Predictors of dropout from cohort study due to deterioration in health status, with focus on sarcopenia, locomotive syndrome, and frailty: From the Shiraniwa Elderly Cohort (Shiraniwa) study

Association Between Sarcopenic Obesity and Frailty Risk in Community-Dwelling Older Women With Locomotive Syndrome: A Cross-Sectional Survey

Background Concurrent sarcopenia and obesity in locomotive syndrome (LS) impair activities of daily living and decrease extremity muscle strength and motor function. However, the increased risk of frailty posed by sarcopenic obesity compared to either sarcopenia or obesity alone remains unclear. Objective To examine the association between sarcopenic obesity and frailty risk in community-dwelling older adult women with LS. Methods This cross-sectional study included 158 women aged ≥65 years with LS stage 1 (age, 74.0 yrs, body mass index, 22.7 kg/m2) according to the Japanese Orthopaedic Association criteria. Bioelectrical impedance analysis was used to measure the skeletal muscle mass index (SMI) and percent body fat (PBF). Participants were classified into four subtypes: normal (non-obesity, non-sarcopenia), sarcopenia (SMI < 5.7 kg/m2), obesity (PBF > 35%), and sarcopenic obesity (SMI < 5.7 kg/m2 and PBF > 35%). Logistic regression analysis was used to adjust for age, body mass index, back pain, knee pain, history of falls, and physical function. Results Among the participants, 52 individuals (32.9%) were classified as frailty risk. The percentage of body phenotypes was 30.4% normal, 32.9% were sarcopenia, 22.8% had obesity (RT1), and 13.9% had sarcopenic obesity. The odds ratios for frailty risk compared to normal were 3.97 (95% confidence interval (CI): 1.51 to 10.4), 1.71 (95% CI: 0.55 to 5.39), and 4.25 (95% CI: 1.34 to 13.5) for sarcopenia (RT2), obesity, and sarcopenic obesity subtypes, respectively, sarcopenia and sarcopenic obesity were significantly associated with frailty risk. Conclusion In older adult women with LS, the presence of sarcopenia or sarcopenic obesity may increase the risk of frailty; however, the addition of obesity does not always further increase this risk. Further investigation of the association between increased body fat and frailty in older adult women is warranted.

Head and neck cancer patients with geriatric deficits are more often non-responders and lost from follow-up in quality of life studies

OBJECTIVES

To identify associations between frailty and non-response to follow-up questionnaires, in a longitudinal head and neck cancer (HNC) study with patient-reported outcome measures (PROMs).

MATERIALS AND METHODS

Patients referred with HNC were included in OncoLifeS, a prospective data-biobank, underwent Geriatric Assessment (GA) and frailty screening ahead of treatment, and were followed up at 3, 6, 12 and 24 months after treatment using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Head and Neck 35. Statistical analysis for factors associated with non-response was done using Generalized Linear Mixed Models.

RESULTS

289 patients were eligible for analysis. Mean age was 68.4 years and 68.5% were male. Restrictions in Activities of Daily Living [OR 4.46 (2.04-9.78)] and Instrumental Activities of Daily Living [OR 4.33 (2.27-8.24)], impaired mobility on Timed Up and Go test [OR 3.95 (1.85-8.45)], cognitive decline [OR 4.85 (2.28-10.35)] and assisted living (OR 5.54 (2.63-11.67)] were significantly associated with non-response. Frailty screening, with Geriatric 8 and Groningen Frailty Indicator, was also associated with non-response [OR, respectively, 2.64 (1.51-4.59) and 2.52 (1.44-4.44)]. All findings remained significant when adjusted for other factors that were significantly associated with non-response, such as higher age, longer study duration and subsequent death.

CONCLUSION

Frail HNC patients respond significantly worse to follow-up PROMs. The drop-out and underrepresentation of frail patients in studies may lead to attrition bias, and as a result underestimating the effect sizes of associations. This is of importance when handling and interpreting such data.

Association between frailty and locomotive syndrome in elderly patients with lumbar spinal stenosis: A retrospective longitudinal analysis

AIMS

With the aging society worldwide, lumbar spinal stenosis (LSS) has become common, and its incidence has been increasing worldwide. Frailty and locomotive syndrome significantly overlap as disorders in older people. The current study aimed to validate the association between frailty and locomotive syndrome in patients with LSS. In particular, the involvement of frailty in locomotive syndrome following surgery was examined.

