OSTEOPOROSIS

DAN SARCOPENIA
SEBAGAI RISIKO FRAKTUR PATOLOGIS
PADA GERIATRI
dr. IB. PT. PUTRAWAN, SpPD-KGer, FINASIM
Div. Geriatri, Bag/SMF Penyakit Dalam
RSUP Sanglah/FK Unud
PENDAHULUAN
The Ageing World

Number 60+
2,092m

Number 60+ 21.5%

of total worldwide
1,402m population

16.5%
of total worldwide
population
Number 60+ 2050
901m
UHH Provinsi Bali
12.3% 2030 2016 : 71,35
of total worldwide
population 2017 : 71,46
2018 : 71,68
2015 Kementrian Kesehatan RI, Jakarta, 4 Juli 2019
• Namun, seringkali peningkatan UHH bukanlah peningkatan harapan
"hidup sehat", dan tahun-tahun tambahan ini sarat dengan masalah
kesehatan dan kecacatan

Ø osteopenia/osteoporosis
Ø sarcopenia FRAILTY
è “osteosarcopenia,”
Aging Medicine. 2019;2:147–156.
Pendahuluan

OSTEOSARCOPENIA DIDEFINISIKAN SEBAGAI KOMBINASI KEPADATAN TULANG YANG RENDAH

(OSTEOPENIA/OSTEOPOROSIS) DAN MASSA OTOT, KEKUATAN, DAN/ATAU KAPASITAS
FUNGSIONAL OTOT YANG MENURUN (SARCOPENIA)
 Osteoporosis
• Penyakit tulang sistemik yang ditandai oleh penurunan
densitas massa tulang dan perburukan mikroarsitektur
tulang, sehingga tulang menjadi rapuh dan mudah patah.

Kekuatan tulang :
1. Kuantitas tulang
2. Kualitas tulang

World Health Organization 2007

Epidemiology
Prevalensi Osteoporosis di Indonesia Berdasarkan Jenis Kelamin Laki-Laki dan
Perempuan th 2006

Sumber: Hasil penelitian Gunawan Tirtaraja, Bambang Setyohadi, LS Weynand, Q Zhou di Pusat OsteoporosisJakarta di RS Medistra bekerja sama dengan Dept. Penyakit Dalam UI,
GE Healtcare, Madisosn, USAdan GE Healthcare Shanghai, China, th 2006
Epidemiology
Insiden Patah Tulang Panggul Per 100.000 Kasus di Indonesia Berdasarkan Jenis Kelamin Laki-Laki
dan Perempuan Th 2011

Sumber: WHO FRAX Calculation th 2011, Pusat Data dan Informasi KemenKes RI
Etiology and Pathogenesis
Type I (postmenopausal Type III (Secondary osteoporosis)
osteoporosis) Type II (Senile osteoporosis)
• Estrogen drop production, • women or men over 70 years old •Hormonal imbalances, cancer, CRF,
women lose nearly 50% of • Decreased bone formation along with a Drug Use, hyperthyroidism , GI
trabecular bone, 35% of cortical decreased ability of the kidney to disorders, hypogonadism in men,
bone throughout their lifetime, produce 1,25-dihydroxyvitamin D3. immobilization, osteogenesis
where as men lose only 25% of imperfecta, inflammatory arthritis and
both types of bone (Iqbal, 2017). poor nutrition (Praet et al., 1992;
Alderman & Hill, 1994; Feber, Cochat, &
Braillon, 2017).

Risk Factors

Non-modifiable risk factors Partly-modifiable risk factors Modifiable risk factors: glucocorticoids, low
(Ethnicity, age, and (Estrogen deficiency, low level of physical activity, smoking, caffeine,
increased calcium excretion, diet poor in
gender) testosterone, Malnutrition) calcium and vitamin D, and alcohol

Kucharska, E. (2017). Osteoporosis: a Social Problem in the Elderly Population. Horizons of Education, 16 (40), 37-57. DOI: 10.17399/ HW.2017.164003.
Remodelling Tulang

• Modelling : pertumbuhan tulang sesuai ukuran dan

bentuk
• Remodelling: pergantian tulang lama dengan yang baru
melalui proses aktivasi, resorpsi, formasi
• Osteoporosis= Resorpsi>formasi
From: www.medscape.com © 2010, Medscape.
Diagnosis Osteoporosis

