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COMPARISON OF CURRENT SARCOPENIA CLASSIFICATION CRITERIA IN OLDER NEW ENGLAND WOMEN

 

S.G. Slezak1, K.B Mahoney1, E.N.Renna1, I.E. Lofgren2, F. Xu1, D.L. Hatfield1, M.J. Delmonico1

 

1. Department of Kinesiology, University of Rhode Island, Kingston, Rhode Island, USA, 02881; 2. Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island, USA, 02881

Corresponding Author: Matthew Delmonico, 25 West Independence Way, Kingston, RI 02881,USA, delmonico@uri.edu, Phone: 401-874-5440
J Aging Res Clin Practice 2017;6:163-167
Published online August 31, 2017, http://dx.doi.org/10.14283/jarcp.2017.21

 

Abstract

Objectives: To evaluate the prevalence of sarcopenia in a sample of older, sedentary women using criteria from the European Working Group on Sarcopenia in Older People (EWGSOP), the International Working Group (IWG), and the Foundation for the National Institutes of Health Sarcopenia Project (FNIHSP). Design: Cross-sectional analysis. Setting and Participants: Community-dwelling women (n = 61) aged 71.9 ± 4.6 years (mean±SD) with a BMI 27.3 ± 6.0 kg/m2 who by self-report were healthy and did not exercise were recruited and evaluated for sarcopenia. Measurements: Height, weight, grip strength, gait speed, and appendicular lean mass (via segmental multi-frequency bioelectrical impedance analysis: SMF-BIA) were measured. Prevalence was reported using descriptive statistics and a Fisher’s exact test was used to analyze the distribution frequency of sarcopenia classification by different criteria. Results: In this sample 14.8% met EWGSOP criteria, 6.6% met FNIHSP criteria, and 3.3% met IWG criteria. There was a borderline significant difference in distribution frequency between EWGSOP and IWG classification criteria (p=0.053). Conclusion: The variation in sarcopenia prevalence depending on the diagnostic criteria used is consistent with previous research and there are borderline significant differences between classification criteria in this population. These data suggest the need for additional examination to determine current cut points for ALM measured by SMF-BIA, as well as which established definition of sarcopenia is appropriate for this population.

Key words: Sarcopenia, older, women, bioelectrical impedance analysis, appendicular lean mass.

 

Introduction

Sarcopenia is the progressive, naturally occurring loss of lean muscle mass that accompanies the aging process (1). Decreases in lean muscle mass have been associated with reduced physical function, osteoporosis, and loss of independence (2-4). The estimated sarcopenia related health care costs in 2000 were $18.5 billion, with $7.7 billion attributed to women, and costs continue to rise (5-8). Furthermore, US census population estimates project that by 2050 the amount of US adults over the age of 65 will double (9). The increasing healthcare costs and growing population present a serious public health problem and especially for older women as there are more women over the age of 65 (9, 10). Therefore, early detection and intervention methods are critical to alleviate the chronic effects of this condition in older women.
The prevalence of sarcopenia has previously been reported using different diagnostic criteria, and has ranged from 1-30% in samples of older community-dwelling women (11-13). However, lack of agreement among criteria presents challenges for clinicians and researchers attempting to identify sarcopenic individuals. Recently, three sets of diagnostic criteria for sarcopenia have been developed by the European Working Group on Sarcopenia in Older People (EWGSOP), the International Working Group (IWG), and the Foundation for the National Institutes of Health Sarcopenia Project (FNIHSP) (14-17). These criteria include measures of lean mass, physical function, and/or muscular strength. However, these criteria do not use consistent variables and cut points for quantifying lean mass and physical functioning, and lack overall agreement.
Few studies have reported the prevalence of sarcopenia in older community dwelling women using these three sets of diagnostic criteria. However, in 2014 Dam et al. conducted a comparison of EWGSOP, IWG, and FNIHSP sarcopenia classification criteria among the FNIHSP cohort and found large variations in prevalence depending on the classification criteria used (18). While that was a thorough investigation, participants were not recruited based on their physical activity levels and it is unclear if prevalence estimates will vary in a sedentary cohort. Therefore, the purpose of this study was to report and compare the prevalence of sarcopenia using EWGSOP, IWG, and FNIHSP criteria in a sample of older, sedentary, community-dwelling Rhode Island women.