METHODS

We retrospectively reviewed the time-course data of consecutive patients aged ≥65 years who underwent lumbar spinal surgery for LSS. The locomotive syndrome stages were determined using the 25-Question Geriatric Locomotive Function Scale: stage 0, score ≤6; stage 1, score ≥7; stage 2, score ≥16; and Stage 3, score ≥24. Robust, pre-frailty, and frailty were defined as a modified frailty index-11 score of 0, <0.21, and >0.21, respectively.

RESULTS

This study included 234 patients. All patients except one were diagnosed with locomotive syndrome preoperatively. Approximately 24.8% of participants were diagnosed with frailty. LSS surgery improved locomotive syndrome regardless of frailty severity. Meanwhile, multivariable analysis indicated that frailty could significantly inhibit improvement in locomotive syndrome after surgery in old patients with LSS (estimated relative risk: 0.6; 95% confidence interval: 0.4-0.9).

CONCLUSIONS

This study first assessed the association between locomotive syndrome and frailty in patients with LSS. Locomotive syndrome could be managed effectively with surgery regardless of frailty severity in old patients with LSS. However, our findings emphasize the need to screen for frailty preoperatively in this patient group. Geriatr Gerontol Int 2024; 24: 116-122.

Association of sarcopenia, pre-sarcopenia, and dynapenia with the onset and progression of locomotive syndrome in Japanese older adults: a cross-sectional study

BACKGROUND

Sarcopenia commonly occurs in older adults with motor disorders requiring long-term care, and the clinical features of sarcopenia are associated with locomotive syndrome. Dynapenia is the age-related loss of muscle strength. However, the association of sarcopenia and dynapenia with the onset and progression of locomotive syndrome in older adults remains unknown. The current study aimed to determine the association of sarcopenia, pre-sarcopenia, and dynapenia with the onset and progression of locomotive syndrome in Japanese older adults.

METHODS

This study included older females (n = 264, 73.9 ± 5.8 years) and males (n = 92, 76.3 ± 6.1 years). Sarcopenia was defined as low muscle function and mass; pre-sarcopenia was defined as low muscle mass with normal muscle function; and dynapenia was defined as low muscle function without low muscle mass. Locomotive syndrome (stage 0-2) severity was determined using the stand-up test, the two-step test, and the 25-question geriatric locomotive function scale. Logistic regression analysis was performed to determine the relationship between sarcopenia category and locomotive syndrome stages.

RESULTS

Age (1.208, 95% confidence interval (CI) 1.124-1.298), sex (2.455, 95% CI 1.241-4.856), and BMI (1.211, 95% CI 1.077-1.361) were significant variables for determining locomotive syndrome stage ≥ 1, whereas pre-sarcopenia (0.543, 95% CI 0.331-0.891) and sarcopenia (1.664, 95% CI 1.005-2.755) were significant variables for determining locomotive syndrome stage 2.

CONCLUSIONS

Only sarcopenia was associated with locomotive syndrome progression, while low muscle mass or low muscle function was not associated with locomotive syndrome. Gaining muscle mass accompanied by an increased muscle function for older adults is warranted to prevent locomotive syndrome progression in the super-aged society.

Associations between physical frailty and living arrangements in Japanese older adults living in a rural remote island: The Shimane CoHRE study

Background

Living arrangements have been known to be associated with physical frailty. However, the prevalence of frailty and its risk factors in remote islands is not understood. We examined the association between living arrangements and objectively measured frailty among older adults living in a remote island of Japan.

Methods

Among older people living in Okinoshima, 656 older adults (75.6 ± 6.4 years) were analyzed. Physical frailty (robust, prefrailty, or frailty) was assessed using the 5-item frailty phenotype (unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity). Physical functions (muscle mass, gait speed, and grip strength) were measured objectively.

Results

The prevalence of frailty and prefrailty was 6.6% and 43.8%, respectively. Living with a spouse resulted in a significantly lower prevalence of frailty (p < 0.001) compared with other living arrangements. All objectively measured physical functions among those who lived with a spouse were significantly superior to those who lived with family or alone (p < 0.001). Multinomial logistic regression showed that living alone was significantly associated with frailty (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.07-5.24) and prefrailty (OR 1.75, 95% CI 1.14-2.69) after adjusting for all covariates.