WHO:
• normal: T score ≥ -1.0
• osteopenia T score antara
-1.0 dan -2,5
• Osteoporosis T score ≤ -2,5
• Osteoporosis berat : T
DXA score ≤ -2,5 dengan
riwayat fraktur fragilitas
 SARCOPENIA
Tubuh yang kurus, kekuatan otot dan kelemahan
merupakan factor yang dapat dipertimbangakn untuk
mendefinisikan sarcopenia pada lansia
Body composition and inflammaging. Body composition is determinant on the inflammatory status. The
expansion of the adipose tissue (specially visceral) leads to increased recruitment of blood monocytes and
their polarization to inflammatory cells (M1 phenotype). Simultaneously, the loss of lean mass that occurs
with aging, particularly skeletal muscle, an important source of anti-inflammatory myokines in response to
contraction (or reduced physical activity, or both), may lead to an imbalance between pro vs. anti-
inflammatory cytokines that culminates in inflammaging and its propagation to all organs
Journal of Science in Sport and Exercise (2019) 1:97–115
 Sarcopenia was originally defined as an age-associated loss of Table 1
SARC-F Screen forSARC-F Screen for Sarcopenia
SARCOPENIA
scle mass.1,2 Recently a number of European and international Sarcopenia

ups have redefined sarcopenia as being a decline in muscle Component Question Scoring
ction (either walking speed or grip strength) associated with loss Strength How much difficulty do you None ¼ 0
muscle mass.3e5 This approach has been validated.6,7 Sarcopenia have in lifting and Some ¼ 1
ds to disability, falls, and increased mortality.8e16 Loss of muscle carrying 10 pounds? A lot or unable ¼ 2
Assistance in How much difficulty do you None ¼ 0
ength and aerobic function are 2 of the hallmarks of frailty.17e21
walking have walking across a room? Some ¼ 1
copenia has been linked to an increased prevalence of osteopo- A lot, use aids, or
is, thus further increasing its propensity to produce hip unable ¼ 2
ctures.22e27 Rise from a chair How much difficulty do you None ¼ 0
Although osteoporosis has been classically diagnosed by have transferring from Some ¼ 1
a chair or bed? A lot or unable without
asuring bone mineral density, it has been recognized that help ¼ 2
number of other factors play into the role of diagnosing the Climb stairs How much difficulty do you None ¼ 0
pensity to have a fracture.28,29 This is particularly true in older have climbing a flight Some ¼ 1
sons with diabetes mellitus who often have good bone mineral of 10 stairs? A lot or unable ¼ 2
Falls How many times have you None ¼ 0
nsity but weak bones, and this is coupled with an increase in
fallen in the past year? 1e3 falls ¼ 1
copenia.30e33 This has led to the concept that the questions 4 or more falls ¼ 2
ociated with the Fracture Risk Assessment Tool (FRAX) (www.shef.
The scores range from 0 to 10, with 0 to 2 points for each component.
uk.FRAX) may be sufficient to screen for osteoporosis. Two studies Our preliminary studies have suggested that a score equal to or greater
Age and Ageing 2019; 48: 16–31
e confirmed that bone mineral density does not need to be than 4 is predictive of sarcopenia and poor outcomes.
Editorial / JAMDA 14 (2013) 531e532
 Fig. 1. AWGS 2019 algorithm for sarcopenia.

© 2019 published by Elsevier. This manuscript is made available under the Elsevier user
license https://www.elsevier.com/open-access/userlicense/1.0/
 Evolutionary Perspectives on the Developing Skeleton

Peak Bone Mass and Functional Capacity

Yang mempengaruhi peak bone mass :

FIGURE 1 | Changes in bone mineral mass across the life cycle. Bone mineral
• Sex dan Ras (70-80%)
mass increases during growth and reaches a plateau, referred to as peak bone
• Life style (20-30%) : calcium, Vit D,
mass, in young adulthood. Women lose bone rapidly in the first few years of
the menopausal transition, and then both men and women continue to lose
merokok, aktivitas fisik, dll
bone gradually in older age. For adults, low bone mass, or osteopenia, is
defined as 1–2.5 standard deviations below peak bone mass; osteoporosis is
Kehilangan massa tulang: 0,5-1 %/tahun
defined as bone mass <2.5 standard deviations below peak bone mass. With
suboptimal lifestyle factors, failure to achieve optimal peak bone mass reduces
Menopause: 1-2 %/tahun
the age of onset of osteopenia or osteoporosis given the usual age-related
Frontiers in Endocrinology
bone mass. Reproduced from Weaver | www.frontiersin.org,
et al. (7) underMarch 2020 | Volume
the Creative 11 | Article 99
Commons H. T. Viljakainen.Proceedings of the Nutrition Society(2016),75, 415–419
 OSTEOSARCOPENIA

