Abstract
Background/Objective
The relationship between frailty and sarcopenia is well-known in older adults, but the factors associated with frailty were not adequately investigated. This study aimed to investigate the relationship between frailty levels and balance, fall risk, and kinesiophobia in older adults with primary sarcopenia and to compare them by sex.
Methods
This cross-sectional study included 68 (32 female, mean age 71.56 ± 5.04 years; 36 male, mean age 71.97 ± 4.86 years) older adults with primary sarcopenia. Sarcopenia was assessed based on grip strength, skeletal muscle mass, and physical performance. Frailty levels (Edmonton Frailty Scale (EFS)), dynamic and static balance (Force plate), fall risk (Denn Fall Risk Assessment Scale), and kinesiophobia (Tampa Kinesiophobia Scale (TSK)) of the individuals were assessed.
Results
Sarcopenic females had statistically significantly higher levels of frailty, fall risk, kinesiophobia, and decreased balance stability areas than males (p < 0.05). The prevalence of frailty among older adults with sarcopenia was 51.5%, with a mean EFS score of 6.54 ± 2.51. Females had significantly higher frailty levels than males (7.53 ± 2.81 vs. 5.67 ± 1.83, p = 0.002). Fall risk was also higher in females (10.66 ± 5.83 vs. 7.17 ± 4.29, p = 0.007), as was kinesiophobia (47.59 ± 6.37 vs. 41.81 ± 5.09, p < 0.001). Frailty showed a moderate positive correlation with fall risk (r = 0.603, p < 0.001) and kinesiophobia (r = 0.510, p < 0.001), and a weak negative correlation with balance stability in the anterior direction (r=-0.249, p = 0.040) and to the right (r=-0.265, p = 0.030).
Conclusion
Sarcopenic females have higher levels of frailty and have a higher risk of falling and kinesiophobia than males. Sarcopenic females also have more impaired balance. Increased frailty levels in older sarcopenic adults are associated with increased fear of falling and kinesiophobia, and impaired balance. Therefore, assessment of frailty and associated factors in older adults with sarcopenia is essential in planning rehabilitation.
Keywords: Sarcopenia, Frailty, Sex, Balance, Fall risk, Kinesiophobia
Introduction
Sarcopenia is defined by the European Working Group on Sarcopenia in Older People (EWGSOP) as low muscle strength, low skeletal muscle mass, and poor physical performance [1]. When it occurs solely due to aging and not due to any other cause, it is called “primary sarcopenia” [2]. Primary sarcopenia reasons include problems such as advanced age, decreased physical activity, anorexia, decreased neuronal motor units, increased cytokines, decreased testosterone, growth hormone, and vascular flow [3].
Sarcopenia may lead to an increase in frailty by causing a decrease in physiological reserves [4]. Frailty is a syndrome resulting from physiological dysfunction. It increases susceptibility to adverse health outcomes and is defined by the combination of at least three frailty parameters: wasting, exhaustion, decreased physical activity, slowness, and weakness [4]. Frailty and sarcopenia, which have similar pathophysiological mechanisms, are generally characterized by common clinical symptoms such as low muscle strength, slow walking speed, and impaired balance [5]. In this context, frailty is associated with balance problems, risk of falling, and kinesiophobia due to decreased physical and psychological capacity [4, 6, 7]. Muscle-related and hormonal factors in females may contribute to increased frailty, balance impairments, and fall risk. However, it is not yet clearly known how the coexistence of sarcopenia and frailty differentially affects males and females [8–10].
Loss of muscle strength and function in sarcopenia impairs balance and increases fall risk [11]. Although sarcopenia and frailty both impair balance, the main factor causing balance problems in frail sarcopenic individuals remains unclear. Therefore, it is important to examine the relationship between frailty and balance. Loss of postural stability due to sarcopenia in elderly individuals is one of the most important factors that increase the risk of falling [12, 13]. Additionally, decreased muscle strength and endurance due to sarcopenia may lead to the development of kinesiophobia in individuals. Muscle weakness may increase kinesiophobia by triggering fear of falling [6].
It was reported that in cases of frailty—such as in individuals with post-COVID-19 symptoms, Alzheimer’s disease, and type 2 diabetes—balance deterioration, fall risk, and kinesiophobia increase [6, 14, 15].Additionally, the level of fragility, balance, risk of falling, and kinesiophobia may differ by sex. While females generally have higher levels of frailty and risk of falling due to hormonal changes and differences in muscle mass, higher physical activity levels in males may reduce balance problems and kinesiophobia [8, 9]. These differences indicate the importance of sex-specific approaches in assessment and intervention processes. Biological sex differences, such as lower baseline muscle mass, postmenopausal estrogen decline, and higher frailty prevalence in females, may further amplify the impact of frailty on balance, fall risk, and kinesiophobia [10, 16]. Because frailty and sarcopenia have similar causes, it is thought that clinical symptoms will worsen in sarcopenic older adults who are frail [17, 18].
