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UNIVERSIDADE ESTADUAL DE CAMPINAS FACULDADE DE EDUCAÇÃO FÍSICA RICARDO AURÉLIO CARVALHO SAMPAIO SARCOPENIA E FATORES ASSOCIADOS EM IDOSOS BRASILEIROS: DO DIAGNÓSTICO À INTERVENÇÃO SARCOPENIA AND ASSOCIATED FACTORS IN BRAZILIAN OLDER ADULTS: FROM DIAGNOSIS TO INTERVENTION CAMPINAS 2017

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Page 1: UNIVERSIDADE ESTADUAL DE CAMPINAS FACULDADE DE …repositorio.unicamp.br/bitstream/REPOSIP/322585/1/... · A TODOS os amigos integrantes do LCA – Laboratório de Cinesiologia Aplicada

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UNIVERSIDADE ESTADUAL DE CAMPINAS

FACULDADE DE EDUCAÇÃO FÍSICA

RICARDO AURÉLIO CARVALHO SAMPAIO

SARCOPENIA E FATORES ASSOCIADOS EM IDOSOS BRASILEIROS: DO

DIAGNÓSTICO À INTERVENÇÃO

SARCOPENIA AND ASSOCIATED FACTORS IN BRAZILIAN OLDER ADULTS:

FROM DIAGNOSIS TO INTERVENTION

CAMPINAS

2017

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RICARDO AURÉLIO CARVALHO SAMPAIO

SARCOPENIA E FATORES ASSOCIADOS EM IDOSOS BRASILEIROS: DO

DIAGNÓSTICO À INTERVENÇÃO

SARCOPENIA AND ASSOCIATED FACTORS IN BRAZILIAN OLDER ADULTS:

FROM DIAGNOSIS TO INTERVENTION

Tese apresentada à Faculdade de Educação Física da

Universidade Estadual de Campinas como parte dos

requisitos exigidos para obtenção do título de Doutor em

Educação Física, na área de concentração Atividade Física

Adaptada.

ORIENTADOR: PROF. DR. GUSTAVO LUIS GUTIERREZ

CO-ORIENTADOR: PROF. DR. MARCO CARLOS UCHIDA

ESTE EXEMPLAR CORRESPONDE À VERSÃO FINAL

DA TESE DEFENDIDA PELO ALUNO RICARDO

AURÉLIO CARVALHO SAMPAIO, E ORIENTADA

PELO PROF. DR. GUSTAVO LUIS GUTIERREZ

CAMPINAS

2017

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Agência(s) de fomento e nº(s) de processo(s): CAPES, 01P04373/2015

Ficha catalográfica

Universidade Estadual de Campinas

Biblioteca da Faculdade de Educação Física

Dulce Inês Leocádio dos Santos Augusto - CRB 8/4991

Sampaio, Ricardo Aurélio Carvalho, 1986-

Sa47s Sam Sarcopenia e fatores associados em idosos brasileiros: do diagnóstico à

intervenção / Ricardo Aurélio Carvalho Sampaio. – Campinas, SP : [s.n.], 2017.

Sam

Orientador: Gustavo Luis Gutierrez.

Coorientador: Marco Carlos Uchida.

Tese (doutorado) – Universidade Estadual de Campinas, Faculdade de

Educação Física.

Sam

1. Envelhecimento. 2. Força muscular. 3. Aptidão física - Testes. 4.

Qualidade de vida. I. Gutierrez, Gustavo Luis. II. Uchida, Marco Carlos. III.

Universidade Estadual de Campinas. Faculdade de Educação Física. IV. Título.

Informações para Biblioteca Digital

Título em outro idioma: Sarcopenia and associated factors in Brazilian older adults: from

diagnosis to intervention

Palavras-chave em inglês:

Aging

Strength

Physical fitness - Tests

Quality of life

Área de concentração: Atividade Física Adaptada

Titulação: Doutor em Educação Física

Banca examinadora:

Gustavo Luis Gutierrez [Orientador]

Edison Duarte

Flávia Silva Arbex Borim

Vanessa Helena Santana Dalla Déa

Reury Frank Pereira Bacurau

Data de defesa: 12-06-2017

Programa de Pós-Graduação: Educação Física

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COMISSÃO EXAMINADORA:

Prof. Dr. Gustavo Luis Gutierrez

(Faculdade de Educação Física/UNICAMP)

(Presidente)

Dr. Edison Duarte

(Faculdade de Educação Física/UNICAMP)

(Membro titular)

Dra. Flávia Silva Arbex Borim

(Faculdade de Ciências Médicas/UNICAMP)

(Membro titular)

Dra. Vanessa Helena Santana Dalla Déa

(Universidade Federal de Goiás)

(Membro titular)

Dr. Reury Frank Pereira Bacurau

(Universidade de São Paulo)

(Membro titular)

A Ata da defesa com as respectivas assinaturas dos membros encontra-se no processo de vida

acadêmica do aluno.

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AGRADECIMENTOS

Agradeço imensamente ao Prof. Dr. Gustavo Luis Gutierrez e ao Prof. Dr. Marco

Carlos Uchida, pelas orientações, incentivos e assistências que por diversas vezes excederam

os limites acadêmicos. Estendo, com mesmo empenho, o agradecimento às suas famílias.

À Priscila e Alice, esposa e filha, maiores parceiras da vida e prontas para

qualquer novo desafio.

Aos meus pais e irmãos, por toda a base, afeto e formação que me possibilitou

chegar muito longe.

À Silvia Toshie por estar presente nas incontáveis coletas, sempre disposta a

ajudar.

A TODOS os amigos integrantes do LCA – Laboratório de Cinesiologia Aplicada

e GEPEFAN – Grupo de Estudos e Pesquisa em Exercício Físico e Adaptações

Neuromusculares, pelo suporte, compromisso e empenho de estarem presentes em diversas

coletas de dados, mesmo que em diferentes cidades.

Aos participantes das pesquisas e aos que viabilizaram a sua execução de alguma

forma, sua confiança e colaboração proporcionaram um período de grande aprendizado.

À banca de qualificação e defesa, Dr. Edison Duarte, Dra. Flávia Silva Arbex

Borim, Dra. Vanessa Helena Santana Dalla Déa e Dr. Reury Frank Pereira Bacurau pela

valiosa contribuição dada ao trabalho.

Aos coordenadores da Pós-graduação, Dra. Cláudia Cavaglieri (anterior) e Dr.

Edivaldo Góis (atual), por todo o suporte quando necessário.

À secretária da pós-graduação da FEF, Simone Ide, por sempre estar de bom

humor e disposta a ajudar prontamente nas questões burocráticas.

Aos Professores e colegas com quem tive a oportunidade de cursar disciplinas,

discutir e aprender bastante durante o período de doutoramento, seja na FEF, seja na

Gerontologia/FCM.

À Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

(#01P04373/2015), pelo apoio financeiro para a realização e conclusão desta tese.

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RESUMO

O envelhecimento no Brasil representa grande desafio para a saúde pública

contemporânea, uma vez que acontece de forma acelerada e pode ser acompanhado de

diversas condições adversas, como a sarcopenia, síndrome da fragilidade, e o consequente

declínio da qualidade de vida (QV), que frequentemente resultam em institucionalização e

mortalidade. Esta tese está estruturada com base em três artigos científicos, além de capítulos

de introdução e conclusão. No primeiro artigo, “Cutoff values of appendicular skeletal

muscle mass and strength associated to fear of falling in Brazilian older adults”, foram

apresentados comparações entre grupos de idade por sexo em relação a aspectos

morfofuncionais; e valores específicos de corte para massa muscular apendicular (i.e., soma

da massa muscular dos membros) ajustada pelo índice de massa corporal (MMA(IMC)) e força

(i.e., força de preensão manual, absoluta e relativa [ajustada pelo índice de massa corporal])

em associação ao medo de cair em idosos brasileiros (n=578). Níveis de funcionalidade

diminuíram com a idade, enquanto a composição corporal variou entre sexos. Associados ao

medo de cair, os pontos de corte para MMA(IMC) foram <0,85 para homens e <0,53 para

mulheres; para força de preensão manual absoluta e relativa foram <30,0 kgf e <21,7 kgf; e

<1,07 e <0,66, para homens e mulheres, respectivamente. O segundo artigo verificou a

associação dos pontos de corte, assim como a combinação desses fatores, com QV (n=577).

Lentidão da caminhada foi estabelecida em <0,8 m/s. O artigo foi intitulado “Sarcopenia

cutoffs in Brazilian older adults are associated to health-related quality of life”. Em homens,

resultados da combinação de força de preensão manual absoluta e/ou velocidade de

caminhada foram associados com os domínios função física, aspectos físicos e saúde geral de

QV. Em mulheres, a combinação de força de preensão manual (absoluta e relativa) e/ou

velocidade da caminhada e MMA(IMC) apresentou associações com os domínios função física,

aspectos físicos, dor corporal, saúde geral e função social. O terceiro artigo analisou a

aplicação de exercícios de potência utilizando bandas elásticas (16 semanas), em idosos

frágeis (n=11) e residentes em uma instituição de longa permanência. O artigo foi intitulado

“Influence of power training on physical function and health-related quality of life in

institutionalized frail older adults: a case-study”. Pós-intervenção, mudanças foram

observadas nos domínios de QV – função física, aspectos físicos, dor corporal, aspectos

emocionais e sumário dos componentes físicos, em homens; e aspectos físicos, aspectos

emocionais e saúde mental, em mulheres. Em relação à função física, melhoras na velocidade

da caminhada e número de repetições no teste de remada com banda elástica foram

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observadas, em homens; e velocidade da caminhada, repetições no teste de remada com

banda elástica e timed up and go, em mulheres. Os dados apresentados podem ser utilizados

como referência para pesquisadores ou na prática profissional. Mais ainda, podem servir de

referência para o desenvolvimento de políticas públicas relacionadas à saúde e bem estar dos

idosos. Pois uma vez conhecidas as demandas, intervenções podem ser melhores destinadas à

promoção da saúde dessa população.

Palavras-Chave: envelhecimento; força muscular; aptidão física - testes; qualidade de vida.

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ABSTRACT

Aging in Brazil represents a major challenge for contemporary public health,

once happens fast and can be associated with several adverse health conditions, such as

sarcopenia, frailty syndrome, and decline in quality of life (QOL), which often result in

higher institutionalization and mortality rates. This work is structured on the basis of three-

paper format, as well as introduction and conclusion sections. In the first article, "Cutoff

values of appendicular skeletal muscle mass and strength associated with fear of falling in

Brazilian older adults", we presented comparisons between age groups by sex with regard to

morphological and functional aspects; and specific cutoff values for appendicular skeletal

muscle mass (i.e., sum of limbs muscle mass) adjusted by body mass index (ASM(BMI)) and

strength (i.e., handgrip strength, absolute and relative [adjusted by body mass index]) in

association with fear of falling in Brazilian older adults (n=578). Physical function decreased

as age increased, while body composition varied according to sex. In association to fear of

falling, cutoff values for ASM(BMI) were <0.85 for men and <0.53 for women; for absolute

and relative handgrip strength were <30.0 kgf and <21.7kgf; and <1.07 and <0.66, for men

and women, respectively. The second article verified the association of these cutoff points,

as well as the combination of such factors, with QOL (n=577). Slow walking speed was

established as <0.8 m/s. The article was entitled "Sarcopenia cutoffs in Brazilian older adults

are associated to health-related quality of life". In men, results of the combination of absolute

handgrip strength and/or walking speed were associated with physical functioning, role-

physical and general health domains of QOL. In women, the combination of handgrip

strength (both absolute and relative) and/or walking speed plus ASM(BMI) were associated

with physical functioning, role-physical, bodily pain, general health and social functioning.

The third article analyzed the application of power exercises using elastic bands (16 weeks),

in frail and institutionalized older people. The article was entitled "Influence of power

training on physical function and health-related quality of life in institutionalized frail older

adults: a case-study". Post-intervention results showed changes on physical functioning, role-

physical, bodily pain, role-emotional and physical component summary QOL domains, in

men; and role-physical, role-emotional and mental health, in women. Regarding physical

function, improvements on walking speed and number of repetitions in the elastic band

rowing test were observed, in men; and waking speed, repetitions in the elastic band rowing

test and the timed up and go, in women. The data presented herein might be useful as

reference for researchers and in professional practice. Moreover, might be useful for the

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development of public policies related to older adults’ health. Once their demands are known,

more efficient intervention can be developed to promote health in this population.

Keywords: aging; strength; physical fitness - tests; quality of life.

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LISTA DE ILUSTRAÇÕES

Artigo 1

Figure 1. ROC curves for appendicular skeletal muscle (ASM) with different

adjustments, and handgrip strength (HGS) (absolute and adjusted by body mass

index). Fear of falling was used as outcome variable. Data of men (A-B) and

women (C-D) are presented…………………………..................................................

33

Artigo 3

Figure 1. Flowchart of study procedures....................................................................... 61

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LISTA DE TABELAS

Artigo 1

Table 1. Older adults’ characteristics………………................................................... 27

Table 2. Characteristics according to age in older men (n=122).................................. 28

Table 3. Characteristics according to age in older women (n=455)............................. 30

Table S1. Appendicular skeletal muscle adjusted by body mass index vs. Fear of

falling (Men).................................................................................................................

41

Table S2. Absolute handgrip strength vs. Fear of falling (Men).................................. 41

Table S3. Relative handgrip strength vs. Fear of falling (Men)................................... 42

Table S4. Appendicular skeletal muscle adjusted by body mass index vs. Fear of

falling (Women)............................................................................................................

42

Table S5. Absolute handgrip strength vs. Fear of falling (Women)............................ 43

Table S6. Relative handgrip strength vs. Fear of falling (Women).............................. 43

Artigo 2

Table 1. Subjects’ general characteristics.................................................................... 49

Table 2. Point biserial correlations for different cutoffs and combinations, and

health-related quality of life (men, n=122)...................................................................

51

Table 3. Point biserial correlations for different cutoffs and combinations, and

health-related quality of life (women, n=455)….…………………………………….

52

Artigo 3

Table 1. Participants’ general characteristics at baseline according to sex.................. 66

Table 2. Health-related quality of life pre and post intervention................................. 67

Table 3. Physical function tests pre and post intervention………………………….. 69

Table 4. Session rating of perceived effort at the beginning and at the final intensity

achieved……………………………………………………………………………….