Prevalence 5–40% in osteosarcopenia across inpatient and community settings. High risk
groups such as those with falls or fractures show the greatest prevalence rates (27.2–40 %)2.
1.http://www.magicalhealth.co.in/wpcontent/uploads/2016/03/bone-strength.jpg 2. B. Kirk, et al. Maturitas 140 (2020) 27–33
OSTEOSARCOPENIA
Muscle-Bone Cross Talk

Risk factors, muscle-bone cross talk, and the pathophysiology of osteosarcopenia. FGF-2, fibroblast growth
factor-2; IGF-1, insulin-like growth factor-1; VEGF, vascular endothelial growth factor
Kirk Ben, et all. Osteosarcopenia: A case of geroscience. Aging Medicine. 2019;2:147–156.
 Falls are Multifactorial

Intrinsic Factors Extrinsic Factors

Medical Medications
conditions
Impaired vision
and hearing Improper use of
FALLS assistive devices

Age related
changes Environment
C. Bree Johnston, MD MPH , Copyright May 2001
Algoritme Diagnosis Osteosarcopenia

Clinical algorithm to diagnose and manage osteosarcopenia. ALM, appendicular lean

mass; BMD, bone mineral density; DXA, dual-energy X-ray absorptiometry.
B. Kirk, et al. A clinical guide to the pathophysiology, diagnosis and treatment of osteosarcopenia Maturitas 140 (2020) 27–33
Penatalaksanan Osteosarcopenia

Fig.. Osteosarcopenia: risk factors, pathophysiology and treatment options.

B. Kirk, et al. A clinical guide to the pathophysiology, diagnosis and treatment of osteosarcopenia
Maturitas 140 (2020) 27–33
Uchitomi, R., Oyabu, M., & Kamei, Y. (2020). Vitamin D and Sarcopenia: Potential of Vitamin D Supplementation in Sarcopenia Prevention and Treatment. Nutrients,
12(10), 3189. https://doi.org/10.3390/nu12103189
Clinical outcomes Fractures

Osteosarcopenia increased risk of falls (OR 2.83–3.63; p < .05) and

fractures (OR 3.86 to 4.38; p < .05) in older, compared with non-
osteosarcopenic individuals when using various sarcopenia definitions [1].
Osteosarcopenic individuals were at a 1.8 greater risk of mortality
compared to non-osteosarcopenic patients [2].

Another prospective study in community-dwelling older adults found an

increased mortality risk in osteosarcopenic older persons (RR= 1.49, 95 %
CI: 1.01–2.21) compared to those without sarcopenia or osteopenia [3]
1.W. Sepúlveda-Loyola, et all, The joint occurrence of osteopenia/osteoporosis and sarcopenia (osteosarcopenia): de- finitions and characteristics, J. Am. Med. Dir. Assoc. (2019).. 2. J. Il Yoo, et all.
Osteosarcopenia in patients with hip fracture is related with high mortality, J. Korean Med. Sci. 33 (2018), https:// doi.org/10.3346/jkms.2018.33.e27. 3.S. Balogun, et all. Prospective associations of
osteosarcopenia and osteodynapenia with incident fracture and mortality over 10 years in community-dwelling older adults, Arch. Gerontol. Geriatr. 82 (2019) 67–73,
https://doi.org/10.1016/j.archger.2019. 01.015.
 SIMPULAN

v Osteoporosis dan Sarcopenia sering terjadi secara bersamaan pada lansia, dikenal sebagai Osteosarcopenia
v Osteosarcopenia: sindrom muskuloskeletal progresif yang menyebabkan peningkatan risiko jatuh, fraktur,
rawat inap è meningkatkan morbiditas, mortalitas, beban sosial dan biaya kesehatan.
v Patofisiologi: multidimensi dengan bukti kuat untuk faktor ketidakaktifan fisik, adipositas ( infiltrasi lemak)
dan status gizi buruk, polimorfisme genetik, ketidakseimbangan hormonal dan faktor endokrin lainnya
mempengaruhi kesehatan otot dan tulang.
v Latihan resistensi dan keseimbangan yang progresif serta meningkatkan asupan nutrisi (protein, vitamin D,
kalsium, dan kreatin) adalah strategi berbasis bukti untuk mengurangi osteosarkopenia.
v Terapi farmakologi anti-resorptive (denosumab, biphosphonantes) dan Anabolik diharapkan memiliki efek
ganda baik meningkatkan masa tulang maupun otot
TERIMA KASIH

MATUR SUKSME