The relationship between frailty and balance, fall risk, and kinesiophobia has been demonstrated in various clinical populations, including individuals with post-COVID-19 symptoms, Alzheimer’s disease, and type 2 diabetes [6, 7, 14]. However, studies examining the relationship between frailty and clinical symptoms in sarcopenic older adults and comparing them by sex are limited. Although frailty and sarcopenia share overlapping physical features, frailty is not limited to physical decline but includes cognitive, social, and functional aspects. Therefore, using a multidimensional frailty scale such as the Edmonton Frailty Scale (EFS) allows for a broader assessment than physical frailty phenotype models. In addition, determining the levels of exposure of different sexes is important for creating individual-specific rehabilitation approaches. Thus, the primary aim of this study is to test the hypothesis that higher frailty levels are associated with poorer balance performance, increased fall risk, and higher levels of kinesiophobia among older adults with sarcopenia. It also aims to evaluate the hypothesis that the impact of these factors is more pronounced in females than in males.
Materials and methods
Study population
Sarcopenia individuals aged 65 years and over from the Internal Medicine Department of Karabük University Training and Research Hospital were included in this cross-sectional study. Seventy-five older adults with sarcopenia were screened between June 2024 and May 2025, and seven individuals were excluded from the study because they did not want to participate. Therefore, this final study population consisted of 68 older adults. Participants who were diagnosed with sarcopenia according to EWGSOP2 criteria, ≥ 65 years old, and who volunteered to participate were included in the study. Those who had a chronic disease that would affect balance (Multiple sclerosis, Parkinson’s, vertigo, vestibular neuritis, etc.), those with a history of trauma in the last six months (fracture, soft tissue injury, etc.), cognitive impairment (Mini-Mental State Examination test score < 24) those who had lower extremity surgery, and those who did not volunteer to participate were excluded from the study. The university ethics committee approved the study (Approved number: 2024/1796) and conducted it according to the guidelines in the Declaration of Helsinki. This study was retrospectively submitted to ClinicalTrials (No.: NCT06931964). Written and verbal informed consent was obtained from all participants.
Study design
Older adults with sarcopenia were included in this cross-sectional, observational study. The presence of sarcopenia in the participants was evaluated according to EWGSOP2 criteria. First, handgrip strength was assessed to screen for probable sarcopenia. Participants with low muscle strength underwent bioelectrical impedance analysis (BIA) to assess skeletal muscle mass and a 4-meter gait speed test to assess physical performance. Participants meeting at least two out of the three EWGSOP2 criteria (low muscle strength, low skeletal muscle mass, and poor physical performance) were classified as having sarcopenia. Sarcopenia evaluation was carried out jointly by a specialist doctor and a physiotherapist. Individuals who did not meet the EWGSOP2 diagnostic criteria for sarcopenia were excluded from the study. A total of 68 participants were confirmed to have sarcopenia. Participants who met the inclusion criteria had their frailty levels (EFS), postural balance (force plate), fall risk (Denn Fall Risk Assessment Scale), and kinesiophobia (Tampa Scale of Kinesiophobia (TSK)) levels assessed by another researcher, a physiotherapist.
Measurements of sarcopenia
Sarcopenia was confirmed in all participants according to the EWGSOP2 criteria, including low muscle strength (hand grip strength), low muscle mass (skeletal muscle mass index measured by BIA), and low physical performance (usual gait speed). National reference cut-offs were applied [10].Height and weight were measured using a stadiometer. Body mass index was calculated by dividing body weight by height (kg/m2). Body composition was assessed by bioimpedance analysis (BIA) using a Tanita-BC532 (Tanita® Corporation, Tokyo, Japan) model body analysis monitor [19]. To reduce the impact of hydration status on BIA results, all participants fasted overnight and refrained from excessive fluid intake, caffeine, and heavy exercise for at least four hours before the assessment. Measurements were conducted in the morning under standardized conditions. The Tanita BC-532 device was chosen because its accuracy in estimating body composition, especially fat-free mass, has been validated against DXA and MRI [20].The participants stood barefoot on the monitor and fat-free mass (FFM) BIA was measured. Skeletal muscle mass (SMM) was calculated using the formula: SMM (kg) = 0.566 * FFM (kg) [19]. Skeletal muscle mass index was calculated using SMM/height2 [21]. Muscle mass below 9.2 kg/m2 in males and 7.4 kg/m2 in females was considered low muscle mass according to Turkish national data [22].