69

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LISTA DE ABREVIATURAS E SIGLAS

ACSM…………….... American College of Sports Medicine

ANOVA……………. Analysis of variance – Análise de variância

ANVISA…………… Brazilian Sanitary Agency – Agência de vigilância sanitária

ASM………………... Appendicular skeletal muscle

ASM(BMI)…..………. Appendicular skeletal muscle mass adjusted by body mass index

AUC………………... Area under the curve

AVD........................... Atividade da vida diária

AWGS……………... Asian Working Group for Sarcopenia

BIA………………… Bioelectrical impedance analysis

BMI……………....... Body mass index

Borg CR-10………... Adapted Borg scale 0-10

BP………………….. Bodily pain domain (Short-form 8 and 36)

d……………………. Cohen’s d effect size

EBRT………………. Elastic band rowing test

EWGSOP.................. European Working Group on Sarcopenia in Older People

FAST......................... Functional Assessment Staging of Alzheimer’s disease

FNIH……………….. Foundation for the National Institutes of Health

GH…………………. General health domain (Short-form 8 and 36)

HGS………………... Handgrip strength

HGS(ABS)…………… Absolute handgrip strength

HGS(BMI)…………… Handgrip strength adjusted by body mass index – relative handgrip

strength

HRQOL……………. Health-related quality of life

ICD-10....................... International Classification of Diseases

KCL………………... Kihon Checklist

LR+………………… Positive likelihood ratios

LR-…………………. Negative likelihood ratios

LTCI……………….. Long term care institution

MCS………………... Mental Component Summary (Short-form 36)

MH……………….… Mental health domain (Short-form 8 and 36)

MMA………………. Massa muscular appendicular

MMA(IMC)…………. Massa muscular appendicular ajustada pelo índice de massa corporal

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MMSE……………... Mini-mental State Examination

NPV………………... Negative predictive value

PA/wk……………… Physical activity per week

PCS………………… Physical Component Summary (Short-form 36)

PF………………….. Physical functioning domain (Short-form 8 and 36)

PPV………………… Positive predictive value

QV.............................. Qualidade de vida

RE………………….. Role-emotional domain (Short-form 8 and 36)

RM…………………. Repetition maximum

ROC……………….. Receiver Operating Characteristics

RP………………….. Role-physical domain (Short-form 8 and 36)

Rpb…………………. Point biserial coefficient of correlation

SD………………….. Standard deviation

SF…………………... Social functioning domain (Short-form 8 and 36)

SF-8………………… Short-form 8 items

SF-36……………….. Short-form 36 items

SRPE………………. Session rating of perceived effort

TUG…………….….. Timed up and go

VO2max..................... Capacidade aeróbia máxima

VT………………….. Vitality domain (Short-form 8 and 36)

WHO......................... World Health Organization

WS…………………. Walking speed

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SUMÁRIO

INTRODUÇÃO ....................................................................................................... 16

CUTOFF VALUES OF APPENDICULAR SKELETAL MUSCLE MASS AND

STRENGTH ASSOCIATED TO FEAR OF FALLING IN BRAZILIAN OLDER

ADULTS ......................................................................................................................

19

Abstract ……………………………………………………………………….. 19

Resumo ……………………………………………………………………….. 20

Introduction …………………………………………………………………... 21

Objective ………………………………………………………………............ 22

Methods ………………………………………………………………………. 22

Results …….………………………………………………………………….. 26

Discussion …………………………………………………………………….. 35

Conclusion ………………………………………………………………......... 38

References ………………………………………………………………......... 38

SARCOPENIA CUTOFFS IN BRAZILIAN OLDER ADULTS ARE

ASSOCIATED TO HEALTH-RELATED QUALITY OF LIFE ……………………

44

Abstract ……………………………………………………………………….. 44

Introduction …………………………………………………………………... 45

Methods ……...……………………………………………………………….. 45

Results ………………………………………………………………………... 47

Discussion …………………………………………………………………….. 53

References ……………………………………………………………………. 55

INFLUENCE OF POWER TRAINING ON PHYSICAL FUNCTION AND

HEALTH-RELATED QUALITY OF LIFE IN INSTITUTIONALIZED FRAIL

OLDER ADULTS: A CASE-STUDY …….................................................................

58

Abstract ……………………………………………………………………….. 58

Introduction ...………………………………………………………………… 59

Methods ………..……………………………………………………………... 59

Results ………………………………………………………………………... 65

Discussion …………………………………………………………………….. 70

References ……………………………………………………………………. 73

CONCLUSÃO ............................................................................................................. 77

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REFERÊNCIAS ........................................................................................................... 78

ANEXO 1...................................................................................................................... 82

ANEXO 2...................................................................................................................... 83

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INTRODUÇÃO

O envelhecimento é constituído e influenciado por mudanças complexas e

dinâmicas. Em nível biológico, é associado com o acúmulo gradual de uma ampla variedade

de danos moleculares e celulares. Com o tempo, estes danos levam a declínios graduais das

reservas fisiológicas, aumentando o risco para diversas doenças, o que resulta num declínio

geral na capacidade do indivíduo.1 Diversas condições adversas podem acompanhar o

envelhecimento tais como a sarcopenia, síndrome da fragilidade, incapacidade funcional, e o

consequente declínio da qualidade de vida (QV);2 que frequentemente resultam em

institucionalização e mortalidade.

A sarcopenia é entendida como a progressiva perda de massa muscular e

força/funcionalidade com o envelhecimento.2 Durante essa fase da vida, ocorre perda

quantitativa de massa muscular e alterações nas propriedades individuais das fibras

musculares, em particular, a redução seletiva no número e tamanho das fibras musculares do

tipo II, de contração rápida.3 Isso gera uma perda gradativa das capacidades físicas (e.g. força

e potência), o que resulta na diminuição do desempenho físico e das atividades da vida diária

(AVD), podendo culminar na perda da independência desses idosos.4

Idosos sarcopênicos apresentam risco elevados de quedas e maior prevalência de

medo de cair, levando a um ciclo vicioso de sarcopenia, declínio das capacidades físicas,

quedas e medo de cair, que resulta em incapacidade.5 Especialmente o medo de cair, é uma

condição associada a aspectos físicos e psicológicos, como quedas, perda de confiança,

restrição de atividades, isolamento social, que podem levar a dependência e incapacidade;6,7

ainda que não seja uma medida objetiva como os tradicionais desfechos, é uma importante

variável sobre condição de saúde dos idosos.

O termo sarcopenia (do grego, perda de carne) foi primeiro proposto por

Rosenberg, em 1989, para descrever o declínio de massa muscular associado à idade.8 No

entanto, conceitos contemporâneos, ainda que difiram em algumas características, suportam

que sarcopenia pode ser definida a partir de aspectos morfofuncionais: quantidade de massa

muscular, força muscular e função física. Assim, a quantidade e qualidade muscular são

utilizadas para o diagnóstico dos estágios sarcopênicos em idosos. Dentre as publicações

referentes à sarcopenia, alguns grupos se destacam no contexto internacional: “European

Working Group on Sarcopenia in Older People” (EWGSOP);2 “Society on Sarcopenia,

Cachexia and Wasting Disorders (study Sarcopenia with limited Mobility - an International

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Consensus)”;9 “Asian Working Group for Sarcopenia (AWGS)”

10 e “Foundation for the

National Institutes of Health (FNIH) Sarcopenia Project”.11

A sarcopenia pode atingir cerca de 30% dos indivíduos com 65 anos ou mais e

50% das pessoas a partir dos 80 anos.2 No Brasil, Diz et al. (2016) verificaram uma

prevalência de 17%, indicando um alerta, à medida em que o crescimento da população idosa

se acentua.12

Tal condição influencia negativamente a QV e a saúde geral dos idosos, através

do aumento de incidência de morbidades (e.g. obesidade, hipertensão, diabetes tipo 2,

dislipidemias, osteoporose), aumento no risco de quedas e fraturas ósseas, diminuição do

condicionamento físico e capacidade aeróbia máxima (VO2max).13

Entende-se que a análise da QV constitui uma das avaliações mais representativas

da saúde de um indivíduo, partindo do pressuposto que uma percepção favorável da sua

própria saúde pode minimizar as condições que acompanham o processo de

envelhecimento.14

Além disso, QV pressupõe boa saúde mental, felicidade e sociabilização;

estando associado negativamente a doenças físicas e estados depressivos.15

Interessante, o

conceito de QV foi introduzido na pesquisa em saúde para complementar os já tradicionais

desfechos médicos, tais como mortalidade e morbidade.16

A literatura sugere que os fatores que contribuem para melhorar a QV de idosos

incluem manutenção da independência, autonomia, adaptabilidade, participação social, papel

na sociedade e outros.17

Adicionalmente, acredita-se que a prática regular de atividade física

pode preservar a saúde, bem–estar, vitalidade e a função social, entre outros fatores

importantes para a QV.18

Programas específicos de atividade física representam fator chave para a

manutenção das capacidades físicas, desaceleração ou até mesmo reversão dos aspectos de

sarcopenia e fragilidade;19,20

e recomendações na última década incluem a prática de

exercícios aeróbios, de força, de flexibilidade e de equilíbrio.21,22

É sabido que o treinamento de força possui papel importante na melhora das

funções musculares, físicas e até psicológicas, mesmo para idosos mais velhos.23,24

Estudos

também demonstraram a importância da utilização de treinos de potência (i.e. força

multiplicado pela velocidade, potência= força x velocidade) para idosos. Acredita-se que o

treinamento de potência pode promover benefícios adicionais à população idosa do que o

treinamento de força convencional,25

uma vez que a produção de força rápida se associa à

função física.26

De fato, em estudo de revisão, pesquisadores observaram que a taxa de

produção de força aumentou somente nos estudos em que os voluntários realizaram ações

explosivas;26

condição também observada em relação à função física.27

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Esta tese está estruturada com base em três artigos. O primeiro, refere-se à

pesquisa “Cutoff values of appendicular skeletal muscle mass and strength associated to fear

of falling in Brazilian older adults”. Neste artigo, são propostos valores de referência de

massa muscular apendicular e força de preensão manual em idosos brasileiros, por acreditar

que valores baseados em idosos locais são preferíveis sob aqueles provenientes de

estrangeiros, principalmente pela diferença cultural e ambiental que influenciam bastante no

estilo de vida da população, o que por sua vez, é um fator determinante para como se

envelhece.

Assim, foram apresentados comparações entre grupos de idade no que concerne a

aspectos morfológicos e funcionais; e valores específicos de corte para massa muscular

apendicular (i.e., soma da massa muscular dos membros) ajustada pelo índice de massa

corporal (IMC) e força (i.e., força de preensão manual absoluta e relativa [ajustada pelo

IMC]) em associação ao medo de cair, em idosos brasileiros (n=578). A pesquisa foi

aprovada no Comitê de Ética da Universidade Estadual de Campinas (UNICAMP) sob o

protocolo #39437514.0.0000.5404 (ANEXO 1). Os dados estão também descritos no artigo

aceito para publicação no São Paulo Medical Journal/Evidence for Health Care, em maio de

2017.

O segundo artigo, verificou a associação dos pontos de corte específicos para

massa muscular apendicular ajustada pelo IMC, força de preensão manual absoluta e relativa,

velocidade da caminhada (com base em valores previamente estabelecidos), bem como a

combinação desses fatores, com QV (n=577). O artigo, com desenho transversal, foi

intitulado “Sarcopenia cutoffs in Brazilian older adults are associated to health-related

quality of life”. A pesquisa foi aprovada no Comitê de Ética da UNICAMP sob o protocolo

#39437514.0.0000.5404 (ANEXO 1).

O último artigo analisou a aplicação de um programa de exercícios em idosos

institucionalizados. O artigo foi intitulado “Influence of power training on physical function

and health-related quality of life in institutionalized frail older adults: a case-study”. A

hipótese do estudo foi que uma intervenção baseada em exercícios de potência poderia

influenciar a função física e melhora da QV. Onze idosos participaram das atividades de

intervenção que durou quatro meses. Eles foram avaliados antes do início do programa de

exercícios e após (17ª semana). Variáveis de função física e QV, entre outras, foram

realizadas. O protocolo de pesquisa foi aprovado pela UNICAMP sob o protocolo

#47092115.4.0000.5404 (ANEXO 2).

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CUTOFF VALUES OF APPENDICULAR SKELETAL MUSCLE MASS AND

STRENGTH ASSOCIATED TO FEAR OF FALLING IN BRAZILIAN OLDER

ADULTS

ABSTRACT

CONTEXT AND OBJECTIVE: Sarcopenia is an emerging public health issue in

Brazil. Due to the rising prevalence, and the lack of national data, the objective was to

identify cutoff values for appendicular skeletal muscle (ASM), and handgrip strength

according to fear of falling in Brazilian older adults.

DESIGN AND SETTING: Cross-sectional study; community.

METHODS: 578 older adults participated in this study. Volunteers underwent to

morphological and functional evaluations; and were questioned about the prevalence of falls

and fear of falling. Different adjustments of ASM and handgrip strength were used. Slow

walking speed was established at <0.8m/s. Gender and age-groups were compared by T tests,

analysis of variance (ANOVA), chi-square or Fisher’s Exact Test. Receiver operating

characteristic curves identified cutoffs for ASM and handgrip strength in association to fear

of falling.

RESULTS: Physical function decreased with increasing age and body

composition varied according to gender. In association to fear of falling, ASM adjusted by

body mass index (ASM(BMI)) cutoffs were <0.85 for men and <0.53 for women; for absolute

handgrip strength and relative handgrip strength (adjusted by BMI) were 30.0 kgf, and 21.7

kgf; and 1.07, and 0.66, for men and women, respectively.

CONCLUSION: Values of physical function tests and other variables can be used

as reference at clinics and practice. Moreover, we encourage the use of ASM(BMI) and to

choose over absolute or relative handgrip strength for both men and women according to

study needs.

KEY WORDS: Aging; Hand strength; Muscle, Skeletal; Sarcopenia; Walking speed.

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RESUMO

CONTEXTO E OBJETIVO: Sarcopenia é um problema de saúde emergente no

Brasil. Devido à alta prevalência e falta de valores nacionais, o objetivo foi identificar pontos

de corte para massa muscular apendicular (MMA) e força de preensão manual em associação

ao medo de cair em idosos brasileiros.

DESENHO E LOCAL: Transversal; comunidade.