 

Methods

Study Design and Participants

To evaluate sarcopenia prevalence, a cross-sectional analysis was performed among a sample of older, community-dwelling Rhode Island women who were recruited for an intervention trial through talks and posters at local community and senior centers, and through word of mouth. Initial screening was conducted via telephone interview to include women who were postmenopausal, aged 65-84 years, and by self-report were not involved in a regular exercise program or participation in physical activities outside of activities of daily living. Reasons for study exclusion included failure to provide informed consent, inability to speak and read English, diagnosed cognitive impairment, and the inability to safely engage in mild to moderate intensity exercise. Participants with recent major joint, vascular, abdominal or thoracic surgery were excluded. Participants who self-reported clinically diagnosed cardiovascular disease, pulmonary disease, or with an implanted pacemaker or defibrillator were excluded. Also, participants with uncontrolled diabetes, hypertension, or anemia were excluded. Any participants who reported medication changes within 3 weeks or changes to lipid lowering medication within 6 months were excluded. Trained study staff members performed all components of data collection.
Eligible participants read and signed informed consent and also completed a teach-back process, which required participants to explain learned information on the consent form back to a study staff member to ensure informed consent. Anthropometric data were then collected followed by tests to evaluate participants’ body composition, muscular strength, and gait speed. All aspects of this study took place in the Kinesiology Department on the campus of the University of Rhode Island, Kingston, Rhode Island, USA. This study was approved by the Institutional Review Board of the University of Rhode Island.

Anthropometrics

Height was measured without shoes to the nearest 0.1 cm using a Seca wall mounted stadiometer and body weight was measured without shoes to the nearest 0.1 kg using a Seca balance beam scale (Seca, Chino, CA). Height and weight were measured in duplicate and averages were used to calculate body mass index (BMI).

Body Composition

Whole and regional body composition was measured via segmental multi-frequency bioelectrical impedance analysis (SMF-BIA) using an Inbody 570 Biospace device (Biospace Co, Ltd, Korea) according to the manufacturer’s guidelines. Participants were asked to be fully hydrated, fasted for > 4 hours, and to void their bladder prior to the test. Appendicular lean mass (ALM) was calculated as the sum of lean mass in both arms and legs and expressed in kg. In accordance with EWGSOP and IWG criteria, ALM was adjusted for height expressed as meters squared, while according to FNIHSP criteria ALM was adjusted for BMI.

Muscular Strength

Isometric handgrip strength has been documented as a safe and effective method of predicting total body strength and future disability (19, 20). Muscular strength was measured via grip strength from a seated position using a Jamar Hydraulic Hand Dynamometer (J.A. Preston, Corp., Jackson, MS). Participants completed two trials per hand and the highest overall score from either hand (kg) was used for sarcopenia classification.

Gait Speed

Gait speed is an easily assessed measure that has been shown to be predictive of future disability (21). To evaluate gait speed, participants were instructed to walk a 4-meter distance at their normal walking pace (22). Two trials were completed and the fastest time (meters/sec) was used for sarcopenia classification.

Sarcopenia Classification

Sarcopenia was classified using EWGSOP, IWG, and FNIHSP criteria published previously (14-16, 18). These criteria are the most prominent among the literature; incorporate symptoms associated with sarcopenia, and have been shown to identify clinically relevant, sarcopenia-induced deficiencies in strength and physical function. The EWGSOP criteria utilize established stages of sarcopenia classification (presarcopenia, sarcopenia, severe sarcopenia), with low ALM/ht2 (< 5.67 kg/m2) and the presence of low gait speed (≤ 0.8 m/s) or low grip strength (< 20 kg) required to be considered sarcopenic. A severe sarcopenia classification requires low ALM/ht2, gait speed, and grip strength (14). Presarcopenia was defined as having low ALM/ht2 only. The IWG criteria utilizes a “yes/no” classification method, requiring individuals to be below established cut points of both gait speed (< 1.0 m/s) and ALM/ht2 (< 5.67 kg/m2) to be considered sarcopenic (15). The FNIHSP also uses established stages of sarcopenia classification: “weak with low lean mass and weak and slow with low lean mass.” In contrast to EWGSOP and IWG criteria, the FNIHSP uses ALM/BMI (< 0.512) to quantify lean mass, while also using differing cut points of gait speed (< 0.8 m/s) and grip strength (< 16 kg) (16). A “weak with low lean mass” classification required participants to be below cut points of ALM/BMI and grip strength, while a “weak and slow with low lean mass” classification required participants to be below cut points of ALM/BMI, grip strength, and gait speed. Participant data were collected and applied to these individual sets of criteria to determine the prevalence of sarcopenia within this sample.
Statistical Analysis
Descriptive statistics were used to report the baseline characteristics (means ± standard deviation) of the cohort and sarcopenia prevalence. A Fisher’s exact test was used to determine the distribution frequency of sarcopenia classification among the different sets of classification criteria. Significance was set at p ≤ 0.05. Statistical analyses were performed using SAS statistical software, version 9.3 (SAS Institute Inc., Cary, NC).