Muscle strength was assessed by measuring handgrip strength (HGS) with a Jamar hand dynamometer (Jamar®, Fabrication Enterprised Inc, Irvington, USA) using a controlled protocol. Grip strength was measured in the sitting position, with the elbow at 90 flexion and the wrist in the neutral position. The participants were asked to squeeze the hand dynamometer with their dominant hand. The measurement was repeated 3 times, and the best value was recorded [23]. According to Turkish national data, the cut-off points were accepted as 22 kg for females and 32 kg for males [22].
Physical performance was assessed using the 4-meter usual gait speed (UGS). The participants were asked to walk 4 m at normal walking speed and the elapsed time was recorded with a stopwatch. Speed was calculated in m/s by dividing the 4 m distance by the test duration [24]. When the UGS was below 0.8 m/s, it was recorded as impaired physical performance [25].
Frailty
EFS was used to assess frailty [26]. The scale consists of 9 frailty dimensions that are considered to be determinants of frailty. These dimensions are “cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance”. Scores of 0–4 on the scale are considered not frail, 5–6 points are vulnerable, 7–8 points are mild frailty, 9–10 points are moderate frailty, and 11 and above points are severe frailty [26]. The validity and reliability study of EFS in the Turkish elderly population was conducted by Aygör et al. (2018) and the scale was shown to be a valid tool in frailty assessment [27].
Balance
Bertec® Balance Legacy System device (OH, USA) was used for postural balance measurements. A valid study of force platform use in elderly individuals was conducted [28]. For the measurements, the participants were asked to keep their arms relaxed and on their sides eon the platform. The participants’ feet were placed on the platform at the medial malleolus line. They were slightly apart and parallel. Balance skills included two main functions: stability area (SA) and postural sway area (PSA). SA assessment was performed on the platform on solid ground only. When the measurement started, the participants were asked to keep the cursor on the straight line and slowly move it forward, backward, right, and left. During PSA measurements, the participants were asked to keep the cursor fixed in the middle of the coordinate plane for 30 s. These measurements were repeated in four different positions: eyes open on a hard surface (EOHS), eyes closed on a hard surface (ECHS), eyes open on a foam surface (EOFS) and eyes closed on a foam surface (ECFS) [29].
Fall risk
The participants’ fall risk was measured with the ‘DENN Fall Risk Assessment Scale’. The test consists of nine main headings (Level of Consciousness/Mental Status, Fall History in the Last 3 Months, Ambulation/Toilet Status, Visual Status, Walking and Balance, Orthostatic Changes, Medications, Diseases, and Equipment Presence). The total score ranges from 0 to 39. As a result of the scoring, 0 to 5 points are considered “low risk” in terms of falling, 6 to 9 points are considered “medium risk”, and 10 and above points are considered “high risk”. The Turkish adaptation and reliability of the scale was performed by Tekin et al. [30].
Kinesiophobia
Kinesiophobia was assessed with TSK. This scale, consisting of 17 questions, includes parameters of injury/re-injury and fear-avoidance in work-related activities. A 4-point Likert scale (1 = I completely disagree, 4 = I completely agree) is used in the scale. The total score is calculated after reversing items 4, 8, 12 and 16. The participant can score between 17 and 68, and as the score increases, kinesiophobia increases [31]. The Turkish version of the scale and its test-retest reliability were conducted by Yılmaz et al. [32].
Statistical analysis
Sample size was calculated using G*Power 3.1.9.7 software (Universitat Kiel, Germany). For a significant difference in sex according to EFS obtained from the pilot study, it is estimated that the sample size for a total of 62 people, 31 people in each group, will have α = 0.05, 95% power, and d = 0.71 effect size.
SPSS 25 (Statistical Package for Social Sciences ®, IBM Corporation, USA) program was used to analyze statistical data. The normality of the data was analyzed by visual (histograms, probability plots) and analytical methods (Kolmogorov-Smirnov test). Demographic and clinical characteristics of the two groups were compared using the student t-test for distributed variables. The difference between qualitative variables was compared using the χ2 test. Descriptive analyses, mean ± standard deviation (X ± SD) for normally distributed variables; as well as a percentage (%) and frequency (n) for categorical variables. Pearson correlation test was used to evaluate the relationships between the EFS and other parameters. The correlation coefficients were r > 0.89 very strong correlation, 0.70–0.89 strong correlation, 0.40 to 0.69 moderate correlation, and 0.20–0.39 weak correlation [33]. Cohen’s d effect size (ES) was categorized as small (0.21–0.49), medium (0.50–0.79), or large (≥ 0.80) [34]. Statistical significance was set at p < 0.05.