Conclusion

The prevalence of frailty on remote islands seemed similar to that in urban areas. Older people living in remote islands might be able to maintain their physical health. Furthermore, living alone may correlate with increased risks of frailty and prefrailty. Among elderly individuals on remote islands, living with a spouse might be desirable to prevent (pre)frailty.

Risk Factors for Denosumab Discontinuation in Patients with Postmenopausal Osteoporosis

OBJECTIVES

Persistence with treatment is key to achieving successful treatment outcomes in patients with osteoporosis. We investigated risk factors for denosumab discontinuation in patients with postmenopausal osteoporosis (PMO).

METHODS

A total of 333 patients with PMO who had never received osteoporosis treatment were included in this study. Baseline demographics and retention rate of denosumab were evaluated in all patients. Univariate analysis was performed in patients divided into two groups according to whether they had continued or discontinued denosumab. A Cox proportional hazards model was used to determine risk factors for denosumab discontinuation.

RESULTS

Mean age was 80.7 years, body mass index (BMI) was 21.5 kg/m2, and T-scores for the lumbar spine and femoral neck were -2.7 and -2.8, respectively. The retention rate of denosumab at 36 months was 50.3%. Patients who continued denosumab were younger and had higher BMI, serum albumin (Alb) levels, and lumbar spine bone mineral density, and fewer vertebral fractures (VFs), compared with those who discontinued denosumab. The Cox proportional hazards model revealed that a low BMI, low serum Alb levels, and a high number of VFs are independent risk factors for denosumab discontinuation.

CONCLUSIONS

A low BMI, low serum Alb levels, and a high number of VFs were associated with denosumab discontinuation in patients with PMO.

The Association of Nutrition Quality with Frailty Syndrome among the Elderly

Low diet quality among the elderly may be correlated with some diseases, including Frailty Syndrome (FS). This decline in function restricts the activity of older people, resulting in higher assistance costs. The aim of this study was to increase knowledge of diet quality predictors. Dietary intake was assessed among 196 individuals aged 60+ years using the three-day record method and FS by Fried’s criteria. Based on the compliance with the intake recommendation (% of EAR/AI), we distinguished three clusters that were homogeneous in terms of the nutritional quality of the diet, using Kohonen’s neural networks. The prevalence of frailty in the entire group was 3.1%, pre-frailty 38.8%, and non-frailty 58.1%. Cluster 1 (91 people with the lowest diet quality) was composed of a statistically significant higher number of the elderly attending day care centers (20.7%), frail (6.9%), pre-frail (51.7%), very low vitamin D intake (23.8% of AI), using sun cream during the summer months (always 19.8% or often 39.6%), having diabetes (20.7%), having leg pain when walking (43.1%), and deteriorating health during the last year (53.5%). The study suggests the need to take initiatives leading to the improvement of the diet of the elderly, especially in day care senior centers, where there are more frail individuals, including nutritional education for the elderly and their caregivers.

Artificial intelligence model to identify elderly patients with locomotive syndrome: A cross-section study

BACKGROUND

Identifying elderly individuals with locomotive syndrome is important to prevent disability in this population. Although screening tools for locomotive syndrome are available, these require time commitment and are limited by an individual's ability to complete questionnaires independently. To improve on this limitation, we developed a screening tool that uses information on the distribution of pressure on the plantar surface of the foot with an artificial intelligence (AI)-based decision system to identify patients with locomotor syndrome. Herein, we describe our AI-based system and evaluate its performance.

METHODS

This was a cross-sectional study of 409 participants (mean age, 73.5 years). A foot scan pressure system was used to record the planter pressure distribution during gait. In the image processing step, we developed a convolutional neural network (CNN) to return the logit of the probability of locomotive syndrome based on foot pressure images. In the logistic regression step of the AI model, we estimated the predictor coefficients, including age, sex, height, weight, and the output of the CNN, based on foot pressure images.

