Sarcopenia is a progressive, generalized skeletal muscle disorder characterized by age-related decline in muscle strength, muscle mass, and physical performance. It has emerged as one of the most important geriatric syndromes because of its strong association with frailty, falls, disability, osteoporotic fractures, hospitalization, poor quality of life, and increased mortality. In 2019, the European Working Group on Sarcopenia in Older People (EWGSOP2) redefined sarcopenia as a muscle disease, emphasizing low muscle strength as the primary diagnostic criterion, with reduced muscle quantity and impaired physical performance confirming the diagnosis and severity.¹

The ageing of the global population has substantially increased the burden of sarcopenia. According to the United Nations, the proportion of people aged 60 years and above is increasing rapidly, and this demographic transition is expected to result in a marked rise in age-related musculoskeletal disorders. Recent systematic reviews have estimated that sarcopenia affects approximately 10–27% of community-dwelling older adults, while the prevalence is considerably higher among hospitalized and institutionalized elderly individuals. The prevalence varies according to age, sex, ethnicity, nutritional status, comorbidities, and the diagnostic criteria used.² These trends have made sarcopenia a significant public health problem worldwide due to its contribution to functional dependence, increased healthcare utilization, and socioeconomic burden.

One of the most important clinical consequences of sarcopenia is an increased risk of falls. Falls are a leading cause of injury, disability, and mortality among older adults and frequently result in osteoporotic fractures involving the hip, vertebrae, wrist, and proximal humerus. Sarcopenia contributes to falls through impaired muscle strength, decreased balance, slower gait speed, poor postural stability, and reduced neuromuscular coordination. Several meta-analyses have demonstrated that older adults with sarcopenia have significantly higher risks of recurrent falls, fractures, loss of independence, and institutionalization than individuals with preserved muscle function.³

The relationship between sarcopenia and osteoporosis has gained increasing attention because both conditions commonly coexist in older adults and share several pathogenic mechanisms. Age-related hormonal decline, chronic inflammation, oxidative stress, mitochondrial dysfunction, insulin resistance, vitamin D deficiency, inadequate protein intake, and reduced physical activity contribute simultaneously to deterioration of skeletal muscle and bone. This interaction has led to the concept of osteosarcopenia, in which muscle and bone act as an integrated functional unit through mechanical loading and endocrine signaling. Consequently, reduced muscle strength not only predisposes older adults to falls but also increases fracture susceptibility by adversely affecting bone quality and bone mineral density.⁴

India is undergoing a rapid demographic transition, with a steadily growing elderly population and an increasing burden of chronic non-communicable diseases. Alongside this transition, the prevalence of sarcopenia is rising because of nutritional deficiencies, sedentary lifestyle, multiple comorbidities, and increased life expectancy. Hospital-based studies from India have reported a substantial prevalence of sarcopenia among older adults attending tertiary care centres, emphasizing the need for routine screening in geriatric practice.⁵ Despite these observations, sarcopenia remains underdiagnosed because assessment of muscle strength and physical performance is not routinely incorporated into clinical evaluation.

Accumulating evidence has established that sarcopenia is an independent predictor of falls and osteoporotic fractures. Large cohort studies have shown that older adults with sarcopenia have significantly greater risks of fragility fractures even after adjusting for bone mineral density and conventional fracture-risk assessment tools such as FRAX.⁶ Early identification of sarcopenia therefore provides an opportunity to implement interventions including resistance exercise, nutritional optimization, vitamin D supplementation, and fall-prevention strategies, thereby reducing fracture risk and improving functional independence.

Although several international studies have evaluated the prevalence of sarcopenia and its association with falls and fractures, evidence from India remains relatively limited. Differences in ethnicity, body composition, nutritional status, socioeconomic factors, physical activity, and healthcare access may influence the prevalence and clinical consequences of sarcopenia among Indian older adults. Furthermore, few studies have simultaneously evaluated sarcopenia, falls, and osteoporotic fractures in elderly patients attending tertiary care hospitals.⁷ Therefore, the present cross-sectional study was undertaken to determine the prevalence of sarcopenia and evaluate its association with falls and osteoporotic fractures among older adults attending a tertiary care hospital. The findings are expected to facilitate early diagnosis, risk stratification, and implementation of targeted preventive and rehabilitative strategies to improve healthy ageing and reduce fracture-related morbidity.

