While sarcopenia and frailty independently contribute to functional impairment and disability, the combined impact resulting from their interplay is unclear. We investigated if functional, physical, cognitive, and nutritional measures were more adversely affected in community-dwelling older adults who were screened positive for both frailty and sarcopenia.
Using the FRAIL (≥1) and SARC-F (Strength, Assistance with walking, Rising from a chair, Climbing stairs, and Falls) (≥1) scales for screening, we categorized 200 participants (age, 67.9±7.9 years) as combined (both positive, 12.5%), intermediate (either positive, 25.5%), or robust (both negative, 62%).
Comparisons of the three groups showed that the combined group had significantly worse functional ability (Frenchay Activities Index and Modified Barthel Index), physical performance (knee extension, gait speed, and Short Physical Performance Battery score), cognition/mood (Chinese Mini-Mental State Examination [CMMSE] score and Geriatric Depression Scale), and nutrition (Mini Nutritional Assessment [MNA] score) (p<0.05, one-way analysis of variance). Post-hoc comparisons revealed similar findings between the combined and robust groups, except for knee extension and CMMSE scores. Only MNA scores were significantly lower between the intermediate and robust groups.
Functional ability, physical performance, and nutrition were more adversely affected in our study population of community-dwelling older adults who screened positive for both frailty and sarcopenia than in those who screened positive for either or neither, supporting the use of community screening for early detection and intervention for both frailty and sarcopenia as opposed to either alone.
Frailty is a modern geriatric giant,
Sarcopenia is a related but a distinct condition
While sarcopenia and frailty independently contribute to functional impairment and disability, the combined impact resulting from the interplay between these two conditions is unclear. Sarcopenia and frailty have generally been studied separately in isolation rather than in parallel.
Thus, we investigated whether functional, physical, cognitive, and nutritional measures were more adversely affected in community-dwelling older adults who were screened positive for both frailty and sarcopenia than in those who were screened positive for either condition alone. If true, this finding would support the use of community screening for the early identification of both conditions to facilitate early intervention and reduce poor health outcomes.
We studied 200 cognitively intact and functionally independent community-dwelling adults aged ≥50 years who participated in the “Longitudinal Assessment of Biomarkers for characterization of early Sarcopenia and predicting frailty and functional decline in community-dwelling Asian older adults Study.” The details of the study have been described previously.
We used the five-item self-report FRAIL scale to screen for the presence of frailty.
We collected demographic data and information on vascular risk factors, including hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, ischemic heart disease, stroke, transient ischemic attack, and smoking. We evaluated functional ability using the Modified Barthel Index (MBI) for bADL,
Regarding physical performance, we measured the upper and lower limb muscle strength and gait speed while walking a distance of 4.5 m; we also used the Short Physical Performance Battery (SPPB).
We assessed cognition using the CMMSE,
Descriptive data are presented as mean±standard deviatin or median (interquartile range, IQR) for quantitative variables and as absolute and relative frequencies for categorical variables. Inferential statistics were applied to compare differences in functional, cognitive, physical performance, and nutritional states between the three groups. We used one-way analysis of variance with Bonferroni correction for post-hoc comparisons; the Kruskal-Wallis test for parametric and non-parametric continuous variables; and the chi-square test for categorical variables. SPSS Statistics for Windows, version 23.0 (IBM, Armonk, NY, USA) was used for data analysis. All statistical tests were two-tailed, with the level of statistical significance set at 5%.