MÉTODOS: 578 idosos foram submetidos a análises morfológicas e funcionais e

questionados sobre a prevalência de quedas e medo de cair. Diferentes ajustes de MMA e

força de preensão manual foram usados. Baixa velocidade da marcha foi estabelecida em

<0.8 m/s. Idosos divididos por gênero e idade foram comparados por testes T, análise de

variância (ANOVA), teste do qui-quadrado ou Exato de Fisher. Curvas Receiver operating

characteristic foram usadas para identificar os pontos de corte para MMA e força de

preensão manual em associação ao medo de cair.

RESULTADOS: Níveis de funcionalidade diminuíram com a idade, enquanto a

composição corporal variou entre sexos. Associados ao medo de cair, os pontos de corte para

MMA ajustada pelo índice de massa corporal (MMA(IMC)) foram <0.85 para homens e <0.53

para mulheres; para força de preensão manual absoluta e relativa (ajustada pelo IMC) foram

30.0 kgf e 21.7 kgf; e 1.07, e 0.66, para homens e mulheres, respectivamente.

CONCLUSÃO: Os valores apresentados podem ser usados como referência na

clínica e prática. Recomendamos o uso da MMA (IMC) e a escolha entre força de preensão

manual absoluta ou relativa para homens e mulheres de acordo com as necessidades do

estudo.

PALAVRAS-CHAVE: Envelhecimento; Sarcopenia; Músculo esquelético; Força da mão;

Marcha.

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INTRODUCTION

Sarcopenia, defined as progressive loss of muscle mass and strength/functionality

with aging, is an emerging public health issue in Brazil.1 The loss of muscle mass and

function may result in loss of physical capabilities (e.g. endurance, strength, and muscle

power), poor quality of life, unfavorable metabolic effects, falls and fear of falling, frailty,

and mortality rate in older adults. Furthermore, sarcopenia is frequently associated with

multimorbidities, smoking habit, low body mass index (BMI), malnutrition, and physical

inactivity.2

Several consensuses and recommendations have been proposed by different

institutions attempting to standardize the conceptual approaches used to diagnose

sarcopenia.2,3,4,5

Among those, experts agree that three key factors should be approached:

body composition (muscle mass); functionality (e.g. walking speed), and muscle strength

(e.g. handgrip strength).

Studies estimate that after the age of 50 the muscle mass decreases consistently at

a rate of approximately 1% per year, walking speed at a rate of 2.0 - 2.2% and handgrip

strength at a rate of 1.9 - 5.0%, as a result of the transition process of decreasing lean body

mass and increasing fat accumulation.6,7

Cutoffs and reference values have also been

presented in the consensuses and recommendations. Besides the international characteristics

of the studies they compiled, most of them were conducted in developed countries and/or in

genetically, ethnically and culturally different countries than Brazil. Even when considering

the miscegenation of Brazilian population, inferences of such values in Brazilian older adults

are difficult and limited.

Therefore, considering the importance given to sarcopenia that recently

culminated in the determination of an International Classification of Diseases (ICD-10)

code;8 the rising prevalence in older Brazilians that already achieved 17%;

1 and the lack of

national preliminary data, the aim of this study was to identify cutoff values for appendicular

skeletal muscle (ASM), and handgrip strength according to fear of falling in Brazilian older

adults.

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OBJECTIVE

The aim of this study was to identify evidence-based cutoff values for ASM, and

handgrip strength according to fear of falling; and secondarily, to verify the morphological

and functional characteristics in Brazilian older adults according to gender and age groups.

METHODS

Design

This study had a cross sectional design (frequency study) and data were collected

during 2015 and 2016.

Subjects

In total, 578 older adults (male n=122, female n=456) participated in this study.

They were recruited voluntarily from four community health centers for older adults in

southeastern and southern Brazil; however, individuals represent diversity of ethnicity, other

geographic areas, and a range of health and functional states.

The inclusion criteria were: a) community-dwelling people; b) 60 years old or

older, from both sexes; c) able to answer the questions, perform the functional and body

composition tests. Exclusion criteria were: a) individuals with uncontrolled cardiovascular or

pulmonary disease, with conditions associated with risk of falling (i.e. Parkinson’s disease or

stroke), physically and cognitively impaired (according to their report of chronical diseases

[e.g., presence of condition that might require assistance for basic activities of daily living],

and items present in the functional assessment staging of Alzheimer’s disease – FAST,

verified onsite); b) individuals using metal prosthesis and/or pacemaker (i.e., interference -

bioelectrical impedance analysis).

The present study was approved by the Ethical Committee of the University of

Campinas, protocol #39437514.0.0000.5404. All participants signed an informed consent

agreeing to participate in the study before data collection.

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Assessments

The assessments were divided into two steps, to quote: a) indirect assessments

based on questionnaires, and b) direct assessments based on morphofunctional evaluations

(i.e., anthropometric characteristics and physical function). Before the evaluations, all tests

were explained in details by an experienced researcher to all participants. Verbal

encouragement was provided to assure that volunteers reached the best performance possible.

Indirect assessments

Chronical degenerative diseases, age, fear of falling and falls

A questionnaire was used to obtain data regarding the presence of chronical

diseases, age, the fear of falling and the occurrence of falls during the year prior to the

research. The questionnaire was based on simple questions, which were answered with

binary constructs (i.e., yes or no) avoiding possible misunderstanding among the researchers

and the volunteers. First, an extensive list of the most prevalent chronic diseases (e.g.,

hypertension, diabetes, osteoporosis) in older adults was presented to the volunteers. They

then stated yes or no if they presented a previous clinical diagnosis of the chronical

condition. These data are not shown and were used solely for exclusion purposes. In relation

to fear of falling, the following question was asked: “Are you afraid of falling?”. And the

following question was asked about the occurrence of falls: “Have you experienced a fall in

the past year?’’. Important to mention, only the question about occurrence of falls was

retrospective, so that all the other questions and evaluations were in relation to the period

where the study was performed.

Direct assessments

Anthropometrical measures

Height was measured by standard stadiometer and waist and hip circumferences

using a measuring tape. The body composition was assessed by bioelectrical impedance

analysis (BIA) (Tanita® BC-108, Tokyo, Japan). The equipment provided the weight of the

subject, and the height was inserted manually by the researcher. After analysis, values of

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absolute and segmented muscle and fat mass were obtained. The Tanita BIA uses a frequency

of 50 kHz to measure the quantity of intra and extracellular water in the body. This

equipment has eight electrodes, four under the feet and four on volunteers’ hands.9,10

The

values of ASM (sum of muscle mass of limbs) are useful to diagnose sarcopenia. In this

study, we used several adjustments (i.e. by BMI, height squared, weight and non-adjusted

data) to verify the best approach in Brazilian older adults. Additional data concerning

absolute skeletal muscle was also provided.

Physical function

The walking speed was evaluated in a 10 meters distance. Outside marks of 12 m

in length were clearly placed on the ground during the walking test. Another 10-m long

delimitation was marked inside the previous one. Participants were asked to walk the entire

distance at their usual pace. The time required to complete the inner 10-m distance was

assessed.11

Continuous values of walking speed, as well as using 0.8m/s and 1.0m/s cutoffs

were also applied. The value 0.8 m/s has been suggested by other studies as representative of

slow walking. Also considering the range in walking speed that they found in such studies,

and the characteristics of the samples that we studied, 1 m/s was also used.2,3

The TUG has been widely described. The subject has to stand from a chair, to

walk three meters in straight line, to surround a cone and to return to the chair and sit.12

The handgrip strength was measured with a digital dynamometer Jamar (Jamar

Plus+®; Sammons Preston, Rolyon, Bolingbrook, IL). While seated, the subject held the

dynamometer with elbow flexed in 90° without touching his/her body. After preparation, they

were instructed to pull the lever at his/her maximum; each hand was tested once and the best

value was used in analysis. Subjects were also instructed to avoid the Valsava maneuver or

blocked breath while performing the test. Handle position two was set as standard for all

subjects as previously recommended.13

Statistical analyses

All analyses were carried out using the Statistical Package for the Social Sciences

(version 21.0, SPSS, IBM Inc., Chicago, IL, USA) and the MedCalc Statistical Software

version 17.2 (MedCalc Software, Ostend, Belgium). Descriptively, values are presented as

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mean ± standard deviation (SD) for continuous variables and frequency (%) for categorical

values.

To compare older adults’ characteristics by gender, unpaired T tests and chi-

square tests were used for continuous and categorical variables, respectively. In analyzes by

age, subjects were divided into five groups (60 to 64, 65 to 69, 70 to 74, 75 to 79 and 80 +

years old). For continuous variables, analysis of variance (ANOVA) was used; when

statistical differences were found, Tukey Post Hoc test was applied. For categorical variables,

chi-square or Fisher’s Exact Test was used.

In addition, receiver operating characteristic (ROC) curve analyses were used to

verify cutoff values for ASM and handgrip strength in association to fear of falling. For this,

different adjustments of ASM, and handgrip strength were used; the curves were then

compared to verify statistical differences among them. The ROC curve compares true-

positive rate (sensitivity) versus false-positive rate (1 - specificity) across a range of values

for the ability to predict a dichotomous outcome. High sensitivity corresponds to high

negative predictive value, while high specificity corresponds to high positive predictive

value. Sensitivity and specificity were used to identify the cutoff values for ASM and

handgrip strength in this study.14

The area under the curve (AUC) is a measure of test

performance and describes the probability that a test will correctly identify individuals who

did and did not have a condition and were randomly selected from the cohort. Generally, the

closer the AUC is to 1, the better the overall diagnostic performance of the test, and the

closer to 0.5, the poorer the test.15,16

Sensitivity, specificity, positive (PPV) and negative

predictive values (NPV), and likelihood ratios (positive [LR+] and negative [LR-]) for ASM

and handgrip strength according to fear of falling were computed. Predictive values describe

the probability of a person having a condition once the results of his or her tests are known.

LR+ and LR- indicate how much the odds of a disease increase or decrease when a test is

positive and negative, respectively.

The fear of falling was selected as the primary outcome for this study because of

its association with psychological and physical aspects, such as falls, loss of confidence,

restriction of activities, social withdrawal, which may lead to dependence and disability.17,18

Other variables were considered as outcomes, such as falls and walking speed; however, due

to the small number of subjects with positive results or missing data further analyses were not

conducted. In all analyses, statistical significance was set at P <0.05.

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RESULTS

In total, 578 older adults (male n=122, female n=456) participated in this study.

Their characteristics are descriptively shown in Table 1. The mean age was 70.0 ± 6.7 years

for male and 69.4 ± 6.6 for female. Women had lower strength and were more overweight

than men. Moreover, more women experienced a fall event in the year prior the research

(women 25.3% and men 14.4%) and reported fear of falling (women 65.7% and men 43.7%).

Regarding physical function, women had slow walking speed than men (Table 1).

Table 2 and 3 present study data according to gender, divided by age groups.

Higher rates of fear of falling in both groups were shown at the age group 80 years old or

more; however, only in men the difference was statistically significant. In older men, the age

group 60 to 64 years was stronger than those aged 80 or more when considering absolute

values of handgrip strength. Such difference was not verified when data was adjusted by

BMI. The age group 60 to 64 years also had higher skeletal muscle (total and adjusted by

height squared), and total ASM. Regarding walking speed and the TUG tests, the function

also decreased as age increased; a similar trend was observed regarding BMI, but not fat

percentage (Table 2).

It was evident that older women had slower walking speed, TUG, and lower

muscle strength than younger women, verified by both absolute and relative handgrip

strength. Fat percentage, BMI and skeletal muscle (total, adjusted by BMI, height squared,

and weight) also decreased with increasing age. Regarding ASM, only the total and the one

adjusted by height squared failed to show statistical differences (Table 3).

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Table 1. Older adults’ characteristics

Older adults (n=578) P

Variables Male (n=122) Female (n=456)

Age (y) 70.5 ± 6.7 69.4 ± 6.6 0.11

Handgrip strength (kgf) 37.4 ± 8.1 24.2 ± 4.8 < 0.001

Relative handgrip strength

(Adjusted by body mass index)

1.4 ± 0.3 0.8 ± 0.2 < 0.001

Body mass index (kg/m2) 26.8 ± 3.5 28.3 ± 4.9 < 0.001

Fat percentage (%) 26.2 ± 6.1 41.1 ± 6.8 < 0.001

Total skeletal muscle mass (kg) 51.4 ± 6.7 36.2 ± 3.3 < 0.001

Skeletal muscle mass

(Adjusted by body mass index)

1.94 ± 0.2 1.31 ± 0.1 < 0.001

Skeletal muscle mass (kg/m2)

(Adjusted by height squared)

18.4 ± 1.4 15.3 ± 0.8 < 0.001

Skeletal muscle mass

(Adjusted by weight)

0.7 ± 0.05 0.5 ± 0.06 < 0.001

Total appendicular skeletal muscle (kg) 25.2 ± 4.0 16.4 ± 1.8 < 0.001

Appendicular skeletal muscle

(Adjusted by body mass index)

0.95 ± 0.1 0.59 ± 0.08 < 0.001

Appendicular skeletal muscle (kg/m2)

(Adjusted by height squared)

9.04 ± 1.0 6.9 ± 0.6 < 0.001

Appendicular skeletal muscle

(Adjusted by weight)

0.34 ± 0.03 0.25 ± 0.02 < 0.001

Falls in the year prior research 17 (14.4) 113 (25.3) 0.01

Fear of falling 52 (43.7) 291 (65.7) < 0.001

Waist circumference (cm) 97.5 ± 9.6 95.2 ± 11 0.03

Hip circumference (cm) 100.6 ± 6.3 103.5 ± 9.8 < 0.001

Timed Up and Go (s) 7.6 ± 2.6 8 ± 2.4 0.14

Usual walking speed (m/s) 1.3 ± 0.3 1.2 ± 0.2 0.03

Slow walking speed (by cutoff <0.8 m/s) 6 (5.0) 17 (3.8) 0.56

Slow walking speed (by cutoff <1.0 m/s) 18 (14.9) 62 (13.8) 0.77

Notes. Values are mean ± standard deviation and n (%).