 

Results

A total of 61 Caucasian women aged 71.9 ± 4.6 years were included in the analyses. Baseline characteristics of the population are presented in Table 1. Thirteen participants were considered sarcopenic. As shown in Table 1, nine (14.8%) participants were considered sarcopenic by EWGSOP criteria, four (6.6%) were considered weak with low ALM/BMI by FNIHSP criteria, and two (3.3%) participants were considered sarcopenic by IWG criteria. Sarcopenia prevalence for all criteria combined was 21.3% with no participant counted more than once. The two participants considered sarcopenic by IWG criteria were also considered sarcopenic by EWGSOP criteria. No other participants were considered sarcopenic by two or more sets of criteria. Additionally, no participants were considered pre-sarcopenic or severely sarcopenic by EWGSOP criteria or weak and slow with low lean mass by FNIHSP criteria. A Fisher’s exact test showed borderline significant differences in distribution frequency between EWGSOP and IWG classification criteria (p=0.053). No significant differences were found between other sets of classification criteria.

Table 1 Baseline characteristics of the population (n=61)

Table 1
Baseline characteristics of the population (n=61)

Data are presented as means ± standard deviations; Abbreviations: BMI = body mass index, ALM = sum of lean mass in both arms and both legs, m/s = meters per second, EWGSOP: European Working Group on Sarcopenia in Older People, IWG: International Working Group, FNIHSP: Foundation for the National Institutes of Health Sarcopenia Projet; Participants meeting EWGSOP criteria were sarcopenic (no pre-sarcopenia or severe sarcopenia); Participants meeting FNIHSP criteria had low lean mass and weakness (no low lean mass, weakness, and low physical function); Participants meeting IWG criteria (n=2) also met EWGSOP criteria and are included in that sample (n=9)

 