RESULTS

The AI model improved the identification of locomotive syndrome among elderly individuals compared to clinical data, with an area under curve of 0.84 (95% confidence interval, 0.79-0.88) for the AI model compared to 0.80 (95% confidence interval, 0.75-0.85) for the clinical model. Including the footprint force distribution image significantly improved the prediction algorithm (the net reclassification improvement was 0.675 [95% confidence interval, 0.45-0.90] P < 0.01; the integrated discrimination improvement was 0.059 [95% confidence interval, 0.039-0.088] P < 0.01).

CONCLUSIONS

The AI system, which includes force distribution over the plantar surface of the foot during gait, is an effective tool to screen for locomotive syndrome.

Impact of the COVID-19 pandemic on the development of locomotive syndrome

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has affected people in various ways, including restricting their mobility and depriving them of exercise opportunities. Such circumstances can trigger locomotor deterioration and impairment, which is known as locomotive syndrome. The purpose of this study was to investigate the incidence of locomotive syndrome in the pandemic and to identify its risk factors. Methods: This was a multicenter questionnaire survey performed between 1 November 2020 and 31 December 2020 in Japan. Patients who visited the orthopedics clinic were asked to answer a questionnaire about their symptoms, exercise habits, and locomotor function at two time points, namely, pre-pandemic and post-second wave (current). The incidence of locomotive syndrome in the COVID-19 pandemic was investigated. Additionally, multiple logistic regression analysis was used to identify the risk factors for developing locomotive syndrome during the pandemic. Results: A total of 2829 patients were enrolled in this study (average age: 61.1 ± 17.1 years; 1532 women). The prevalence of locomotive syndrome was 30% pre-pandemic, which increased significantly to 50% intra-pandemic. Among the patients with no symptoms of locomotive syndrome, 30% developed it in the wake of the pandemic. In the multinomial logistic regression analysis, older age, deteriorated or newly occurring symptoms of musculoskeletal disorders, complaints about the spine or hip/knee joints, and no or decreased exercise habits were independent risk factors for developing locomotive syndrome. Conclusions: The prevalence of locomotive syndrome in patients with musculoskeletal disorders has increased during the COVID-19 pandemic. In addition to age, locomotor symptoms, especially spine or hip/knee joint complaints, and exercise habits were associated with the development of locomotive syndrome. Although the control of infection is a priority, the treatment of musculoskeletal disorders and ensuring exercise habits are also essential issues to address during a pandemic such as COVID-19.

Reductions in the Frequency of Going Out Due to the COVID-19 Pandemic Negatively Affect Patients with Spinal Disorders

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has greatly changed the lifestyles of individuals due to the need to prevent disease spread. Globally, governments have enforced various policies, including travel bans, quarantine, home confinement, and lockdowns, as safety measures. Consequently, the frequency of individuals going out has decreased. This survey aimed to assess how decreasing the frequency of going out due to the COVID-19 pandemic impacts patients with spinal disorders.

Methods

This multicenter cross-sectional questionnaire survey included patients who visited four private spine clinics for any symptoms. Participants completed questionnaires pre- and post-pandemic that assessed the following topics: frequency of leaving home, exercise habits, locomotive syndrome, and health-related quality of life (HRQOL). Patients were divided into decreased and non-decreased frequency of going out groups, according to observed changes in their frequencies of leaving home. Both groups were statistically compared using univariate and multivariate logistic regression analyses to identify factors associated with the frequency of going out.

Results

Among 855 patients, 160 (18.7%; the decreased group) reported that they went out less frequently, and 695 (81.3%; the non-decreased group) reported that they left home equally frequently post- versus pre-pandemic. Multivariate analyses showed that exercise habits significantly decreased (adjusted odds ratio (aOR) = 2.67, p = 0.004), the incidence of locomotive syndrome significantly increased (aOR = 2.86, p = 0.012), and HRQOL significantly deteriorated (aOR = 4.14, p < 0.001) in the decreased group compared to the non-decreased group.

Conclusions

Restrictions regarding leaving home due to the COVID-19 pandemic significantly decreased exercise frequency, increased the occurrence of locomotive syndrome, and were associated with deterioration of HRQOL in patients with spine disorders. It may be beneficial for spine surgeons to encourage patients with spinal disorders to leave home at a frequency similar to what they did pre-pandemic while avoiding crowded areas, despite the presence of the COVID-19 pandemic.