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Table 2. Characteristics according to age in older men (n=122)

Variables 60~64 (n=25) 65~69 (n=35) 70~74 (n=27) 75~79 (n=24) 80+ (n=11) P

Falls in the year prior research 3 (12.5) 5 (14.7) 3 (11.1) 3 (13.0) 3 (30.0) 0.69

Fear of falling 8 (32.0) 13 (38.2) 8 (30.8) 15 (65.2) 8 (72.7) 0.02

Waist circumference (cm) 99.9 ± 8.3 95.4 ± 8.1 99.6 ± 9.7 97.6 ± 11.3 93.4 ± 11.3 0.16

Hip circumference (cm) 102.3 ± 6 100.2 ± 4.6 100.8 ± 6.3 101.0 ± 7.4 96.4 ± 8.8 0.16

Handgrip strength (kgf) 40.4 ± 8.3 39.3 ± 6.5 37.7 ± 8.7 35.6 ± 6.8 28.6 ± 6.9ǂ < 0.001

Relative handgrip strength

(Adjusted by body mass index)

1.4 ± 0.2 1.4 ± 0.3 1.4 ± 0.4 1.3 ± 0.2 1.2 ± 0.2 0.13

Usual walking speed (m/s) 1.4 ± 0.2 1.4 ± 0.2 1.3 ± 0.3 1.2 ± 0.3† 1.0 ± 0.3

ǂ† < 0.001

Slow walking speed (by cutoff <0.8 m/s) -- -- 1 (3.7) 3 (12.5) 2 (18.2) 0.01

Slow walking speed (by cutoff <1.0 m/s) 1 (4) 1 (2.9) 5 (18.5) 5 (20.8) 6 (54.5) < 0.001

Timed Up and Go (s) 7 ± 1.8 6.6 ± 1.6 7.5 ± 2.10 8.8 ± 3.9† 10 ± 2.4

ǂ† < 0.001

Fat percentage (%) 27.5 ± 5.3 25.2 ± 5.9 26.7 ± 6.3 27.1 ± 5.3 22.3 ± 8.9 0.16

Body mass index (kg/m2) 27.8 ± 3.3 26.5 ± 3.2 27.1 ± 3.5 26.9 ± 3.8 23.4 ± 3.1

ǂ 0.03

Total skeletal muscle mass (kg) 54.4 ± 6.8 52.4 ± 4.4 50.4 ± 6.5 50.8 ± 7.8 44.0 ± 5.7ǂ 0.001

Skeletal muscle mass

(Adjusted by body mass index)

1.9 ± 0.2 1.9 ± 0.2 1.9 ± 0.2 1.9 ± 0.2 1.8 ± 0.2 0.51

Skeletal muscle mass (kg/m2)

(Adjusted by height squared)

18.9 ± 1.2 18.5 ± 1.5 18.4 ± 1.1 18.4 ± 1.5 17.1 ± 1.7ǂ 0.03

Skeletal muscle mass 0.6 ± 0.05 0.7 ± 0.05 0.7 ± 0.05 0.6 ± 0.05 0.7 ± 0.08 0.22

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(Adjusted by weight)

Total appendicular skeletal muscle (kg) 26.3 ± 3.9 25.7 ± 2.8 26.6 ± 4.1 25.3 ± 5.0 21.6 ± 3.7ǂ 0.03

Appendicular skeletal muscle

(Adjusted by body mass index)

0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.9 ± 0.1 0.70

Appendicular skeletal muscle (kg/m2)

(Adjusted by height squared)

9.1 ± 0.8 9.1 ± 0.9 8.9 ± 0.9 9.0 ± 1.1 8.4 ± 1.2 0.34

Appendicular skeletal muscle

(Adjusted by weight)

0.3 ± 0.02 0.3 ± 0.02 0.3 ± 0.03 0.3 ± 0.02 0.3 ± 0.04 0.15

Notes. Values are n (%) and mean ± standard deviation. Tukey Post Hoc test: ǂ: ≠60~64; †: ≠65~69.

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Table 3. Characteristics according to age in older women (n=455)

Variables 60~64 (n=127) 65~69 (n=123) 70~74 (n=102) 75~79 (n=68) 80+ (n=35) P

Falls in the year prior research 25 (20.2) 30 (25.0) 27 (27.0) 21 (31.3) 9 (26.5) 0.52

Fear of falling 75 (60.5) 73 (60.8) 69 (69.7) 49 (73.1) 24 (75) 0.06

Waist circumference (cm) 95.7 ± 10.9 94.9 ± 10.1 97.2 ± 12.1 92.7 ± 10.8 93.3 ± 10.2 0.07

Hip circumference (cm) 104.7 ± 9 102.7 ± 8.9 105.2 ± 11.7 101.7 ± 9.9 100.7 ± 7.3 0.03

Handgrip strength (kgf) 25.5 ± 5 25.1 ± 4.5 24.5 ± 4.4 21.5 ± 3.8ǂ†‖

20.9 ± 4.7ǂ†‖

< 0.001

Relative handgrip strength

(Adjusted by body mass index)

0.8 ± 0.2 0.9 ± 0.2 0.8 ± 0.2 0.8 ± 0.1† 0.8 ± 0.2 0.01

Usual walking speed (m/s) 1.3 ± 0.2 1.3 ± 0.2 1.2 ± 0.2ǂ 1.2 ± 0.3

ǂ† 1 ± 0.3

ǂ†‖‡ < 0.001

Slow walking speed (by cutoff <0.8 m/s) -- 3 (2.5) 1 (1.0) 7 (10.4) 6 (17.6) < 0.001

Slow walking speed (by cutoff <1.0 m/s) 8 (6.5) 11 (9.2) 13 (12.7) 15 (22.4) 15 (44.1) < 0.001

Timed Up and Go (s) 7.0 ± 1.4 7.5 ± 1.9 8.2 ± 2.1ǂ 9.0 ± 2.9

ǂ† 11.0 ± 3.8

ǂ†‖‡ < 0.001

Fat percentage (%) 42.0 ± 6.1 40.9 ± 6.5 42.6 ± 6.7 39.4 ± 6.9‖ 37.3 ± 8.2

ǂ†‖ < 0.001

Body mass index (kg/m2) 29.2 ± 5.5 28.1 ± 4.2 29.1 ± 4.9 27.0 ± 4.3

ǂ‖ 25.9 ± 4.1

ǂ‖ < 0.001

Total skeletal muscle mass (kg) 36.9 ± 3.2 36.5 ± 3.2 35.9 ± 3.3 35.2 ± 3.4ǂ 34.9 ± 3.7

ǂ 0.001

Skeletal muscle mass

(Adjusted by body mass index)

1.3 ± 0.2 1.3 ± 0.1 1.2 ± 0.1 1.3 ± 0.1 1.3 ± 0.2‖ 0.008

Skeletal muscle mass (kg/m2)

(Adjusted by height squared)

15.4 ± 0.8 15.3 ± 0.8 15.4 ± 0.7 15.1 ± 0.6 14.9 ± 0.8ǂ‖ 0.009

Skeletal muscle mass 0.5 ± 0.05 0.5 ± 0.06 0.5 ± 0.05 0.5 ± 0.06ǂ‖ 0.5 ± 0.07

ǂ†‡ < 0.001

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(Adjusted by weight)

Total appendicular skeletal muscle (kg) 16.4 ± 1.7 16.6 ± 1.8 16.4 ± 1.8 16.1 ± 2.0 16.3 ± 2.1 0.62

Appendicular skeletal muscle

(Adjusted by body mass index)

0.5 ± 0.07 0.5 ± 0.07 0.5 ± 0.07 0.6 ± 0.08ǂ 0.6 ± 0.09

ǂ‖ < 0.001

Appendicular skeletal muscle (kg/m2)

(Adjusted by height squared)

6.8 ± 0.6 6.9 ± 0.6 7.1 ± 0.6 6.9 ± 0.6 7.0 ± 0.7 0.15

Appendicular skeletal muscle

(Adjusted by weight)

0.2 ± 0.02 0.2 ± 0.02 0.2 ± 0.02 0.2 ± 0.03ǂ‖ 0.2 ± 0.03

ǂ†‖ < 0.001

Notes. Values are n (%) and mean ± standard deviation. Tukey post hoc test: ǂ: ≠60~64; †: ≠65~69; ‖: ≠70~74; ‡: ≠75~79.

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The ROC curves and comparisons among them are presented in Figure 1.

Regarding ASM, the adjustment by BMI showed the best AUC for the association with fear

of falling. Then, cutoff values were identified for both men (0.85; AUC=0.81; confidence

interval 95% [CI 95%]: 0.73 – 0.89; P <0.001; sensitivity=33.3% and specificity=93.1%;

PPV=73% and NPV=70%; LR+=4.71 and LR-=0.72) and women (0.53; AUC=0.76; CI 95%:

0.71 – 0.81; P <0.001; sensitivity=30.6% and specificity=92.1%; PPV=87% and NPV=41%;

LR+=3.75 and LR-=0.76).

Concerning handgrip strength, absolute values showed slight better AUC than

relative handgrip strength in men, while the AUC of relative handgrip strength showed better

results in women. Considering this, cutoff values for both data will be provided. Thus, in

men, the identified cutoffs for absolute handgrip strength were 30.0 kgf (AUC=0.75; CI 95%:

0.66 – 0.84; P <0.001; sensitivity=39.1% and specificity=94.7%; PPV=81% and NPV=71%;

LR+=6.5 and LR-=0.64), and for women 21.7 kgf (AUC=0.56; CI 95%: 0.51 – 0.62; P=0.02;

sensitivity=29.9% and specificity=73.2%; PPV=67% and NPV=36%; LR+=1.07 and LR-

=0.97). Identified cutoffs for relative handgrip strength were 1.07 (AUC=0.74; CI 95%: 0.65

– 0.83; P <0.001; sensitivity=27.9% and specificity=93.2%; PPV=70% and NPV=69%;

LR+=3.85 and LR-=0.78), and 0.66 (AUC=0.67; CI 95%: 0.62 – 0.73; P <0.001;

sensitivity=22% and specificity=90%; PPV=82% and NPV=39%; LR+=2.2 and LR-=0.86),

for men and women, respectively. For computed 2x2 tables, refer to supplementary Tables

S1 to S6.

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Men

A

B

AUC ASM (adjusted by BMI): 0.81 ASM (adjusted by height squared): 0.66 ASM (adjusted by weight): 0.74 ASM (non-adjusted): 0.73

AUC Handgrip strength (absolute): 0.75 Relative handgrip strength (adjusted by BMI): 0.74

ASM (non-adjusted) ≠ ASM (adjusted by height squared), p = 0.03 ASM (adjusted by BMI) ≠ ASM (adjusted by height squared), p = 0.02

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Women

C

D

Figure 1. ROC curves for appendicular skeletal muscle (ASM) with different adjustments,

and handgrip strength (HGS) (absolute value and adjusted by BMI). Fear of falling was used

as outcome variable. Data of men (A-B) and women (C-D) are presented. Statistical

difference among or between curves were presented, when they occurred. AUC: area under

the curve.

ASM (non-adjusted) ≠ ASM (adjusted by BMI), p<0.001 ASM (adjusted by BMI) ≠ ASM (adjusted by weight), p<0.001 ASM (adjusted by BMI) ≠ ASM (adjusted by height squared), p<0.001 ASM (adjusted by height squared) ≠ ASM (adjusted by weight), p<0.001

Handgrip strength (absolute) ≠ Relative handgrip strength (adjusted by BMI), p<0.001

AUC ASM (adjusted by BMI): 0.76 ASM (adjusted by height squared): 0.43 ASM (adjusted by weight): 0.70 ASM (non-adjusted): 0.55

AUC Handgrip strength (absolute): 0.56 Relative handgrip strength (adjusted by BMI): 0.67

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DISCUSSION

This study presented reference values of strength, physical function tests, body

composition, anthropometric measures, falls, and fear of falling by age in a community-based

cohort of older men and women from 60 years old. Moreover, cutoff values for ASM and

handgrip strength, useful to verify sarcopenia in older adults, were also presented according

to fear of falling.

As extensively reported in the literature, differences by gender concerning ASM,

strength, and body composition were observed, as well as decline in physical function with

increasing aging in older adults. The tests used in this study have clinical relevance, and

reference values of this nature are limited in Brazilian literature, increasing external validity

of this study. Even though some of them presented similar values as found in other

populations, local values are preferable when available, once regional characteristics can alter

results and comparison. This data can be useful for the clinician that needs reference values

to compare observed performance at clinical practice and in research, to compare different

populations.

Evidence from this study highlights the imminent hazard that surrounds the oldest

old group (80 years or more). They showed the highest fear of falling, which might have

impacted on their worst physical performance among groups. It is difficult to predict the

beginning of such cascade effect; however, for health promoters, it is crucial to implement

interventions addressing physical and psychosocial aspects to face these conditions.

The values we found herein for handgrip strength were similar to those shown by

Yoshimura et al., 2011; however, the subjects in this study performed better in walking

speed. Importantly, in such study subjects were categorized by decades and walking speed

was measured in a 6-m path.19

The Asian Working Group for Sarcopenia (AWGS)

recommended using the lower 20th

percentile of handgrip strength of the study population as

the cutoff value for low strength, due to lack of outcome-based cutoff values. Then, they

suggest values of <26 kgf for men and <18 kgf for women.2 Similarly, the European Working

Group on Sarcopenia in Older People (EWGSOP) suggests <30 kgf for men and <20 kgf for

women3 as cutoff values; in this study, we found the cutoffs of 30 kgf for Brazilian men and

21.7 kgf for Brazilian women, when considering absolute handgrip strength values. Despite

the fact we could not contribute providing cutoff values for walking speed in Brazilian older

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adults at this time, both studies (AWGS and EWGSOP) recommend the use of <0.8 m/s as

the cutoff for slow walking performance.2,3

Concerns have been raised regarding the influence of body mass on the

relationships among performance, strength, and muscle mass, especially by the Foundation

for the National Institutes of Health (FNIH Sarcopenia Project), a large sample study that

used multiple existing data sources to identify criteria for clinically relevant weakness and

low lean mass.5,20,21

Then, we performed several analyses to clarify the need to adjust

handgrip strength and muscle mass for body mass. In this sense, we found the cutoffs for

relative handgrip strength adjusted for BMI of 1.07 for men and 0.66 for women. The values

suggested by FNIH Sarcopenia Project were: men with ratio <1.0 and women with a ratio

<0.56 defined as weak.21

The necessity of this adjustment will be further discussed.

Regarding the TUG, Bohannon (2006), in a descriptive meta-analysis verified

mean values (95% confidence intervals - CI) according to age (60 to 69, 70 to 79 and 80 to

99 years) of 8.1s (95% CI=7.1 – 9.0), 9.2s (95 % CI=8.2 – 10.2) and 11.3s (95% CI=10.0 –

12.7), respectively.12

Indicating that those whose performance exceeds the limits of reported

confidence intervals can be considered to have worse than average performance. These

values are within the range we found in this study. Furthermore, considering healthy

Japanese individuals from 60 years or more, Kamide, Takahashi and Shiba (2011) verified

the weighted mean of TUG with maximum effort at 6.60 (95% CI=6.18 – 7.02) seconds, and

that at usual pace was 8.86 (95% CI=7.99 – 9.72) seconds;22

certainly, shorter than other

populations.