Our study population comprised 200 older adults with a mean age of 67.9±7.9 years, with female predominance (68.5%), and mostly Chinese ethnicity (92%). Using the FRAIL and SARC-F scales for screening, we identified 10 pre-frail/frail and 41 sarcopenic subjects. The robust, intermediate, and combined groups comprised 124 (62%), 51 (25.5%), and 25 (12.5%) subjects, respectively. Age increased and educational level decreased moving from the robust to intermediate and combined groups. We observed no significant differences in sex, ethnicity, or cardiovascular risk factors. Not surprisingly, the combined group scored the highest on the FRAIL and SARC-F scales, followed by the intermediate and robust groups (both p<0.001) (
The combined group performed significantly worse in functional measures of bADL (100 [IQR 100–100] vs. 100 [IQR 100–100] vs. 100 [IQR 95–100]; p=0.002) and on the Frenchay Activities Index (32.77±4.50 vs. 31.55±6.09 vs. 29.80±5.24; p=0.025), but not on iADL, than other groups. For physical performance measures, the combined group had significantly worse SPPB scores (12 [IQR 11–12] vs. 12 [IQR 11–12] vs. 11 [IQR 8–12]; p=0.013), knee extension (36.22±7.55 vs. 33.63±7.88 vs. 32.63±7.84 kg; p=0.031), and gait speed (1.49±0.26 vs. 1.49±0.26 vs. 1.27±0.37 m/s; p=0.01). We also observed a significant decrease in CMMSE scores from the robust to the intermediate/combined groups. Regarding nutritional measures, the MNA score was significantly lower in the intermediate and combined groups (27.40±1.77 vs. 26.52±1.99 vs. 25.98±2.33; p=0.001), but we observed no significant differences in vitamin D levels and BMI. Post-hoc comparisons between the combined and robust groups revealed similar findings, except for knee extension and CMMSE scores. In contrast, only MNA scores were significantly lower in the post-hoc comparisons between the intermediate and robust groups (
Conventionally, sarcopenia, being organ-specific, has been researched in the basic science domain, whereas frailty has been predominantly applied in clinical settings.
The results of our study support this approach in two ways. First, they demonstrate that the community proportion of older adults with both frailty and sarcopenia is not low. While the prevalence of 12.5% observed in our study is half of that reported in an earlier study of medical outpatients,
It is interesting to consider the theoretical framework that underpins this observation. Consistent reports of sarcopenia as opposed to the converse situation of sarcopenia with concomitant frailty in frail older adults supports the premise that sarcopenia may precede physical frailty.
Another finding was the lower CMMSE scores in the intermediate/combined group. A recent meta-analysis showed that sarcopenia was independently associated with cognitive impairment.
Taken together, our study results add to the growing body of evidence regarding the intertwined relationship between sarcopenia and frailty by corroborating the deleterious impact of the combination of sarcopenia and frailty on functional, physical, cognitive, and nutritional domains beyond those for either condition alone.
This study had some limitations. For instance, we included community-dwelling older adults who were functionally independent and had high baseline scores on the functional assessment scale. As such, small differences in function may not be detected by these scales owing to the ceiling effect. This limitation probably accounted for the lack of differences in iADL scores among the three groups.
In conclusion, functional ability, physical performance, and nutrition were more adversely affected in our study population of community-dwelling older adults who screened positive for both frailty and sarcopenia than in those positive for either or neither condition. Our findings support screening for both sarcopenia and frailty among community-dwelling adults to effect interventional measures to preserve function and avoid disability.
The researchers claim no conflicts of interest.
This study was funded by a 2013 Lee Foundation Grant. We thank the following Senior Activity Centers (SACs): Wesley SAC, Care Corner SAC, Xin Yuan Community Service, Potong Pasir Wellness Centre, Tung Ling Community Services (Marine Parade and Bukit Timah), Viriya Community Services-My Centre@Moulmein, House of Joy) and the study participants who have graciously consented to participate in the study.
Conceptualization, WSL, YYD, LT; Data Curation, AY, CNT, SY; Formal Analysis, WSL, HXL, CNT; Funding Acquisition, WSL, YYD, Methodology, WSL, YYD; Project Administration, WSL; Supervision, WSL; Visualization, WSL, HXL, Writing-original draft, WSL, YYD, HXL; Writing-review and editing, WSL, YYD, HXL.