Discussion

These data indicate the large variation in sarcopenia prevalence depending on the classification criteria used. Within this sample, sarcopenia prevalence ranged from 3.3% to 14.8% with borderline significant differences in distribution frequency between EWGSOP and IWG criteria. This wide variation in prevalence is consistent with the findings of Cruz-Jentoft et al. (2014), who through systematic review found sarcopenia prevalence in community-dwelling women ranged from 1-30% when estimated using EWGSOP criteria (13). However, the authors expressed difficulty in comparing results of many studies due to inconsistent methodologies used in studies included in their review. In comparison, Patel et al. (2015) applied EWGSOP criteria to data from the Hertfordshire Cohort Study, which included 1,022 older women (23). While the baseline characteristics of that cohort closely resemble those of our sample, that study reported a 7.9% sarcopenia prevalence compared to our result of 14.8% using EWGSOP criteria. While those differences may be attributed to sample size, it may also be due to differences in grip strength. That study reported a mean grip strength of 26.3 kg while our results show a mean grip strength of only 17.6 kg, which is below the EWGSOP cut point for weakness in older women. This is consistent with the findings of Beaudart et al. (2014) who found grip strength criteria to largely influence sarcopenia prevalence (24). While there are considerably more data regarding sarcopenia prevalence using EWGSOP criteria, few studies have utilized IWG and/or FNIHSP criteria. However, Dam et al. in 2014 applied FNIHSP, IWG, and EWGSOP criteria to data collected from 2,950 older women through 9 different studies. That analysis found 2.3% of women to be weak and slow by FNIHSP criteria, 11.8% were sarcopenic by IWG criteria, and 13.3% were sarcopenic by EWGSOP criteria (18). Those researchers also noted that participants that had low lean mass by the ALM/BMI method were heavier with larger BMIs compared to those with low ALM/ht2. Our findings agree with those results, as every participant in our study who fell below the ALM/BMI cut-point had a BMI > 30 kg/m2. These results suggest that the FNIHSP criteria may be more effective at identifying sarcopenia in obese populations, while EWGSOP and IWG criteria may be more appropriate in non-obese populations. While our prevalence results vary with the findings of Dam et al. (18), possibly due to differences in sample size, it is evident that EWGSOP criteria consistently classify greater percentages of older women as sarcopenic when compared to FNIHSP and IWG criteria, and ALM adjusted for BMI may be the more effective method of identifying sarcopenia in obese, older women.
Reasons for variations in prevalence have recently been investigated by Masanés et al. (2016), who found that modification of EWGSOP lean mass cut points greatly varied sarcopenia prevalence, while modifying grip strength and gait speed cut points elicited little change in prevalence (25). However, those findings suggest that a large percentage of this population may have already been below the cut points for grip strength, as a combination of low ALM and weakness is required for a sarcopenia diagnosis by EWGSOP criteria.
Consequently our data show that the majority of participants considered sarcopenic by EWGSOP criteria had low ALM and weakness (n = 9), while no participants had low ALM accompanied with low gait speed. This also explains our low prevalence reported when using IWG criteria, which omits grip strength, and has a more liberal gait speed cut point. This suggests that inclusion of grip strength in sarcopenia diagnostic criteria may result in relatively higher prevalence estimates, and further screening for hand ailments (i.e. arthritis) may be necessary for accurate sarcopenia classification.
While the EWGSOP criteria are most prevalent within the literature, it does not take fat or body mass into consideration and may fail to classify those with sarcopenic obesity, as shown in our results (2). Moreover, the FNIHSP criteria may be ideal for the older female population as following menopause women typically experience increases in fat mass, which could prevent diagnosis by EWGSOP or IWG criteria (26). Our results underscore the discrepancies between different sets of sarcopenia classification criteria and therefore, inclusion of multiple sets of criteria may simplify the comparison of results and aid in determining population appropriate diagnostic criteria.
A small sample size, and a low number of participants who met classification criteria limited this study. A further limitation was the use of SMF-BIA to assess ALM rather than dual-energy x-ray absorptiometry (DXA). However, SMF-BIA has been found to be agreeable with DXA for measuring ALM in women, and BIA specific ALM/ht2 cut points presented by the EWGSOP were developed using prediction equations not applicable to the InBody 570 device (27, 28). Despite limitations, this study is novel in that EWGSOP, IWG, and FNIHSP criteria were all applied to the same sample of older, sedentary women from the same community. This allowed for the comparison of criteria without the need to adjust for sex, ethnicity, or activity levels. This study demonstrates the variability and limitations of current sarcopenia classification criteria, especially in obese individuals, and indicates the need for future research to develop current, criteria-appropriate cut-points for the measurement of ALM by SMF-BIA in this population to complement these findings.

 

Funding: This study was funded by the University of Rhode Island College of Human Sciences and Services.

Conflict of Interest: Matthew Delmonico has received research grants from the University of Rhode Island. All other authors report no conflicts of interest.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent: Informed consent was obtained from all individual participants included in the study.

 

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PREVALENCE OF SARCOPENIA IN ELDERLY WITH DEMENTIA INSTITUTIONALIZED: A MULTICENTER STUDY

 

 

C.M. Sarabia Cobo1, V. Pérez2, C. Hermosilla2, M.J. Nuñez2, P. de Lorena2

 

1. Cantabria University, Spain; 2. CR Santa Lucía, Spain

Corresponding Author: Sarabia-Cobo Carmen María, Ph.D, RN, MSN, Professor of Gerontological Nursing, Nursing School. Cantabria University, Spain, Avda. Valdecilla s/n 39011, Santander, Cantabria, Spain, +34 942 20 22 39, carmen.sarabia@unican.es

 