The study data presented the decline of physical performance through specific

tests in both genders as age increases, but the changes in skeletal muscle depended on the

adjustment applied. The identified ASM (adjusted by BMI) cutoff values for older adults

according to gender were 0.85 for men and 0.53 for women. Interestingly, the values

proposed by the FNIH sarcopenia project were 0.789 and 0.512, for men and women,

respectively.5 We also verified that adjustments by BMI were the best approach in both

genders; then, we suggest the use of these cutoffs to screen older adults from both sexes for

increasing disability risk, according to fear of falling, being these values a more realistic

approach to Brazilian older individuals.

Because of the adjustments of data we conducted herein, our results are not

directly comparable to other proposed definitions of low ASM or sarcopenia. Initially, both

the EWGSOP and AWGS groups suggested the approach of using – 2 SD of ASM of young

individuals as cutoff points of muscle mass.2,3

However, low muscle mass alone is not

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consistently associated with adverse health outcomes5 challenging new approaches. Then, the

adopted methodology in this study limits our comparisons, but stimulates other researchers to

provide more suitable and comparable data.

Considering the role of body mass, it was different according to gender. In men,

the AUC was slightly lower in the relative than absolute handgrip strength. However, in

women the relative handgrip strength showed better results. Interestingly, a similar finding

was verified by Alley et al. (2014); and even with our small sample size in men’s group and

with a different outcome-based variable we verified a similar condition.20

It remains unclear

why this occurs, and BMI would be more important for women than for men.

To our knowledge, this is the first study providing reference data and cutoff

values adjusted by body mass in Brazilian older adults. We expect that these data will be

useful for both clinicians at practice and researchers, which can use national data regarding

physical function and muscle mass in older adults.

We provided several adjustments of data, but for consistency, we encourage

researchers to use ASM adjusted by BMI and to choose by convenience absolute handgrip

strength or relative handgrip strength adjusted by BMI for both men and women, or even

different types of indicators for each gender. For walking speed, a cutoff value <0.8 m/s, as

previously suggested2,3,5

can be applied to research and clinical practice to identify mobility

impairment. Values of physical function tests and other variables can be used as reference by

age categories as we presented in this study.

The limitations of this study included: (i) its cross-sectional design that did not

permit the determination of a cause-effect relationship between variables; (ii) the small

number of older male subjects; (iii) the retrospective nature of data about the occurrence of

falls that might be biased; and (iv) the use of fear of falling, and no other disability condition

or mortality, as outcome. However, although longitudinal analyses are preferable over cross-

sectional designs, it is appropriate for establishing clinical diagnostic cutoff values.5

Moreover, even though mortality or other disability outcomes seems more representatives to

sarcopenia, fear of falling was highly associated to sarcopenia in older adults23

, as previously

verified, certifying its use. We suggest future studies to recruit a higher number of male

subjects, to use different sampling fields and alternative methods to verify body composition,

such as dual-energy x-ray absorptiometry. In addition, longitudinal studies using disability or

mortality as an outcome are necessary to determine optimal cutoffs for ASM, handgrip

strength and walking speed.

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In summary, we have identified age-related decline in physical function, changes

in body composition and anthropometrical measures. Moreover, cutoff values of handgrip

strength (absolute: men <30 kgf; women <21.7 kgf; and relative: men <1.07; women <0.66)

and ASM (ASM adjusted by BMI: men <0.85; women <0.53) in association with fear of

falling in Brazilian older adults were also provided. Further analyses also suggested that

adjustment for BMI may influence how data can be interpreted. Value of walking speed was

established at <0.8 m/s as previously recommended. In future studies, we intend to evaluate

the capacity of these cutoff values to discriminate those in vulnerable conditions, especially

regarding low quality of life and frailty.

CONCLUSION

The values of physical function tests and the other variables presented by age

groups highlights the hazard surrounding the oldest old. Such data are useful references for

both clinicians at practice and researchers. Moreover, ASM adjusted by BMI was the best

approach, while adjustment of handgrip strength varied by gender. We recommend the use of

ASM adjusted by BMI and to choose over absolute handgrip strength or relative handgrip

strength (adjusted by BMI) for both men and women according to study needs.

REFERENCES

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4. Morley JE, Abbatecola AM, Argiles JM, et al. Sarcopenia with Limited Mobility: An

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5. Studenski SA, Peters KW, Alley DE, et al. The FNIH Sarcopenia Project: Rationale, study,

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12. Bohannon RW. Reference values for the timed up and go test: a descriptive meta-

analysis. J Geriatr Phys Ther. 2006;29(2):64-8.

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Hand Surg. 2012;37(11):2368-73.

14. Florkowski CM. Sensitivity, specificity, receiver-operating characteristic (ROC) curves

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15. Akobeng AK. Understanding diagnostic tests 1: sensitivity, specificity and predictive

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18. Trombetti A, Reid KF, Hars M, et al. Age-associated declines in muscle mass, strength,

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Int. 2016;27(2):463-71.

19. Yoshimura N, Oka H, Muraki S, et al. Reference values for hand grip strength, muscle

mass, walking time, and one-leg standing as indices for locomotive syndrome and associated

disability: the second survey of the ROAD study. J Orthop Sci. 2011;16:768-77.

20. Alley DE, Shardell MD, Peters KW, et al. Grip strength cutpoints for the identification of

clinically relevant weakness. J Gerontol A Biol Sci Med Sci. 2014;69(5):559-66.

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Supplementary tables

Table S1. Appendicular skeletal muscle adjusted by body mass index vs. fear of falling

(Men).

Fear of falling Total

Had fear of falling No fear of falling

ASM(BMI) < 0.85 14 5 19

ASM(BMI) > 0.85 28 67 95

Total 42 72 114

Pearson Chi-square P<0.001. ASM(BMI)= Appendicular skeletal muscle adjusted by body

mass index.

Sensitivity: {14/(14+28)}=0.33=33%

Specificity: {67/(5+67)}=0.93=93%

Positive predictive value (PPV): {14/(14+5)}=0.73=73%

Negative predictive value (NPV): {67/(28+67)}=0.70=70%

Positive likelihood ratio (LR+): sensitivity/(1-specificity)=4.71

Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.72

Table S2. Absolute handgrip strength vs. fear of falling (Men).

Fear of falling Total

Had fear of falling No fear of falling

Absolute HGS < 30 kgf 18 4 22

Absolute HGS > 30 kgf 28 71 99

Total 46 75 121

Pearson Chi-square P<0.001. HGS= Handgrip strength.

Sensitivity: {18/(18+28)}=0.39=39%

Specificity: {71/(4+71)}=0.94=94%

Positive predictive value (PPV): {18/(18+4)}=0.81=81%

Negative predictive value (NPV): {71/(28+71)}=0.71=71%

Positive likelihood ratio (LR+): sensitivity/(1-specificity)=6.5

Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.64

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Table S3. Relative handgrip strength vs. fear of falling (Men).

Fear of falling Total

Had fear of falling No fear of falling

HGS(BMI) < 1.07 12 5 17

HGS(BMI) > 1.07 31 69 100

Total 43 74 117

Pearson Chi-square P=0.002. HGS(BMI)= Handgrip strength adjusted by body mass index.

Sensitivity: {12/(12+31)}=0.27=27%

Specificity: {69/(5+69)}=0.93=93%

Positive predictive value (PPV): {12/(12+5)}=0.70=70%

Negative predictive value (NPV): {69/(31+69)}=0.69=69%

Positive likelihood ratio (LR+): sensitivity/(1-specificity)=3.85

Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.78

Table S4. Appendicular skeletal muscle adjusted by body mass index vs. fear of falling

(Women).

Fear of falling Total

Had fear of falling No fear of falling

ASM(BMI) < 0.53 84 12 96

ASM(BMI) > 0.53 194 140 334

Total 278 152 430

Pearson Chi-square P<0.001. ASM(BMI)= Appendicular skeletal muscle adjusted by body

mass index.

Sensitivity: {84/(84+194)}=0.30=30%

Specificity: {140/(12+140)}=0.92=92%

Positive predictive value (PPV): {84/(84+12)}=0.87=87%

Negative predictive value (NPV): {140/(194+140)}=0.41=41%

Positive likelihood ratio (LR+): sensitivity/(1-specificity)=3.75

Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.76

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Table S5. Absolute handgrip strength vs. fear of falling (Women).

Fear of falling Total

Had fear of falling No fear of falling

Absolute HGS < 21.7 kgf 87 42 129

Absolute HGS > 21.7 kgf 204 115 319

Total 291 157 448

Pearson Chi-square P=0.48. HGS= Handgrip strength.

Sensitivity: {87/(87+204)}=0.29=29%

Specificity: {115/(42+115)}=0.73=73%

Positive predictive value (PPV): {87/(87+42)}=0.67=67%

Negative predictive value (NPV): {115/(204+115)}=0.36=36%

Positive likelihood ratio (LR+): sensitivity/(1-specificity)=1.07

Negative likelihood ratio (LR-): (1-sensitivity)/specificity=0.97

Table S6. Relative handgrip strength vs. fear of falling (Women).

Fear of falling Total

Had fear of falling No fear of falling

HGS(BMI) < 0.66 kgf 65 14 79

HGS(BMI) > 0.66 kgf 218 141 359

Total 283 155 438

Pearson Chi-square P < 0.001. HGS(BMI) = Handgrip strength adjusted by body mass index.

Sensitivity: {65/(65+218)} = 0.22 = 22%

Specificity: {141/(14+141)} = 0.90 = 90%

Positive predictive value (PPV): {65/(65+14)} = 0.82 = 82%

Negative predictive value (NPV): {141/(218+141)} = 0.39= 39%

Positive likelihood ratio (LR+): sensitivity/(1-specificity) = 2.2

Negative likelihood ratio (LR-): (1-sensitivity)/specificity = 0.86

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SARCOPENIA CUTOFFS IN BRAZILIAN OLDER ADULTS ARE ASSOCIATED

TO HEALTH-RELATED QUALITY OF LIFE

ABSTRACT

As age increases, physical limitations become frequent and might be related to

sarcopenia, with implications in older adults’ health-related quality of life (HRQOL). The

aim of this study was to verify the relationship of cutoffs for appendicular skeletal muscle

adjusted by body mass index (ASM(BMI)), absolute handgrip strength (HGS(ABS)), relative

handgrip strength adjusted by BMI (HGS(BMI)) and walking speed (WS), as well as the

combination of these factors, with HRQOL in older adults. This study had a cross sectional

design and 577 older adults (men n=122, women n=455) participated. All of them had

collected information about age and the Short-form 8 (SF-8); and the BMI, appendicular

muscle mass, the WS, and handgrip strength. To compare older adults’ characteristics,

unpaired t tests and chi-square tests or Fisher’s exact test were used. Variables were

categorized as normal and low HGS(ABS) and/or WS; normal and low HGS(BMI) and/or WS;

normal and low ASM(BMI); normal and low HGS(ABS) and/or WS plus ASM(BMI); and normal

and low HGS(BMI) and/or WS plus ASM(BMI). Point biserial correlation coefficient was run to

determine the relationship between these categories and HRQOL. In men, the results of the

combination HGS(ABS) and/or WS were linked to SF-8 physical functioning, role-physical

and general health domains. In women, the combination of the three factors, HGS (both,

absolute and adjusted by BMI) and/or WS plus ASM(BMI) showed associations with physical

functioning, role-physical, bodily pain, general health and social functioning. Physical and

mental components of HRQOL were associated with the specific cutoffs.

KEYWORDS: Aging; Cutoffs; Muscle mass; Physical function; Sarcopenia.

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INTRODUCTION

As age increases, physical limitations become frequent and might be related to

sarcopenia, the progressive loss of muscle mass and strength/functionality with aging,1 with

implications in older adults’ health-related quality of life (HRQOL).

Several studies verified that HRQOL is related to physical activity levels,

physical function, chronic disease, self-rated health and others;2,3,4,5

sharing common

associated factors with sarcopenia.

Previously, we identified cutoffs of appendicular skeletal muscle mass adjusted

by body mass index [ASM(BMI)] (<0.85 and <0.53, for men and women), absolute handgrip

strength [HGS(ABS)] (<30.0 kgf and <21.7 kgf for men and women) and handgrip strength

adjusted by BMI [HGS(BMI)] (<1.07 and <0.66 for men and women)6; walking speed (WS)

<0.8 m/s was considered as mobility impairment.1,7,8

These values are useful to identify

vulnerable older adults, especially because muscle mass and strength are subject to ethnic

differences9 and to provide local data.

Specific cutoffs seem effective to identify morphological and functional changes

in older adults; however, aging process goes beyond physical changes and is associated to

several psychosocial alterations. This made us hypothesize their ability to identify differences

in HRQOL in older adults.

Therefore, the aim of this report was to verify the relationship of specific cutoffs

for ASM(BMI), HGS(ABS), HGS(BMI) and WS, as well as the combination of these factors, with

HRQOL in older adults.

METHODS

Design

This study had a cross sectional design and was approved by the Ethical

Committee of the University of Campinas, protocol #39437514.0.0000.5404. All participants

signed an informed consent agreeing to participate in the study before data collection.

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Subjects

In total, 577 older adults (men n=122, women n=455) participated in this study.

They were recruited in community health centers in southeastern and southern Brazil.

The inclusion criteria were: a) community-dwelling people; b) 60 years old or

older, from both sexes; c) able to answer the questions, perform the physical and body

composition tests.

Exclusion criteria were: a) individuals with uncontrolled cardiovascular or

pulmonary disease, with conditions associated with risk of falling (e.g., Parkinson’s disease

or stroke); b) individuals using metal prosthesis and/or pacemaker (i.e. interference

bioelectrical impedance analysis).

Assessments

All participants had collected by questionnaire the information about age and

HRQOL [by the Short-form 8 items (SF-8)]; and had objectively measured BMI,

appendicular muscle mass by bioelectrical impedance analysis, the WS, and handgrip

strength. For those illiterate, SF-8 was performed by interview.