AIM

To determine the prevalence of sarcopenia and evaluate its association with falls and osteoporotic fractures among older adults attending a tertiary care hospital.

OBJECTIVES

1. To determine the prevalence of sarcopenia among older adults attending a tertiary care hospital using the European Working Group on Sarcopenia in Older People 2 (EWGSOP2) diagnostic criteria.
2. To assess the association of sarcopenia with falls and osteoporotic fractures among older adults and identify the clinical factors associated with sarcopenia.

Study Design A Hospital-based cross-sectional observational study. Study Population Older adults aged 60 years and above attending the outpatient department or admitted to the inpatient wards of the tertiary care hospital during the study period. Sample Size A total of 50 participants fulfilling the eligibility criteria will be included in the study. Sampling Technique Consecutive sampling. Inclusion Criteria • Adults aged ≥60 years. • Patients attending the outpatient department or admitted to the hospital during the study period. • Patients willing to participate and provide written informed consent. • Patients able to perform physical performance and muscle strength assessments. Exclusion Criteria • Patients with acute stroke within the previous six months. • Advanced Parkinson's disease or other severe neurological disorders affecting muscle strength. • Advanced malignancy. • Severe cognitive impairment preventing participation. • Patients who are bedridden or critically ill. • Patients with limb amputation. • Refusal to participate. Methodology After obtaining approval from the Institutional Ethics Committee, eligible participants will be recruited consecutively after obtaining written informed consent. A detailed history regarding demographic characteristics, socioeconomic status, educational status, smoking, alcohol consumption, nutritional status, physical activity, comorbid illnesses, medication history, previous falls during the last one year, and history of osteoporotic fractures will be recorded using a structured proforma. Clinical examination including height, weight, body mass index (BMI), calf circumference, blood pressure, and systemic examination will be performed. Assessment of Sarcopenia (EWGSOP2 Criteria) 1. Muscle Strength • Handgrip strength will be measured using a calibrated hand dynamometer. • Low muscle strength: o Men: <27 kg o Women: <16 kg 2. Muscle Mass • Appendicular skeletal muscle mass (ASM) will be assessed using Bioelectrical Impedance Analysis (BIA). • Low muscle mass: o Men: ASM index <7.0 kg/m² o Women: ASM index <5.5 kg/m² 3. Physical Performance • Gait speed over a 4-metre walk will be assessed. • Gait speed <0.8 m/second will indicate poor physical performance. Participants fulfilling the EWGSOP2 criteria will be classified as having probable, confirmed, or severe sarcopenia. Assessment of Falls A fall will be defined as an unexpected event in which the participant comes to rest on the ground, floor, or lower level. The following details will be recorded: • Number of falls during the previous 12 months. • Single or recurrent falls. • Circumstances leading to falls. • Fall-related injuries. Assessment of Osteoporotic Fractures History of previous low-energy (fragility) fractures involving: • Hip • Vertebrae • Distal radius • Proximal humerus • Pelvis Fractures will be confirmed using previous medical records and available radiographs whenever possible. Statistical Analysis Data will be entered into Microsoft Excel and analysed using Statistical Package for Social Sciences (SPSS) version 26.0. Continuous variables will be expressed as mean ± standard deviation (SD). Categorical variables will be expressed as frequency and percentage. The prevalence of sarcopenia will be calculated with 95% confidence intervals (CI). Independent Student's t-test or Mann–Whitney U test will be used to compare continuous variables. Chi-square test or Fisher's exact test will be used to compare categorical variables. Variables showing statistical significance on univariate analysis will be entered into multivariable logistic regression analysis to identify independent factors associated with sarcopenia. Odds ratios (OR) with 95% confidence intervals (CI) will be calculated. A p-value <0.05 will be considered statistically significant.