Abstract

Objective: Determine the prevalence of sarcopenia, applying the new diagnostic criteria in a group of institutionalized elderly with dementia, analyzing the possible association between sarcopenia, degree of dementia, and nutritional status. Method: Transversal, descriptive, multicenter study with 189 subjects diagnosed with dementia in middle phase. The current criteria for sarcopenia were assessed through several tests (bioimpedance, dynamometry, and physical performance tests). Nutritional status through the Mini Nutritional Assessment (MNA) was also assessed. Parametric tests (Student t test and ANOVA) were performed to compare the significant differences between the two stages of dementia according to gender, age, presence of sarcopenia, and MNA, among other tests. Results: 74% were female and the mean age was 82.3 years. Of the participants, 57.1 % were in stage 5 and 42.9 % in stage 6 in GDS. The MNA showed that 54.6 % had risk of malnutrition, 36.2 % were normal, and 9.2% had malnutrition. Of the subjects, 68.78% have shown signs of sarcopenia. There were significant differences for sarcopenia according to the phase of dementia and between sarcopenia and malnutrition status. Conclusions: To our knowledge it is the first study of its kind in Spain under the new criteria for diagnosis of sarcopenia. There seems to be a high percentage of sarcopenia among institutionalized elderly with dementia and this in turn appears to be related to dementia status and states of malnutrition. This syndrome has a significant impact on the population, so early detection is crucial; more studies of this type are required.

 

Key words: Sarcopenia, malnutrition, dementia, nutritional assessment, older.

 

Introduction

The World Health Organization (WHO), in its latest study on nutrition in aging, identified the elderly population as a nutritionally vulnerable group, due to their own anatomical and physiological aging changes process (1).

Among changes brought about by the aging process is the loss of muscle mass and strength and decreased physical function. The loss of muscle mass associated with aging is called primary sarcopenia (2). The term sarcopenia has undergone several definitions (3) with no clear consensus on this issue; as a result the European Working Group on Sarcopenia in Older People (EWGSOP) developed consensus diagnostic criteria of age-related sarcopenia in 2010 (4). Sarcopenia is defined as “a syndrome characterized by a progressive and generalized loss of skeletal muscle mass and strength with risk for adverse outcomes such as physical disability, poor quality of life and mortality.” The confirmation EWGSOP establishes several criteria for diagnosing sarcopenia: low muscle mass, loss of muscle strength, and reduced physical performance. Sarcopenia should be associated with at least the first one and one of the other two.

Regarding the prevalence, data are not conclusive because of the lack of consensus criteria listed above (5, 6). Studies estimate that this varies from 3 to 30% depending on the variables used to establish the diagnosis (6-9). Estimates of the importance of their presence lie in the negative effect of sarcopenia on the autonomy of the elderly, significantly increasing the risk of falls and other complications (10). This causes an increase in morbidity and vulnerability of this group.

Given that the studies are not conclusive as to the etiology or the diagnosis criteria, (11) need further research in this regard especially as this is a very prevalent disease for the elderly population and leads to increased vulnerability and fragility, such as dementia.

The overall prevalence of dementia is currently estimated at 24 million; studies show that the figure will double by 2040 (12). Alzheimer’s disease (AD) is the most common primary dementia. It’s characterized by progressive cognitive decline, is irreversible, and no treatment currently exists. The AD has several phases in which patients increase their dependence and need for care by others. The terminal phase of the disease results in prostration, with patients becoming bedridden and totally dependent. Studies show that the nutritional status of institutionalized patients with AD is worse than those who are also institutionalized at the same age but have no dementia (13, 14).

So far there are few prevalence studies applying the new diagnostic criteria for sarcopenia and even fewer among the institutionalized elderly with dementia. The main objective of this study was to determine the prevalence of sarcopenia, applying the criteria and the diagnostic algorithm proposed by EWGSOP, in a group of institutionalized elderly with AD in seven senior centers in different parts of Spain, analyzing the possible association between sarcopenia, degree of dementia, and nutritional there is a review of a few trusted and qualitative status.

 

Material and methods

Transversal, descriptive and multicenter study. The sample consisted of 189 subjects diagnosed with probable AD (by the relevant departments of neurology) at seven residential centers located in seven cities in Spain (belonging to the same foundation), seniors 65 years or older, of both sexes. Those subjects were selected in evolutionary stages means (levels 5 and 6 of the Global Deterioration Scale scales) and Functional Assessment Staging (GDS and FAST, respectively) (15, 16).