Reciprocal relationship between locomotive syndrome and social frailty in older adults

AIM

States of vulnerability are multidimensional and become more prevalent with advancing age. These states and the causal relationships between them, merit thorough investigation. This study aimed to understand the reciprocal relationship between the constructs of the locomotive syndrome and social frailty among a community of older adults.

METHODS

This 2-year cohort study examined a community of older adults (≥75 years) consisting of 1177 members. Using Makizako's method, social frailty was deemed to be present if more than two out of five questions were answered negatively. Locomotive syndrome was measured with the Geriatric Locomotive Function Scale-25, which consists of 25 items measuring an individual's risk of developing locomotive syndrome; a total score of ≥16 identified the presence of locomotive syndrome. Possible reciprocal associations between locomotive syndrome and social frailty were assessed using Cox proportional hazards analyses.

RESULTS

A total of 748 older adults were analyzed in the following subgroups. Among 574 participants without social frailty at the baseline, the presence of locomotive syndrome at the baseline was associated with new-onset social frailty during the next 2 years, after adjusting for confounding factors (hazard ratio 1.76, 95% confidence interval 1.17-2.65). Conversely, the presence of social frailty among participants without locomotive syndrome in the baseline was not associated with new-onset locomotive syndrome.

CONCLUSION

The presence of locomotive syndrome was determined to be a risk factor for the onset of social frailty. Therefore, interventions that address the negative impact of locomotive syndrome are a first step toward addressing these vulnerable conditions. Geriatr Gerontol Int 2021; 21: 981-984.

Trunk Muscle Mass Measured by Bioelectrical Impedance Analysis Reflecting the Cross-Sectional Area of the Paravertebral Muscles and Back Muscle Strength: A Cross-Sectional Analysis of a Prospective Cohort Study of Elderly Population

Trunk muscles play an important role in supporting the spinal column. A decline in trunk muscle mass, as measured by bioelectrical impedance analysis (TMM-BIA), is associated with low back pain and poor quality of life. The purpose of this study was to determine whether TMM-BIA correlates with quantitative and functional assessments traditionally used for the trunk muscles. We included 380 participants (aged ≥ 65 years; 152 males, 228 females) from the Shiraniwa Elderly Cohort (Shiraniwa) study, for whom the following data were available: TMM-BIA, lumbar magnetic resonance imaging (MRI), and back muscle strength (BMS). We measured the cross-sectional area (CSA) and fat-free CSA of the paravertebral muscles (PVM), including the erector spinae (ES), multifidus (MF), and psoas major (PM), on an axial lumbar MRI at L3/4. The correlation between TMM-BIA and the CSA of PVM, fat-free CSA of PVM, and BMS was investigated. TMM-BIA correlated with the CSA of total PVM and each individual PVM. A stronger correlation between TMM-BIA and fat-free CSA of PVM was observed. The TMM-BIA also strongly correlated with BMS. TMM-BIA is an easy and reliable way to evaluate the trunk muscle mass in a clinical setting.

Relationship of back muscle and knee extensors with the compensatory mechanism of sagittal alignment in a community-dwelling elderly population

Compensatory mechanisms, such as a decrease in thoracic spine kyphosis and posterior tilting or rotation of the pelvis, aim to achieve optimal alignment of the spine. However, the effect of muscle strength on these compensatory mechanisms has not been elucidated. This study aimed to investigate the impact of back muscle and lower extremity strength on compensatory mechanisms in elderly people. Overall, 409 community-dwelling elderly participants (164 men, 245 women) were included. Age, disc degeneration, and 2 or more vertebral fractures showed a significant increase of risk for sagittal vertical axis (SVA) deterioration. Conversely, stronger back, hip flexor, and knee extensor muscles reduced the risk for SVA deterioration. To investigate the association of each muscle's strength with compensatory mechanisms, 162 subjects with pelvic incidence-lumbar lordosis > 10° were selected. The linear regression model for thoracic kyphosis demonstrated a negative correlation with back muscle strength and positive correlation with vertebral fracture. The regression analysis for pelvic tilt demonstrated a positive correlation with knee extensor strength. Back, hip flexor, and knee extensor muscle strength were associated with sagittal spinal alignment. Back muscle strength was important for the decrease in thoracic kyphosis, and knee extensor strength was associated with pelvic tilt.