The SF-8 is a brief, generic, and multipurpose survey of health status. It is

composed by eight domains: physical functioning, role-physical, bodily pain, general health,

vitality, social functioning, role-emotional, and mental health. Among its application, it has

been used for evaluating and monitoring functioning and well-being of populations.10

Appendicular muscle mass was assessed by bioelectrical impedance analysis

(Tanita® BC-108, Tokyo, Japan). The equipment provided the subject’s weight, and height

was inserted manually by the researcher. After analysis, values of BMI and segmented

muscle mass were obtained. The equipment uses a frequency of 50 kHz to measure the

quantity of intra and extracellular water in the body; it has eight electrodes, four under the

feet and four on volunteers’ hands.11,12

The WS was evaluated in a 10 meters distance. Outside marks of 12 m in length

were clearly placed on the ground during the walking test. Another 10-m long delimitation

was marked inside the previous one. Participants were asked to walk the entire distance at

their usual pace. The time required to complete the inner 10-m distance was assessed.13

And handgrip strength was measured with a digital dynamometer Jamar (Jamar

Plus+®; Sammons Preston, Rolyon, Bolingbrook, IL). While seated, the subject held the

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dynamometer with elbow flexed in 90° without touching his/her body. Then, they were

instructed to pull the lever at their maximum; each hand was tested once. Subjects were also

instructed to avoid the Valsava maneuver or blocked breath while performing the test. As

standard, handle position two was set for all participants.14

Statistical analyses

Values are presented as mean ± standard deviation for continuous variables and

frequency (%) for categorical values. To compare older adults’ characteristics, unpaired t

tests were used for continuous variables, while chi-square tests or Fisher’s exact test were

used for categorical variables.

Appendicular muscle mass, handgrip strength and WS were adjusted and/or

divided by specific cutoffs. ASM(BMI) cutoffs were <0.85 and <0.53, for men and women;

HGS(ABS) cutoffs were <30.0 kgf and <21.7 kgf, for men and women; and 1.07 and 0.66 for

HGS(BMI), for men and women.6 WS <0.8 m/s was considered mobility impairment according

to previous recommendations.1,7,8

Continuous values of appendicular muscle mass, handgrip strength and WS were

used to characterize participants. Moreover, such variables were categorized as (i) normal

and low HGS(ABS) and/or WS; (ii) normal and low HGS(BMI) and/or WS; (iii) normal and low

ASM(BMI); (iv) normal and low HGS(ABS) and/or WS plus ASM(BMI); and (v) normal and low

HGS(BMI) and/or WS plus ASM(BMI).

Point biserial correlation coefficient was run to determine the relationship

between (i) to (v) categories and HRQOL.

Statistical significance was set at P <0.05 and all analyses were carried out using

the Statistical Package for the Social Sciences (version 21.0, SPSS, IBM Inc., Chicago, IL,

USA).

RESULTS

Table 1 represents participants’ general characteristics. Men had more years of

education and were more engaged on work activities. In addition, they had lower BMI and

polypharmacy than women; moreover, men presented more total and adjusted appendicular

muscle mass and better performance on HGS(ABS) and HGS(BMI) and WS. Regarding

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HRQOL, men presented better results on role-physical, bodily pain, social functioning, role-

emotional and mental health than women (Table 1).

Table 2 presents point biserial correlations for different cutoffs combinations

for men, considering strength and physical function; and strength and physical function plus

ASM(BMI) with HRQOL. Most of the combinations showed similar results, varying on the

coefficient of correlation (Rpb)) found, except for the combination HGS(BMI) and/or WS.

Results were especially linked to SF-8 physical functioning, role-physical and general health

domains.

Table 3 presents point biserial correlations for different cutoffs arrangements for

women. The combination of the three factors, HGS (both absolute and adjusted by BMI)

and/or WS plus ASM(BMI) showed the best approach in the association with HRQOL. Even

though the Rpb coefficients were lower than those found for men, they were statistically

significant.

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Table 1. Subjects’ general characteristics.

Variables Men (n=122) Women (n=455) P

Age (y) 70.5 ± 6.7 69.4 ± 6.5 0.11

Educational level <0.001

Illiterate 6 (5%) 14 (3.1%)

Elementary school 43 (35.8%) 215 (47.7%)

Junior high school 22 (18.3%) 95 (15.1%)

High school 15 (12.5%) 68 (15.1%)

Technical school 15 (12.5%) 9 (2%)

University 19 (15.8%) 50 (11.1%)

Work status 0.007

None/retired 82 (68.3%) 347 (78.7%)

Formal work 2 (1.7%) 18 (4.1%)

Autonomous work 14 (11.7%) 41 (9.3%)

Farmwork 14 (11.7%) 17 (3.9%)

Other 8 (6.7%) 18 (4.1%)

BMI (kg/m2) 26.8 ± 3.5 28.3 ± 4.9 <0.001

HGS(BMI) 1.4 ± 0.3 0.8 ± 0.2 <0.001

HGS(ABS) 37.4 ± 8.1 24.2 ± 4.8 <0.001

Walking speed (m/s) 1.3 ± 0.3 1.2 ± 0.2 0.03

Walking speed < 0.8 m/s 6 (5%) 17 (3.8%) 0.60

ASM(BMI) 0.95 ± 0.13 0.59 ± 0.08 <0.001

Total ASM (kg) 25.2 ± 4.0 16.4 ± 1.8 <0.001

Polypharmacy 15 (12.6%) 95 (22%) 0.02

Non-engaged on PA 30 (25.2%) 96 (21.2%) 0.34

< 150 min of PA/wk 63 (57.3%) 253 (59.4%) 0.68

SF-8 PF 48.1 ± 7.3 47.7 ± 8.1 0.58

SF-8 RP 50.5 ± 6.3 48.9 ± 7.8 0.02

SF-8 BP 52.8 ± 8.8 48.9 ± 10.0 <0.001

SF-8 GH 46.2 ± 5.8 46.2 ± 7.1 0.96

SF-8 VT 49.6 ± 8.5 50.7 ± 8.7 0.28

SF-8 SF 51.7 ± 5.4 50.2 ± 7.3 0.02

SF-8 RE 51.8 ± 6.3 48.6 ± 8.7 <0.001

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SF-8 MH 49.4 ± 6.2 48.0 ± 6.8 0.03

Values are mean ± standard deviation or frequency (%). BMI: body mass index; HGS(BMI):

handgrip strength adjusted by the body mass index; HGS(ABS):handgrip strength absolute

values; ASM(BMI): appendicular muscle adjusted by the body mass index; ASM: appendicular

skeletal muscle; PA/wk: physical activity/week; SF: short-form; PF: physical functioning;

RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning;

RE: role-emotional; MH: mental health.

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Table 2. Point biserial correlations for different cutoffs and combinations, and health-related quality of life (men, n=122).

Variables Normal (n=97) and low

HGS(ABS) and/or WS

(n=25)

Normal (n=113) and

low HGS(BMI) and/or

WS (n=9)

Normal (n=95) and

low ASM(BMI) (n=19)

Normal (n=110) and

low HGS(ABS) and/or

WS + ASM(BMI) (n=11)

Normal (n=111)

and low HGS(BMI)

and/or WS +

ASM(BMI) (n=11)

Rpb P Rpb P Rpb P Rpb P Rpb P

SF-8 PF -0.19 0.04 -0.005 0.96 -0.29 0.002 -0.24 0.01 -0.25 0.007

SF-8 RP -0.26 0.005 0.10 0.30 -0.31 0.001 -0.41 <0.001 -0.38 <0.001

SF-8 BP -0.10 0.30 0.11 0.22 -0.60 0.55 -0.89 0.36 -0.11 0.24

SF-8 GH -0.18 0.04 -0.01 0.91 -0.03 0.73 -0.10 0.27 -0.08 0.35

SF-8 VT -0.12 0.18 0.21 0.02 -0.11 0.26 -0.95 0.32 -0.10 0.26

SF-8 SF -0.11 0.22 0.02 0.77 -0.18 0.06 -0.14 0.13 -0.14 0.14

SF-8 RE 0.10 0.29 0.07 0.46 -0.76 0.44 -0.10 0.28 0.01 0.89

SF-8 MH -0.07 0.42 0.03 0.69 0.009 0.92 -0.06 0.52 -0.008 0.93

SF: short-form; PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-

emotional; MH: mental health.

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Table 3. Point biserial correlations for different cutoffs and combinations, and health-related quality of life (women, n=455).

Variables Normal (n=318) and

low HGS(ABS) and/or

WS (n=137)

Normal (n=364) and

low HGS(BMI) and/or

WS (n=91)

Normal (n=334) and

low ASM(BMI) (n=96)

Normal (n=417) and

low HGS(ABS) and/or

WS + ASM(BMI) (n=38)

Normal (n=410)

and low HGS(BMI)

and/or WS +

ASM(BMI) (n=45)

Rpb P Rpb P Rpb P Rpb P Rpb P

SF-8 PF -0.04 0.36 -0.08 0.08 -0.17 <0.001 -0.16 <0.001 -0.14 0.002

SF-8 RP -0.07 0.11 -0.08 0.06 -0.18 <0.001 -0.16 0.001 -0.12 0.01

SF-8 BP -0.06 0.14 -0.10 0.02 -0.16 0.001 -0.16 0.001 -0.13 0.006

SF-8 GH -0.003 0.95 -0.06 0.15 -0.11 0.02 -0.11 0.01 -0.13 0.004

SF-8 VT -0.05 0.21 -0.04 0.40 -0.09 0.06 -0.09 0.05 -0.07 0.13

SF-8 SF -0.07 0.11 -0.05 0.25 -0.04 0.31 -0.11 0.01 -0.10 0.02

SF-8 RE 0.07 0.10 0.05 0.22 -0.04 0.37 -0.001 0.98 -0.02 0.61

SF-8 MH -0.01 0.70 0.02 0.60 -0.03 0.53 -0.02 0.57 -0.03 0.46

SF: short-form; PF: physical functioning; RP: role-physical; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role-

emotional; MH: mental health.

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DISCUSSION

This study tested associations of different combinations of cutoff values

(HGS(ABS), HGS(BMI), WS and ASM(BMI)) with HRQOL in Brazilian older adults. It aimed to

verify their ability to be associated with psychosocial factors beyond morphological aspects

and physical function.

To characterize normal and low values, we used the cutoffs we previously

identified for each variable in association to fear of falling.6 Fear of falling is highly

associated to sarcopenia;15

thus, representative of disability. A walking speed < 0.8 m/s was

used to represent mobility impairment.1,7,8

.

When combining strength and physical function variables, was considered the

association between strength and walking speed.16

In addition, the small number of

participants with slow walking, made impossible consider this category alone.

Several differences by sex concerning educational level, work status, muscle

mass, strength, walking speed and BMI were observed. In addition, women had more

polypharmacy and worse HRQOL scores on role-physical, bodily pain, social functioning,

role-emotional and mental health than men.

The abovementioned sex differences are well reported in the literature16,17,18,19

and some factors may be involved in this condition. In a cross-sectional study involving 2420

individuals (725 men and 1695 women, > 40 years old) Campolina et al. (2011) verified, by

the SF-8, that women had worse HRQOL scores in most domains, as we also verified.17

Furthermore, men had less polypharmacy comparing to women. Similar findings were

verified by Sebastião et al. (2009) when authors verified that men had a better perception of

HRQOL and less use of medications than women.18

Concerning physical function, higher fat mass was associated with slower

walking speed and greater likelihood of functional limitation, while higher lean mass was

associated with increased handgrip strength.19

Moreover, being overweight was correlated

with impaired HRQOL (also measured by the SF-8) but not with mental HRQOL (n=2399).20

Dealing with the association of strength and/or function, muscle mass alone, and

the combination of strength and/or function plus muscle mass with HRQOL, similar results

were found for men, except for the condition HGS(BMI) and/or WS that showed significant

association only for vitality. In our previous study, HGS(ABS) showed the best cutoff for men,6

and this situation seems sustained. The other approaches we followed herein were similar

among them; however, the combination of HGS(ABS) and/or WS showed association with

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physical functioning, role-physical and general health domains of the SF-8. In the others,

general health domain did not show significant associations. This might represent that

strength and function are important factors for apparently healthy older men, more than

muscle mass itself.

In fact, some reports have been provided stating that although muscle strength

and mass are highly correlated, low muscle mass did not explain the strong association of

strength with mortality, demonstrating that muscle strength as a marker of muscle quality is

more important than quantity in estimating mortality risk.16

Although it is more important

than quantity to estimate mortality risk; regarding HRQOL in older women, it seems that

strength and/or function plus quantity was more relevant than strength and function alone.

Contrastingly, when analyzing the association between sarcopenia, sarcopenic

obesity and muscle strength and variables related to HRQOL (Short-form 36) in elderly

women (n=56, age=64.9 ± 5.7 years), Silva Neto et al. (2012) verified that although there

were no statistically significant differences between the studied parameters and HRQOL

among those with sarcopenia or sarcopenic obesity, the values were lower in affected

individuals. Interestingly, handgrip strength correlated positively and significantly with all of

the SF-36 dimensions except vitality and mental health.21

Our results do not explain why different results were found by sex; however,

HRQOL is a subjective measure and individual factors, including living environment,

educational level, working status and others, should be taken into account when analyzing it.

Indeed, environmental factors and educational level are essential in determine a person

HRQOL.17,22

The limitations of this study included: (i) its cross-sectional design that did not

permit the determination of a cause-effect relationship between variables; (ii) the small

number of older subjects with slow walking speed that impede analyze this variable alone.

The evidences from this study were that the combination of low strength, slow

walking and low muscle mass was associated with poorer HRQOL results in older adults. In

men, this association was identified especially by strength and/or function in physical

functioning, role-physical and general health domains; while in women, the combination of

strength, walking and muscle showed association with physical functioning, role-physical,

bodily pain, general health and social functioning. Then, physical and mental components

were associated with the specific cutoffs.

This study is useful once the development of approaches aiming to identify those

at risk of develop a pathological condition is imperative. We provided comparable data that

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can be useful for researchers and clinical professionals when evaluating HRQOL in older

adults.

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with quality of life between Japanese older adults living in rural and urban areas. Journal of

Clinical Gerontology and Geriatrics. 2013;4:51-56.