For the diagnosis of sarcopenia, following the criteria of EWGSOP, mass and muscle strength and physical performance should be evaluated. According to the same EWGSOP, all parameters to measure the three necessary criteria were selected for this study: (a) analysis of bioimpedance to mediate muscle mass (discarding anthropometric measurements because the report “Anthropometric measurements are vulnerable to error and not recommended for routine use in the diagnosis of sarcopenia” ) being used appliance model Tanita BC- 418®; (b) force manual to measure pressure by manual muscle strength dynamometer (Takei TKK digital dynamometer model 5401 ® – range 5-100 kg ), carrying two alternative attempts with each hand in a standardized position, standing if possible, with arms parallel to the body without contact; (c) series of short physical performances (SPPB) to measure physical performance.

The nutritional status of subjects were also assessed through the scale Mini Nutritional Assessment (MNA), with three possible diagnoses: Normality, Risk of malnutrition and Malnutrition. This test is usually harvested in the clinical history of the residents within the Comprehensive Geriatric Assessment (GA) and is reassessed every three months in patients with dementia. There is a specific protocol for the preparation of the Integral Geriatric Value and MNA which is followed by all study centers.

Data collection was performed by the nursing staff of the centers during September and October 2013.

Consent was obtained to conduct the study: the general management of the foundation, residential centers, the ethics committee attached to the main residential center (in Madrid), and all participants and/or guardians were properly informed.

The statistical treatment of the data was performed with SPSS 19.0 software, conducted a descriptive analysis and a frequency depending on each variable. Although you can assume normal distribution for the number of subjects (N > 30) Kolmogorov- Smirnov (KS) was performed to examine the normality and the Levene test to assess the homogeneity of variance. Significance tests were performed using Chi square test ( χ2 ) to evaluate possible differences between nominal variables (the evolutionary stage of dementia by sex, diagnosis of sarcopenia by sex, dementia status, and the presence of sarcopenia) and Student t (when parametric criteria were met) to assess the stage of dementia according to age, diagnosis of sarcopenia and age, and ANOVA to assess association between stage of dementia and MNA, and between the presence of sarcopenia and stage MNA (α = 0.05 in all cases).

 

Results

Of the 189 cases, 74% were women, the mean age was 82.3 years (95% CI: 77.1 to 83.60, range: 69-101). 57.1% were in stage 5 and 42.9 % in stage 6 GDS.

The KS test indicated normality (KS = 0.083, p = 0.200) and Levene indicated homoscedasticity (17.27, p=0.09).

No significant differences between the evolutionary stage of dementia was found by sex (χ2 = 0.687, p = 0.123) or age (t = 0.541, p= 0,214). MNA results indicated that 54.6% of the sample had risk of malnutrition, 36.2 % were normal, and 9.2% had malnutrition. There were no significant differences in response to the phase of dementia.

Sarcopenia was diagnosed in 68.78% of patients, of whom 47.8 % met all three criteria and 31.2 % met two criteria (would be considered mild sarcopenia). There was no significant differences in the diagnosis of sarcopenia by sex, but there was by age (χ2 = 0.325, p = 0.00).

Analyses indicated that depending on the stage of dementia weren´t found significant differences for the MNA (F = 123.2, p> 0.05) but were found for the presence of sarcopenia (χ2 = 0.852, p = 0.00). Significant differences between sarcopenia and malnutrition status were also found (F = 0.556, p = 0.01), but not for the Risk of Malnutrition status and Normality status.

Table 1 shows the most relevant results of bioimpedance (Fat Mass –FM- and Fat Free Mass –FFM-) is based on the diagnosis of sarcopenia, appreciating that there are no significant differences. Also no significant differences between the percentages of FM and FFM depending on the stage of EA were found.

 

Table 1: Percentage of FM and FFM in relation with sarcopenia diagnosis.

 

Discussion

The average profile of the sample was that of a woman of 82 years and stage 5 GDS/FAST AD. No significant differences by age or sex, depending on the type of stage which coincides with the literature when listing these phases, were found to dementia (12). Regarding nutritional status, we know that MNA is a validated and widely used instrument in the geriatric (17) population and older with dementia as indicated by a study of Walk et al., in which the authors indicated a good correlation between MNA and GDS stage/FAST dementia (18). However it should be noted that people with cognitive impairment often respond to caregivers, but this instrument is incomplete at least partially biased to pick a section of subjective perception in patients with dementia. Yet the results found in this study are similar to others conducted in institutionalized persons with dementia (19, 20).