A total of 50 older adults (≥60 years) attending the tertiary care hospital were included in the study. Sarcopenia was diagnosed according to the EWGSOP2 criteria. The prevalence of sarcopenia was 17 (34.0%), while 33 (66.0%) participants did not have sarcopenia.

Table 1. Demographic and clinical characteristics of the study participants (n = 50)

Mean age: 72.4 ± 7.8 years

Interpretation

Most participants were aged 70–79 years (40%), and females constituted 54% of the study population. Hypertension (58%) and diabetes mellitus (42%) were common comorbidities. Nearly two-thirds of participants reported inadequate physical activity.

Table 2. Prevalence of sarcopenia, falls and osteoporotic fractures

Interpretation

The prevalence of sarcopenia was 34%. Falls during the previous year were reported by 40% of participants, while 26% had sustained an osteoporotic fracture. Hip fractures were the most frequent osteoporotic fractures observed.

Table 3. Association between sarcopenia and demographic/clinical variables

Interpretation

Older age, diabetes mellitus, hypertension, underweight nutritional status, and inadequate physical activity were significantly associated with sarcopenia. Gender was not significantly associated with the presence of sarcopenia.

Table 4. Association of sarcopenia with falls and osteoporotic fractures

Interpretation

Participants with sarcopenia had significantly higher rates of falls, recurrent falls, and osteoporotic fractures compared with those without sarcopenia. They also demonstrated significantly lower handgrip strength and slower gait speed, indicating poorer muscle function and physical performance.

Table 5. Multivariable logistic regression analysis showing factors associated with sarcopenia

• p <0.001

Interpretation

Multivariable logistic regression identified advanced age, diabetes mellitus, underweight BMI, inadequate physical activity, previous falls, and osteoporotic fractures as independent factors associated with sarcopenia. Participants with a history of falls had more than five-fold higher odds of having sarcopenia, while inadequate physical activity and osteoporotic fractures also significantly increased the likelihood of sarcopenia. These findings suggest that routine screening for sarcopenia among older adults, particularly those with falls and fragility fractures, may facilitate early intervention and improve geriatric outcomes.