Baseline characteristics
Robust (n=124) | Intermediate (n=51) | Combined (n=25) | p-value | |
---|---|---|---|---|
Demographics | ||||
Age (y) | 67.35±7.77 | 68.10±8.11 | 70.52±7.57 | 0.18 |
Sex, female | 83 (67) | 34 (67) | 20 (80) | 0.42 |
Chinese ethnicity | 112 (90) | 49 (96) | 23 (92) | 0.48 |
Education (y) | 9.81±4.51 | 8.39±5.53 | 6.48±4.17 |
0.004 |
Cardiovascular risk factors | ||||
Diabetes | 22 (18) | 13 (26) | 8 (32) | 0.21 |
Hypertension | 58 (47) | 25 (49) | 13 (52) | 0.88 |
Hyperlipidemia | 85 (69) | 30 (59) | 17 (68) | 0.46 |
Atrial fibrillation | 6 (5) | 2 (4) | 1 (4) | 0.96 |
Ischemic heart disease | 3 (2) | 0 (0) | 1 (4) | 0.44 |
Stroke/transient ischemic attack | 2 (2) | 3 (6) | 0 (0) | 0.18 |
Smoking | 5 (4) | 2 (4) | 1 (4) | 0.49 |
Frailty/sarcopenia | ||||
FRAIL score | 0 (0–0) | 0 (0–0) |
1 (1–1) |
<0.001 |
FRAIL ≥1 | 0 (0) | 10 (20) |
25 (100) |
<0.001 |
SARC-F score | 0 (0–0) | 1 (1–1) |
2 (1–2) |
<0.001 |
SARC-F ≥1 | 0 (0) | 41 (80) |
25 (100) |
<0.001 |
Values are presented as mean±standard deviation or number (%) or median (interquartile range).
p<0.01, compared with the robust group (post-hoc test).
Outcome characteristics
Robust (n=124) | Intermediate (n=51) | Combined (n=25) | p-value | |
---|---|---|---|---|
Functional ability | ||||
bADL (0–100) | 100 (100–100) | 100 (100–100) | 100 (95–100) |
0.002 |
iADL (0–23) | 23 (23–23) | 23 (23–23) | 23 (23–23) | 0.089 |
FAI (0–45) | 32.77±4.50 | 31.55±6.09 | 29.80±5.24 |
0.025 |
Physical performance | ||||
SPPB (0–12) | 12 (11–12) | 12 (11–12) | 11 (8–12) |
0.013 |
Gait speed (m/s) | 1.49±0.26 | 1.49±0.26 | 1.27±0.37 |
0.001 |
Knee extension (kg) | 36.22±7.55 | 33.63±7.88 | 32.63±7.84 | 0.031 |
Grip strength (kg) | 22.44±6.70 | 21.02±5.75 | 19.57±6.70 | 0.089 |
Cognition | ||||
CMMSE (0–28) | 26.44±1.66 | 25.68±1.79 | 25.84±1.84 | 0.042 |
Mood | ||||
GDS (0–15) | 0 (0–1) | 0 (0–1) | 1 (0–5) | 0.083 |
Nutritional measures | ||||
MNA (0–30) | 27.40±1.77 | 26.52±1.99 |
25.98±2.33 |
0.001 |
Vitamin D (ng/mL) | 29.64±9.52 | 29.20±8.77 | 28.25±11.90 | 0.809 |
BMI (kg/m2) | 23.94±3.54 | 23.96±4.11 | 24.16±4.34 | 0.963 |
Values are presented as median (interquartile range) or mean±standard deviation.
bADL, basic activities of daily living; iADL, instrumental activities of daily living; FAI, Frenchay Activities Index; SPPB, Short Physical Performance Battery; CMMSE, Chinese Mini-Mental State Examination; GDS, Geriatric Depression Scale; MNA, Mini-Nutrition Assessment; BMI, body mass index.
p<0.01,
p<0.05, compared with the robust group (post-hoc test).