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INFLUENCE OF POWER TRAINING ON PHYSICAL FUNCTION AND HEALTH-

RELATED QUALITY OF LIFE IN INSTITUTIONALIZED FRAIL OLDER

ADULTS: A CASE-STUDY

ABSTRACT

Frailty is a syndrome composed by physical and psychological aspects that can

lead to institutionalization and mortality. This study verified the influence of power training

on physical function and health-related quality of life (HRQOL) in institutionalized frail older

adults. Eleven participants (men n=5, 74 ± 8.3 years; women n=6, 83.8 ± 5.5 years)

concluded all research procedures and had collected physical function tests and

questionnaires before and after intervention. The physical training lasted 16 weeks (2x/week,

60 min/session, using elastic bands) and was composed by upper and lower limbs exercises,

in which participants had to perform the concentric actions as fast as possible. At baseline,

Mann Whitney U test and Fisher’s exact test were used. To compare moments, Wilcoxon

Signed Ranks tests were performed and Cohen’s d test was used to verify the effect size.

After intervention, we observed improvements on HRQOL domains physical functioning

[P=0.04, d=1.39], role-physical [d=1.18], bodily pain [P=0.04, d=1.62], role-emotional

[d=0.66] and the physical component summary [P=0.04, d=2.31] of SF-36, in men. In

women, role-physical (d=1.03) and role-emotional (d=0.82) showed small magnitude of

changes. Concerning physical function, improvements in walking at usual (d=0.75) and

maximum speeds (d=0.52); and number of repetitions in the elastic band rowing test (EBRT)

(P=0.004, d=1.30) were observed in men. In women, maximum walking speed (P=0.02,

d=0.98), EBRT (d=0.83) and the timed up and go (P=0.02, d=1.41) showed better results

after intervention. Power training is a useful strategy to promote physical function and

HRQOL in institutionalized older adults.

KEYWORDS: Aging; Exercise; Elastic bands; Frailty; Long-term care institution.

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INTRODUCTION

Frailty is a geriatric syndrome composed by physical and psychological aspects.1

It is associated to sarcopenia, functional impairment, and decline in quality of life.2

Moreover, frailty is reversible but if not adequately approached often lead to higher

institutionalization and mortality rates.1

According to Santiago and Mattos (2014), evidences regarding frailty are

alarming in Brazil. A study verified that the prevalence of frailty reached 52% in 442 older

adults living in a long term institution when using the Tilburg Frailty Indicator.3 Similar

results we found previously when analyzing aged people from day care centers using the

Kihon Checklist (KCL), 52%; while in community-dwelling older adults, frail represented

approximately 45% of the individuals.4

Studies have been developed to verify the reversibility condition of frailty

through strength and power training (i.e., strength multiplied by speed) or multicomponent

exercises in community-dwelling, and institutionalized older adults.5,6,7,8,9

And verified

improvement on strength, muscle power output, functional outcomes, and decreased fear of

falling and risk of falls.

Thus, considering that (i) strength and power training are important non-

pharmacological approaches to maintain physical and morphological functions; (ii) studies

about exercise protocols involving different muscle groups and cadence of movement in

institutionalized older people are still scarce; (iii) the importance in evaluate health-related

quality of life (HRQOL), since it is often affected due to institutionalization (e.g., by the need

to adapt to a new routine, need of sharing personal environment, living away from

relatives);10

the aim of this study was to verify the influence of power training on physical

function and HRQOL in institutionalized frail Brazilian older adults.

METHODS

This was a case-study, using power training as therapeutic intervention on frail

older adults from a long term care institution (LTCI) in southeastern Brazil. According to the

Brazilian Sanitary Agency (acronym in Portuguese ANVISA), LTCI’s are institutions

maintained by the government or not, destined to promote integral attention assuring equal

conditions of liberty and dignity to residency, in which target-population is people aged over

60 years old, regardless family support, costless or private organizations. Each institution has

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maximum capacity of 40 residents. Multidisciplinary team includes medical doctors, nurse,

nutritionist and physical therapist, with strategies to promote health.11

Although they follow

common regulations, LTCI’s has peculiarities and own demands. Therefore, we decided to

study a single LTCI in this research that was chosen because there weren’t physical exercise

intervention included on residents’ routine. The LTCI had in total, 37 residents, all of them

over 60 years old. The multidisciplinary team was composed by geriatrician, nutritionist,

nurse, technical nursing staff, social assistant, and volunteers (e.g., physical therapist,

occupational therapist, and psychologist).

The geriatrician made the preliminary screening of all residents to verify who

were able to participate in this study, ensuring their safety during intervention. From them, 17

were allowed to begin the data collection. Inclusion criteria were: to live in the LTCI for at

least 3 months; be diagnosed as frail by the institution’s geriatrician and by the KCL; and be

able to perform physical activity and answer to the questionnaires. Were excluded residents

with heart or pulmonary diseases, musculoskeletal impairment, diseases associated to

increasing risk of falls (i.e., Parkinson’s disease or stroke); cognitive impairment according to

the Mini-mental State Examination (MMSE); use of pacemaker; any other condition that

affect physical activity or the understanding about research procedures; and frequency in

exercise sessions less than 75%.

Residents that succeeded the initial screening and were willing to participate in

this study signed an informed consent. This study was approved by the Ethical Committee of

University of Campinas, protocol #47092115.4.0000.5404.

From the initial 17 subjects allowed by the geriatrician to participate in this study,

11 concluded all research procedures. Figure 1 is a flowchart of study procedures. During the

study period, one participant died of causes unrelated to the exercise intervention, and three

others had fall incidents; one of them was recurrent and with medical complications, which

induced dropout from the study. The falls incidents did not happen during exercise sessions.

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Figure 1. Flowchart of study procedures.

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Assessments

Data collections were performed in two moments: 1) pre-intervention (one week

before training program); and 2) on the week after intervention (17th

week). All participants

had collected (i) physical function tests (i.e., walking speed, handgrip strength, the timed up

and go [TUG], and the elastic band rowing test [EBRT]); and (ii) answered questionnaires

(i.e., socio-demographic and lifestyle topics, KCL and the Short-form 36 [SF-36] for

HRQOL). The KCL was collected only at baseline to characterize individuals according to

frailty status. Aiming to avoid physical or mental distress, each data collection was divided in

two consecutive days. All assessments were performed by the same researcher to avoid

interevaluator bias. Moreover, to minimize the risk of accidents, each participant was assisted

during tests by at least two researchers.

Physical function tests

To verify the usual walking speed, the participants were asked to walk 12 meters

in a normal cadence. To assess maximum walking speed, they were requested to walk the

same distance at their maximum pace, returning to the initial position. Even though they

walked 12 meters in each length, only the time to complete the inner 10 meters was registered

(disregarding one meter by side to avoid acceleration and deceleration).12

Handgrip strength was verified with a Jamar digital dynamometer (Jamar Plus+®;

Sammons Preston, Rolyon, Bolingbrook, IL) once on each hand, the best value achieved was

used in analysis. Moreover, relative handgrip strength adjusted by BMI was also used.13

The

participants, while seated, were asked to push the dynamometer using maximum strength.

Elbows were kept at 90 degrees, without touching their bodies. Volunteers were requested to

avoid Valsava like maneuvers during the test.

In the TUG, the participants had to stand from a chair, walk three meters in

straight line, return and sit again. They were not allowed to run during this test, but were

encouraged to safely perform the test as fast as possible.14

The EBRT is a test designed to verify upper limbs muscle function. For this,

Thera-Band® was used (i.e., blue bands for women, and black bands for men) with the same

length of participant’s arm (from the olecranon to the greater tubercle [humerus]). The

participants, while standing, had to hold the elastic band on the dominant hand; on the other

extremity, the elastic band was fixed in a bar at the same height of participant’s elbow. The

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movement recruited three joints simultaneously (elbow, shoulder and scapulothoracic) and

the radioulnar joint had to stay in a semi pronated grip during the test. The participant’s

elbow joint started from a full extension to full flexion, and full shoulder extension;

participant’s hand had to finish each movement at the anterolateral of the trunk. This test

lasted 15 seconds, and the participant had to perform the maximum number of repetitions

within this time. Important to mention, eccentric muscle actions had to be controlled to assure

safety and integrity of the joints involved in this task.15

Questionnaires

At baseline, the participants had socio-demographic and lifestyle information

collected. Data included, but were not restricted to age, educational level, time living at the

LTCI, history of falls, and medical history. The frailty syndrome was approached by the 25

items of the KCL as complement to the geriatrician assessment. This instrument is separated

into domains (i.e., instrumental activities of daily living, physical function, nutrition, eating,

socialization, memory, and mood) and a score higher than seven suggest a frail health

condition.16

At baseline and after intervention, the HRQOL was assessed by the SF-36

questionnaire. It is a questionnaire composed by eight domains: physical functioning, role-

physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental

health; and two summaries of specific physical and mental domains.17

All questionnaires

were performed by interview.

Physical training protocol

The physical training lasted 16 weeks, twice a week, with 72 h interval between

sessions. Each session lasted approximately 60 minutes, and was supervised by a physical

education professional. Besides, it was used elastic bands (Theraband®) to induce external

resistance, aiming to promote a positive and effective response from the training, also

favoring accessibility, low cost, and easy to perform exercises.

During the first four weeks, participants had a period of familiarization and

adaptation. In this phase, they were taught the correct movements (i.e., chest press [pectoralis

major muscle], squat [lower limbs muscles], seated rowing [dorsal muscles], plantar flexion

[triceps surae muscle], front lift [deltoid and upper pectoral], elbow curl [elbow flexor

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muscles], hip abduction [leg and gluteus muscles], and hip flexion (knee at 90 degrees) [thigh

muscles]. Importantly, in this phase, participants were instructed about how to use the elastic

bands, starting from those with low resistance (e.g., yellow band), and progressively

increasing to those with higher resistance. Intensity planned to this stage was “easy” and

controlled by the Borg Scale adapted by Foster et al. (2001), and the number of repetitions

was 10-15. During the first week, a single set was performed and from the second week

ahead, multiple sets (e.g., two or three). Warm-up was composed by the same exercises for

each muscle group; however, using a set with 12-15 repetitions, in a “very easy” to “easy”

intensity. Interval was 1-2 two minutes and/or respecting participants’ recovery.

To monitor training loads it was used the session rating of perceived effort

(SRPE), proposed by Foster et al. (2001), in which the researcher asks to each participant

individually “How was your training?” 30 minutes after the end of the session.18

In this

research, we verified this data after 10 minutes,19

and the participant answered according to

his/her global perception indicating a value 0 to 10 in the Borg Scale CR-10.18

The first four

weeks was also useful to participants familiarize how to report their efforts by the Borg CR-

10 scale. The SRPE information was registered from the fifth week to the end of intervention.

And for analytical purposes, mean SRPE was calculated in two moments, values regarding

the fifth to eighth week (initial intensity), and 12th

to 16th

week (final intensity).

From the fifth week of intervention, participants performed the power training.

Considering study protocol, intensity was progressively increased by changing elastic bands

monthly (i.e., yellow, red, green and blue). Intensity of elastic bands by color can be found in

our previous study.20

When performing concentric actions, participants were asked to perform

as fast as possible, aiming to promote neuromuscular adaptations to increase muscle power;

and during eccentric actions, cadence was slower (e.g., between three to six seconds to assure

safety and integrity of the joints involved in the exercise); following other protocols designed

to promote power, strength and hypertrophy.21,22,23

Statistical analyses

Variables are presented as mean ± standard deviation or frequency (%). At

baseline, variables were compared by Mann Whitney U test and Fisher’s exact test. Then,

Wilcoxon Signed Ranks tests were performed to verify differences pre and post intervention

in older men and women. Finally, to verify the effect size (d), Cohen’s d test was performed.

Interpretation of the magnitude of effect sizes in strength training research followed Rhea

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(2004) (i.e., magnitude of effect sizes in strength training research in untrained individuals:

<0.5 trivial; 0.50 - 1.25 small; 1.25 - 1.9 moderate; and >2.0 large).24

Statistical difference

was set at P <0.05. All analyses were conducted using the Social Package for the Social

Sciences (SPSS, IBM Inc., Chicago, IL, USA), version 20.0.

RESULTS

In total, 11 participants (men n=5, 74 ± 8.3 years; women n=6, 83.8 ± 5.5 years)

concluded all research procedures. Table 1 presents subjects general characteristics. Most of

them had low educational level; institutionalization period longer than 4 years, fall

experience in previous year and polypharmacy. Important to note, participants presented

similar characteristics regarding educational level, institutionalization time, falls,

hospitalization, previous femur or hip fracture, number of medications and frailty scores even

though women were older than men. Important to mention, in addition to the geriatrician’s

diagnosis, all the subjects were identified as frail according to the KCL (Table 1).

Table 2 presents subjects pre and post results for HRQOL. In men, there were

improvements on physical functioning (P=0.004, d=1.39), role physical (d=1.18), bodily pain

(P=0.04, d=1.62), role emotional (d=0.66) and the physical component summary (P=0.004,

d=2.31) of SF-36. In women, role physical (d=1.03), role emotional (d=0.82) and mental

health (d=0.69) showed small magnitude of changes by the intervention (Table 2).

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Table 1. Participants’ general characteristics at baseline according to sex.

Variable Men (n=5) Women (n=6) P

Age (y) 74.0 ± 8.3 83.8 ± 5.5 0.05

Education 1.00

Illiterate 1 (20) --

Elementary school 3 (60) 4 (66.7)

High School -- 1 (16.7)

Technical School 1 (20) --

University -- 1 (16.7)

Time at institution (y) 4.6 ± 2.70 4.17 ± 5.67 0.42

Smoking (yes) 2 (40) -- 0.18

Alcohol (yes) -- 1 (16.7) 1.00

Fall in previous year 0.74

No 1 (20) 3 (50)

1 fall 3 (60) 2 (33.3)

2 ~ 4 falls 1 (20) 1 (16.7)

Hospitalization in 6 months (yes) 1 (20) -- 0.45

Previous femur or hip fracture 2 (40) 2 (33.3) 1.00

Number of medications 4.50 ± 2.38 5.16 ± 2.63 0.91

Kihon Checklist score 11.0 ± 3.0 13.6 ± 3.1 0.17

Values are mean ± standard deviation or frequency (%).

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Table 2. Health-related quality of life pre and post intervention.