The present cross-sectional study assessed the prevalence of sarcopenia and its association with falls and osteoporotic fractures among 50 older adults attending a tertiary care hospital. Sarcopenia was identified in 34.0% of participants, indicating that approximately one in three older adults had clinically significant impairment of muscle strength, muscle mass, or physical performance. This prevalence was higher than the 10% overall prevalence reported by Bhat et al. among middle-aged adults from Western India, although their prevalence was greater in rural than urban participants (14.8% vs. 6.8%). The difference may be explained by the older age and hospital-based characteristics of our participants, who were more likely to have comorbidities and functional limitations.⁸ The prevalence observed in our study was comparable with several hospital-based Indian studies. Yogesh et al. reported sarcopenia in 45.3% and possible sarcopenia in 89.6% of patients with type 2 diabetes attending a tertiary care hospital in Gujarat.⁹ The relatively lower prevalence in our study may be related to inclusion of both diabetic and non-diabetic participants and the use of strict EWGSOP2 criteria. Nevertheless, both studies demonstrate that sarcopenia is common among older Indian patients and warrants routine screening in tertiary-care settings. Participants with sarcopenia were significantly older than those without sarcopenia (77.1 ± 6.2 vs. 69.9 ± 7.4 years; p<0.001), and age ≥75 years independently increased the odds of sarcopenia nearly fourfold. This finding agrees with the systematic review and meta-analysis by Gao et al., which included 68 studies and 98,502 older adults and demonstrated that increasing age was significantly associated with sarcopenia (pooled OR 1.12, 95% CI 1.10–1.13).¹⁰ Ageing contributes to motor-unit loss, reduced anabolic hormone activity, chronic inflammation, mitochondrial dysfunction, and decreased muscle-protein synthesis, thereby accelerating the decline in muscle mass and strength. In the present study, gender was not significantly associated with sarcopenia, although the proportion of women was numerically higher in the sarcopenia group. Gao et al. similarly reported inconsistent evidence regarding the independent relationship between sex and sarcopenia.¹⁰ Differences in body composition, hormonal status, nutritional intake, diagnostic thresholds, and sampling characteristics may explain variations in sex-specific prevalence between studies. Underweight participants had a significantly greater prevalence of sarcopenia, and underweight BMI remained an independent associated factor (AOR 4.25, p=0.037). This is strongly supported by Gao et al., who reported that underweight older adults had almost fourfold higher odds of sarcopenia (OR 3.78, 95% CI 2.55–5.60), while malnutrition or risk of malnutrition was associated with an OR of 2.99.¹⁰ Low body weight may reflect inadequate energy and protein intake, chronic illness, and depletion of both fat and skeletal muscle reserves. Inadequate physical activity was present in 88.2% of participants with sarcopenia compared with 51.5% of those without sarcopenia and independently increased its likelihood nearly fivefold. Bhat et al. demonstrated that inadequate protein intake and lower socioeconomic status were independent determinants of sarcopenia among Indian adults, while physical inactivity was biologically linked to reduced muscle-protein synthesis and earlier muscle deterioration.⁸ A larger meta-analysis also found physical inactivity to be associated with sarcopenia with a pooled OR of 1.73.¹⁰ These findings emphasize the importance of resistance exercise, regular walking, and nutritional optimization in older adults. Diabetes mellitus was significantly more frequent among participants with sarcopenia (64.7% vs. 30.3%; p=0.019) and remained independently associated with sarcopenia (AOR 3.11, p=0.047). Yogesh et al. reported a high burden of sarcopenia and sarcopenic obesity among Indian patients with type 2 diabetes.⁹ The systematic review by Gao et al. also demonstrated a significant association between diabetes and sarcopenia (OR 1.40, 95% CI 1.18–1.66).¹⁰ Insulin resistance, diabetic neuropathy, chronic inflammation, microvascular dysfunction, and reduced physical activity may contribute to accelerated muscle loss in diabetes. A history of falls was reported by 76.5% of participants with sarcopenia compared with 21.2% of those without sarcopenia. Previous falls independently increased the odds of sarcopenia more than fivefold (AOR 5.41, p=0.009). Veronese et al., in a study of 13,101 older adults from five low- and middle-income countries, including India, found that sarcopenia was associated with 1.85 times greater odds of fall-related injury.¹¹ The present findings therefore reinforce the close relationship between impaired muscle function, postural instability, and falls in older populations. Recurrent falls were also significantly more common in the sarcopenia group (41.2% vs. 6.1%; p=0.004). Cawthon et al., in a prospective cohort of 1,382 older men, reported that participants in the lowest quartile of directly measured muscle mass had slower gait speed, poorer physical performance, and 2.49-fold greater odds of serious injurious falls compared with those in the highest quartile.¹² These findings suggest that reduced muscle quantity and quality compromise balance recovery and the ability to prevent a fall after an external perturbation. The mean handgrip strength was significantly lower among participants with sarcopenia (18.4 ± 4.1 kg) than among those without sarcopenia (28.6 ± 5.3 kg; p<0.001). Similarly, mean gait speed was markedly reduced in the sarcopenia group (0.64 ± 0.13 vs. 0.94 ± 0.18 m/s; p<0.001). Cawthon et al. demonstrated that low muscle mass was strongly related to lower Short Physical Performance Battery scores, slower gait speed, mobility limitation, and injurious falls.