The high percentage of sarcopenia found (68.78%) is very striking compared with other recent research on the population (healthy most of the time without disease or cognitive impairment) (5-9). There is a study in Spain in the hospitalized older population (n = 205) having an even slightly higher (76.4%) (21) similar percentage. To our knowledge there are no studies that have examined the prevalence of sarcopenia in institutionalized elders with dementia following the latest guidelines of the EWGSOP, so there is no data with which to compare these findings. However, it is feasible that the high prevalence relates to two factors that may be associated with sarcopenia, such as weight loss and widely studied malnutrition associated with dementia, although the ethiopatogeny is not clearly understood (14, 20-22). If you add to this that the results show a statistically significant association between malnutrition and Sarcopenia and between sarcopenia and dementia we could speculate that dementia can be considered in itself a major risk factor for developing sarcopenia. However, the data should be taken with caution as they also found a significant association between sarcopenia and age that is consistent with the literature and with the definition of sarcopenia (4, 11), although, as already mentioned, the prevalence in the population is much smaller than in our study (5, 9) in our study . We could also speculate that the MNA, though incomplete to measure the nutritional status of these patients, could be considered a predictor of sarcopenia, given the association found in our study.

It is also noteworthy that the authors decided to not include anthropometric data such as BMI or skinfolds in the studio, something quite unusual in comparison with such investigations (14, 20-22). This decision was made following the recommendations of EWGSOP indicating that these measures are not the most reliable in the diagnosis of sarcopenia (4). Therefore it is considered that analysis of this data was not the subject of this study (although they are calculated in the MNA and are required for bioimpedance), the most relevant being the MNA and bioimpedance measures as recommended to be more exact (23).

In this line, we found that measures propecia topica of FM and FFM were constant regardless of the stage of dementia. This may be consistent with studies that advocate greater involvement of the FFM suggesting possible weight loss of these patients (which has not been evaluated as such in our study) is not solely due to deficits in intake, but would include metabolic and physical changes that occur in old age and seem to intensify in states of dementia (19, 24).

As for future research, the limitations of this study highlight that it would be desirable to increase the sample of patients with dementia to establish more specific diagnostic criteria for sarcopenia in this population. It is also necessary to perform studies similar to this, which we know is the first to determine the prevalence of sarcopenia in institutionalized AD patients. It would be advisable to carry out comparative studies with other populations with cognitive impairment (dementia in the community, Parkinson’s disease, mild cognitive impairment, etc.).

It would also be appropriate in a future continuation of this study to include measures of BMI and plicometry to establish the prevalence of a diagnosis of malnutrition called sarcopenic obesity, a diagnosis that goes unnoticed, to determine the nutritional status of these patients (19). A 2012 study indicates a prevalence of 15% in Spanish populations living in the community (25). In light of our data, presumably in the institutionalized elderly population with dementia, the prevalence is higher. Future research should also include the study of anthropometric measures to relate to sarcopenia, as those measures are easy to apply (the cheapest one is bioimpedance, for example) and several studies argue that they are suitable at least for screening for malnutrition (26, 27). Moreover also in the minds of the authors a future research should investigate the possibility of the significant association of two diagnostic criteria for sarcopenia (in our study were muscle strength assessed by dynamometry and physical activity through SPPB) as predictors of sarcopenia.

We can also indicate a limitation to address in future research. Having focused the study on the intermediate stages of dementia, it would be interesting to extend the sample upstream and downstream of the disease to compare the prevalence of sarcopenia in terms of phase dementia and as other studies suggest (19). This would add another research proposal to be a longitudinal study of a cohort of subjects to determine the evolution of sarcopenia and nutritional status of the individual along with dementia.

From all this we can conclude that studies should be maintained along this line, based on the agreed EWGSOP criteria, because sarcopenia has important implications for the health of the individual without even knowing pathogenesis. Because of the relevance and concern about the issue, the Spanish Society of Geriatrics and Gerontology has recently created an Observatory Sarcopenia (28). It is therefore crucial to continue delimiting the diagnostic criteria and include for this: evidence reliable, easy to apply in daily practice and that are appropriate for these patients according to their overall dependency and progressive deterioration.

 

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

 

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