryana, Dian Daniella, Raden Ayu Tuty Kuswardhani, & Siti Setiati. (2022). Acute Sarcopenia in Elderly with COVID-19: An Overlooked Problem. Bali Medical Journal, 11(3), 1269–1276.




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