Variable Men (n=5) Women (n=6)

Baseline Post P ES Baseline Post P ES

Short-form 36

Physical Functioning 38.7 ± 9.7 53.3 ± 3.4 0.04 1.39 35.5 ± 3.1 40.6 ± 10.0 0.24 0.43

Role-physical 44.5 ± 4.3 54.4 ± 4.8 0.07 1.18 33.9 ± 6.1 47.4 ± 11.2 0.07 1.03

Bodily Pain 43.4 ± 5.7 52.4 ± 7.8 0.04 1.62 48.8 ± 8.1 43.5 ± 11.1 0.34 0.31

General Health 50.3 ± 4.5 53.2 ± 12.6 0.50 0.25 54.6 ± 12.4 48.4 ± 15.3 0.50 0.40

Vitality 53.7 ± 4.9 57.3 ± 11.6 0.59 0.27 53.5 ± 4.0 55.5 ± 8.4 0.58 0.17

Social Functioning 53.3 ± 5.4 48.3 ± 11.9 1.00 0.34 50.6 ± 12.1 47.3 ± 11.4 0.46 0.20

Role-emotional 40.1 ± 10.6 51.2 ± 6.7 0.22 0.66 35.8 ± 10.8 47.4 ± 10.0 0.11 0.82

Mental Health 55.0 ± 3.9 49.8 ± 14.4 0.71 0.32 60.4 ± 1.3 53.4 ± 9.5 0.11 0.69

PCS 42.2 ± 5.1 54.5 ± 1.6 0.04 2.31 39.5 ± 4.9 42.5 ± 8.5 0.75 0.24

MCS 53.8 ± 9.6 50.1 ± 15.0 0.68 0.18 55.3 ± 5.9 54.2 ± 6.0 0.75 0.17

Values are mean ± standard deviation. PCS: physical component summary; MCS: mental component summary; ES: effect size.

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Table 3 presents comparisons concerning physical function pre and post

intervention in older men and women. In men, there were improvements regarding walking at

usual (d=0.75) and maximum speeds (d=0.52); and number of repetitions in the EBRT

(P=0.004, d=1.30). In women, maximum walking speed (P=0.02, d=0.98), EBRT (d=0.83)

and the TUG (P=0.02, d=1.41) showed better results after intervention; relative handgrip

strength (adjusted by BMI) decreased after intervention (pre 0.9 ± 0.3, post 0.8 ± 0.2, P=0.04,

d=1.26) (Table 3). The BMI for men were 25.1 ± 3.0 at baseline and 25.1 ± 3.5 after

intervention (P=0.06, d=1.65). For women were 21.2 ± 4.1 at baseline and 21.5 ± 3.9 (P=0.46,

d=0.29).

Difference in the SRPE from the beginning to the end of the intervention in both

groups was observed. As expected, volunteers reported higher SRPE at final intensity. In

agreement, there were large effects regardless sexes. These values are presented in Table 4.

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Table 3. Physical function tests pre and post intervention.

Variable Men (n=5) Women (n=6)

Baseline Post P ES Baseline Post P ES

Absolute handgrip strength (kg) 28.4 ± 10.6 28.5 ± 8.2 0.89 0.02 18.7 ± 4.0 18.3 ± 4.3 0.46 0.39

Relative handgrip strength (kg/BMI) 1.1 ± 0.4 1.2 ± 0.2 0.46 0.22 0.9 ± 0.3 0.8 ± 0.2 0.04 1.26

Walking at usual speed (m/s) 0.6 ± 0.2 0.7 ± 0.2 0.22 0.72 0.6 ± 0.1 0.6 ± 0.2 0.17 0.64

Walking at maximum speed (m/s) 0.9 ± 0.2 1.0 ± 0.3 0.22 0.52 0.7 ± 0.1 0.9 ± 0.3 0.02 0.98

Timed Up and Go (sec) 14.2 ± 2.5 14.5 ± 5.7 0.50 0.06 20.0 ± 7.2 17.2 ± 7.0 0.02 1.41

Elastic band rowing test (#rep) 12.8 ± 3.7 18.6 ± 4.9 0.04 1.30 14.7 ± 3.8 16 ± 2.0 0.18 0.83

Values are mean ± standard deviation. BMI: body mass index; ES: effect size.

Table 4. Session rating of perceived effort at the beginning and at final intensity achieved.

Variable Men (n=5) Women (n=6)

Initial intensitya Final intensity

b P ES Initial intensity

a Final intensity

b P ES

SRPE 3.36 ± 0.62 4.5 ± 0.58 0.04 3.48 3.0 ± 0.40 4.8 ± 0.66 0.02 3.06

Values are mean ± standard deviation. SRPE: session rating of perceived effort; ES: effect size. aInitial intensity represents 5

th to 8

th week of intervention

(participants using red elastic bands); bFinal intensity represents 12

th to 16

th week of intervention (participants using blue elastic bands).

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DISCUSSION

This study aimed to verify the effects of power training using elastic bands on

physical function and HRQOL in institutionalized frail older adults. The studied sample was

particularly vulnerable, most of them had several years of institutionalization, more than half

reported fall incident in previous year of the study, had hip or femur fractures as consequence

of fall, and were under polypharmacy condition. After intervention, we verified improvement

in several aspects as result of power training; study volunteers improved physical function

and physical and mental aspects of HRQOL.

In the case of interpreting only the P values, our evidences might be considered

modest, as older men had improvements on HRQOL, especially on physical components, but

not women. Regarding physical functioning, men presented improvement on EBRT scores,

while women presented better functional performance on maximum walking speed and the

TUG; and lower relative handgrip strength adjusted by BMI, justified by the slight increase

in BMI after intervention.

On the other hand, when analyzing the effect sizes we confirmed potential change

magnitudes due to the exercise protocol we followed herein.

Indeed, strength training has an important role to improve muscle function, even

in the oldest-old. A classic study by Fiatarone et al., (1994) verified that strength training

with nutritional supplementation in institutionalized older adults (n=100) increased strength

and gait speed. Moreover, authors verified increase in the stair-climbing power test and cross

sectional thigh-muscle area increased in the exercisers. The nutritional supplement had no

effect on any primary outcome measure and total energy intake was significantly increased

only in the exercising subjects who also received nutritional supplementation.9

In this study, exercise was applied solely; we did not use nutritional

supplementation. Despite this fact, we observed improvements in walking speed and EBRT

in men and women. Nutritional supplementation has important effect on older adults’

physical condition; however, its association with exercise in frail older adults still needs

further evidence.25

And frailty may be delayed or even reversed by exercise, with or without

nutritional supplementation.26

As confirmed by Cadore et al., (2014) that performed a multicomponent training

(12-week, twice a week, composed by muscle power training [8-10 repetitions, 40-60% of

the one-repetition maximum – 1RM] combined with balance and gait retraining) on muscle

power output, muscle mass, and muscle tissue attenuation; and functional outcomes in frail

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nonagenarians (n=24; 91.9 ± 4.1 years old). Authors verified that the intervention group

improved the TUG, ability to rise from a chair and balance performance, and a reduced

incidence of falls. In addition, they also showed enhanced muscle power and strength.

Moreover, there were increases in the total and high-density muscle cross-sectional area in

the intervention group; while the control group reduced strength and functional outcomes.7

Interestingly, similar results were found when authors verified the effects of

multicomponent exercise intervention in frail older adults with dementia after long-term

physical restraint, followed by 24 weeks of training cessation. After the first 4 weeks of

training, there was improvement only in the balance test; however, after the second part of

the training, the participants required less time for the TUG, and improved the handgrip

strength, hip flexion and knee extension strength, as well as the leg press 1RM. Moreover,

after 24 weeks of training cessation, decreases were observed in almost all of the physical

outcomes; showing that exercise should be a chronic intervention in this population.6

The values we found for the SRPE at the end of the intervention were similar to

that proposed in other study (i.e., moderate intensity about 5 or 6 on a scale from 0 to 10 to

frail older adults).21

However, the time in which the participants exercised at this intensity

possibly was short to promote all changes we expected. Even though, we found important

psychological and functional improvements after intervention. High-intensity resistance

exercise is a feasible and effective means of counteracting muscle weakness and physical

frail in very elderly people;9 but, low intensity exercise showed a similar effect on the

adverse health consequences as well.27

Our interventions lasted 16 weeks and within this period the first four weeks were

adaptation. Although it was possible to achieve progress, we suppose that a longer

intervention would favor more improvements. Studies supported that interventions to frail

older adults should last at least 12 weeks.25

Indeed, it seems that interventions lasting longer

than five months resulted in greater gains on the adverse health outcomes of the frail people

than shorter duration interventions. These differences likely occur because frail adults need

more time to reach a level of exercise that may engender health and fitness benefit. However,

longer duration interventions had more dropouts that shorter duration interventions since

many frail people would experience several health problems and/or not survive to complete a

long intervention;27

this condition has been verified by other studies, especially in

institutionalized people.7

Exercise seems to benefit the older frail females more than younger frail males.

This difference may be explained by the fact that younger frail people may experience effects

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on some outcome measures (e.g., activities of daily living, disability, mobility, balance). Sex-

related differences were also verified herein and may be due the fact that baseline physical

and functional ability were less in women compared to men; therefore, it seems that women

are more likely to improvement than men.27

Regarding HRQOL, a review study verified firm evidences for training effects on

physical fitness, functional performance, activity of daily living performance, and quality of

life in institutionalized older adults. Especially for depression, vitality, and perceived

health.28

A large number of disease-specific quality of life instruments exist, but none

specific for sarcopenia or frailty. It is considered necessary specific tools and without a clear

conceptual framework of quality of life in these patients, an important element in the

characterization and follow-up of these conditions seems to be missing.29

Concerning this,

the SF-36 should still serve as a generic-core to compare populations across studies and that

it should complement other health outcome measures, as we followed in this study.

Interestingly, after intervention the magnitude of change effects in physical

domains in men and in physical and mental domains in women were observed, confirming

the influence of exercise on people’s quality of life. Also important to mention, the mental

health domain presented a discrete decline in women. Punctual situations experienced by

these participants and the limited sample size are important to clarify this finding, especially

because some women were facing mourning for friends and relatives during research

activities.

Limitations should be pointed in this study: (i) the small sample size in men and

women groups; but, due to the highly specificity of this population, and its case-study nature

can justify it and do not limit our general conclusions; (ii) nutritional supplementation was

not used because of study logistics and financial condition; but as verified in other studies,

exercise alone can be used as intervention to promote physical and psychological outcomes.

Evidence shows that there is a relationship among training, improvement in

physical function and some aspects of HRQOL.28

Thus, interventions to promote physical

function are essential for institutionalized older adults once it can lead to other several

adaptations. Moreover, such interventions are important for governments and healthcare

providers to understand and implement strategies by the needs and concerns of this specific

population. By this understanding, it is possible to allocate resources and define healthcare

politics at LTCI’s accordingly. We also consider that as important as the geriatrician or

gerontologist approaches; patient-reported outcomes (such as HRQOL) should be valued,

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once subjective report of the patients’ health condition, especially in frailty and sarcopenia,

seems to reliably represent individual’s health.

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8. Yamada M, Arai H, Uemura K, et al. Effect of resistance training on physical performance

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9. Fiatarone MA, O’Neil EF, Ryan ND, et al. Exercise training and nutritional

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CONCLUSÃO

Os artigos aqui apresentados, quando considerados em conjunto, abordaram a

sarcopenia e QV numa perspectiva a partir do diagnóstico, usando como base idosos

residentes na comunidade, até a intervenção com exercícios de potência em idosos frágeis e

institucionalizados.

No primeiro artigo, os valores de referência para massa muscular apendicular

ajustada pelo IMC foram <0.85 para homens e <0.53 para mulheres; para força de preensão

manual absoluta foram <30.0 kgf para homens e <21.7 kgf para mulheres; enquanto para

força de preensão manual relativa (também ajustada pelo IMC) foram <1.07 para homens e

<0.66 para mulheres. O medo de cair foi usado como desfecho das análises, que indicaram

que o peso do indivíduo deve ser considerado em relação à massa muscular apendicular em

ambos os sexos; já em relação à força, mostrou-se o melhor ajuste para mulheres, mas não

para homens.

Valores de referência baseados em amostras locais são preferíveis sobre valores

estrangeiros; assim, recomenda-se o uso de massa muscular apendicular ajustada pelo IMC

em homens e mulheres, e a escolha entre força de preensão manual absoluta ou relativa de

acordo com as necessidades do estudo. Tais pontos de corte podem auxiliar profissionais da

área da saúde na avaliação, planejamento e atuações mais eficientes visando identificar e

intervir prontamente naqueles vulneráveis.

Sobre o segundo artigo, verificou-se que a combinação de baixa força, lentidão

da marcha e baixa massa muscular appendicular ajustada pelo IMC foi associada à baixa QV

em idosos residentes na comunidade. Nos homens, essa associação foi identificada

especialmente pela condição força e/ou velocidade da marcha, que se relacionou com os

domínios capacidade funcional, aspectos físicos e estado geral da saúde. Em mulheres, a

combinação de força, velocidade da marcha e massa muscular foi associada com os domínios

capacidade funcional, aspectos físicos, dor, estado geral da saúde e aspectos sociais. Logo, os

pontos de corte previamente identificados, além de verificarem diferenças morfofuncionais,

também estão associados a aspectos subjetivos em idosos.

No terceiro artigo, verificou-se o efeito do treinamento de potência em variáveis

de função física e QV em idosos frágeis e institucionalizados. Após as atividades de

pesquisa, melhoras foram verificadas na velocidade da marcha, número de repetições do teste

remada com banda elástica, em homens e mulheres; e no teste timed up and go,

especificamente em mulheres. Componentes físicos e mentais da QV também melhoraram -

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função física, aspectos físicos, dor corporal e aspectos emocionais, em homens; e aspectos

físicos e aspectos emocionais, em mulheres.

Há de se ressaltar a dificuldade na realização da pesquisa com idosos frágeis,

uma amostra vulnerável, com anos de institucionalização, incidência de quedas e fraturas,

que necessitam de cuidados e motivação constantes. Fora a necessidade de lidar com fatores

além da pesquisa, mas que certamente influenciam os resultados e participação, como morte

de parentes e amigos, e até mesmo negligência da família; situações comuns em idosos

residentes em instituições de longa permanência. Assim, intervenções para promover a

função física de idosos institucionalizados são essenciais uma vez que podem provocar outras

adaptações positivas, incluindo melhora da QV.

O desenvolvimento de estratégias para identificar idosos vulneráveis e propostas

de intervenção visando maximizar suas capacidades, sejam físicas ou mentais, é imperativo.

Os estudos incluídos nessa tese apresentaram dados que podem ser utilizados tanto por

pesquisadores como na prática profissional. Mais ainda, podem servir de referência ao

desenvolvimento de políticas públicas relacionadas à saúde e ao bem estar da população

idosa.

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ANEXO 1

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ANEXO 2