¹² These results support the clinical value of handgrip strength and gait speed as simple and practical screening tools for identifying older adults at high risk of adverse outcomes. Osteoporotic fractures were observed in 52.9% of participants with sarcopenia compared with only 12.1% of those without sarcopenia (p=0.002). Salech et al. found that osteosarcopenia affected 16.4% of community-dwelling older adults and increased to 33.7% among those older than 80 years. Sarcopenia was present in 34.4% of osteoporotic individuals, while osteoporosis was identified in 40.8% of those with sarcopenia.¹³ Their findings demonstrate the substantial overlap between muscle and bone deterioration and support simultaneous screening for both conditions. The strong association between sarcopenia and fractures in our study is also supported by Cawthon et al., who studied 1,363 older men and found that directly measured low skeletal muscle mass was associated with incident fractures even after considering conventional fracture-risk variables.¹⁴ Reduced muscle mass can increase fracture risk both indirectly, by increasing falls, and directly, through reduced mechanical loading and deterioration of bone strength. Cawthon et al., in the Osteoporotic Fractures in Men cohort, further demonstrated that consensus definitions of sarcopenia identified older men at increased risk of mobility limitation, falls, fractures, and other adverse outcomes.¹⁵ However, the magnitude of association varied according to the diagnostic definition used, emphasizing the importance of applying standardized criteria when estimating prevalence and comparing studies. Hip fractures were the most frequent osteoporotic fractures in the present study. This may be attributed to the combined effects of falls, low muscle strength, poor balance, and reduced bone mineral density. Yoshii et al. reported that musculoskeletal ambulation disability independently predicted incident bone fragility fractures, with an adjusted hazard ratio of 2.70 before propensity matching and 1.83 after matching.¹⁶ Their findings demonstrate that impaired mobility should be considered alongside bone mineral density when assessing fracture risk. The coexistence of sarcopenia and osteoporosis has important clinical implications because individuals with both disorders may have a substantially greater risk of falls, fractures, functional decline, and mortality than those with either disorder alone. Salech et al. reported mortality of 15.9% among participants with osteosarcopenia compared with 6.1% among those without it, with an adjusted hazard ratio of 2.48.¹³ Thus, identifying sarcopenia among patients with osteoporosis or fragility fractures could enable earlier multidisciplinary intervention. The overall findings are consistent with the systematic review and meta-analysis by Beaudart et al., which demonstrated that sarcopenia is associated with several adverse outcomes, including falls, functional decline, hospitalization, and mortality.¹⁷ The study highlighted sarcopenia as a clinically important public-health problem rather than an inevitable consequence of ageing. Similarly, Xia et al., in an umbrella review of meta-analyses, concluded that sarcopenia was significantly associated with falls, fractures, cognitive impairment, functional deterioration, hospitalization, and mortality.¹⁸ These findings support routine evaluation of muscle strength, muscle mass, gait speed, nutritional status, and fall history during geriatric assessment. The present study has certain limitations. Its cross-sectional design does not establish whether sarcopenia preceded the falls and fractures or developed as a consequence of reduced mobility after these events. The small hospital-based sample may also limit generalizability to the wider community. Recall bias may have affected the reporting of previous falls, while bone mineral density was not measured in all participants. Nevertheless, the study demonstrates a clinically relevant burden of sarcopenia and a strong association with falls, recurrent falls, and osteoporotic fractures among older adults. Overall, the findings indicate that sarcopenia is common among older adults attending a tertiary care hospital and is strongly associated with advanced age, diabetes mellitus, underweight status, inadequate physical activity, falls, and osteoporotic fractures. Routine screening using handgrip strength, gait speed, and muscle-mass assessment, followed by resistance exercise, adequate protein intake, management of comorbidities, osteoporosis evaluation, and fall-prevention measures, may reduce disability and fracture-related morbidity in this vulnerable population.

The present study demonstrated that sarcopenia was highly prevalent among older adults attending a tertiary care hospital, affecting 34.0% of the study population. Sarcopenia was significantly associated with advanced age, diabetes mellitus, hypertension, underweight nutritional status, and inadequate physical activity. Older adults with sarcopenia had markedly lower handgrip strength and gait speed, indicating impaired muscle function and physical performance. A strong association was observed between sarcopenia and both falls and osteoporotic fractures. Participants with sarcopenia had significantly higher rates of previous falls, recurrent falls, and fragility fractures than those without sarcopenia. Advanced age, diabetes mellitus, underweight BMI, inadequate physical activity, previous falls, and osteoporotic fractures were identified as independent factors associated with sarcopenia.

These findings emphasize the need for routine sarcopenia screening as part of comprehensive geriatric assessment, particularly among older adults with a history of falls, fractures, diabetes, malnutrition, or reduced physical activity. Early identification and targeted interventions, including resistance exercise, adequate protein intake, nutritional correction, osteoporosis evaluation, and fall-prevention measures, may reduce disability, fractures, hospitalization, and loss of independence among older adults.

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