Results
The study was completed with a total of 68 (32 female; 36 male) older adults with sarcopenia. Demographic characteristics of the study participants were given in Table 1. When compared by sex, there were statistically significant differences in hand grip strength, usual gait speed, skeletal muscle mass index, smoking, and BMI (p < 0.05) (Table 1).
Table 1.
Demographic and characteristic features of the participants
| Characteristics | Total (n = 68) X ± SD |
Female (n = 32) X ± SD |
Male (n = 36) X ± SD |
p |
|---|---|---|---|---|
| Age, years | 71.78 ± 4.91 | 71.56 ± 5.04 | 71.97 ± 4.86 | 0.734 |
| Height, cm | 160.28 ± 10.26 | 152.84 ± 8.06 | 166.89 ± 6.98 | < 0.001 |
| Weight, kg | 75.78 ± 12.76 | 71.93 ± 11.89 | 79.21 ± 12.68 | 0.018 |
| BMI, kg/m2 | 29.52 ± 4.44 | 30.81 ± 4.86 | 28.37 ± 3.72 | 0.023 |
| Smoking, n (%) | ||||
| Current | 5 (7.4%) | 1 (3.1%) | 4 (11.1%) | < 0.001 |
| Ex-smoker | 23 (33.8%) | 2 (6.3%) | 21 (58.3%) | |
| Non-smoker | 40 (58.8%) | 29 (90.6%) | 11 (30.6%) | |
| Chronic disease, n (%) | ||||
| No | 13 (19.1%) | 5 (15.6%) | 8 (22.2%) | 0.490 |
| Hypertension | 38 (55.9%) | 20 (62.5%) | 18 (50.0%) | 0.300 |
| Diabetes mellitus | 26 (38.2%) | 11 (34.4%) | 15 (41.7%) | 0.537 |
| Heart diseases | 14 (20.6%) | 5 (15.6%) | 9 (25.0%) | 0.340 |
| Pulmonary diseases | 21 (30.9%) | 14 (43.8%) | 7 (19.4%) | 0.038 |
| Usual gait speed (m/s) | 1.19 ± 0.44 | 1.33 ± 0.59 | 1.07 ± 0.20 | 0.026 |
| Hand grip strength (kg) | 22.39 ± 7.96 | 19.09 ± 6.14 | 25.32 ± 8.31 | 0.001 |
| Skeletal muscle mass index (kg/m2) | 7.64 ± 2.56 | 9.67 ± 1.60 | 5.83 ± 1.77 | < 0.001 |
The prevalence of frailty in older adults with sarcopenia was 51.5%. The mean frailty score of older adults with sarcopenia was 6.54 ± 2.51. Additionally, a significant difference was found between sex regarding frailty levels (p = 0.033). Statistically, this difference was due to the increase in frailty levels in female participants. In addition, female participants’ fall risk and kinesiophobia levels were statistically higher than those of male participants, with medium (ES = 0.68) and large (ES = 1.00) effect sizes, respectively (p < 0.05) (Table 2). Not frail, 5–6 points are vulnerable, 7–8 points are mild frailty, 9–10 points are moderate frailty, and 11 and above points are severe frailty [26].
Table 2.
Frailty, fall risk, and kinesiophobia scores of the participants
| Total (n = 68) X ± SD |
Female (n = 32) X ± SD |
Male (n = 36) X ± SD |
p | |
|---|---|---|---|---|
| EFS | 6.54 ± 2.51 | 7.53 ± 2.81 | 5.67 ± 1.83 | 0.002 |
| Frail classification | ||||
| Not frail (0–4) | 15 (22.1%) | 5 (15.6%) | 10 (27.8%) | 0.033 |
| Vulnerable (5–6) | 18 (26.5%) | 5 (15.6%) | 13 (36.1%) | |
| Mild frailty (7–8) | 14 (20.6%) | 7 (21.9%) | 7 (19.4%) | |
| Moderate frailty (9–10) | 17 (25%) | 11 (34.4%) | 6 (16.7%) | |
| Severe frailty (> 11) | 4 (5.9%) | 4 (12.5%) | 0 (0.0%) | |
| Fall Risk Assessment Scale (0–39) | 8.81 ± 5.33 | 10.66 ± 5.83 | 7.17 ± 4.29 | 0.007 |
| Fall risk classification | ||||
| Low | 22 (32.4%) | 9 (28.1%) | 13 (36.1%) | 0.004 |
| Medium | 21 (30.9%) | 5 (15.6%) | 16 (44.4%) | |
| High | 25 (36.8%) | 18 (56.3%) | 7 (19.4%) | |
| Kinesiophobia (17–68) | 44.53 ± 6.39 | 47.59 ± 6.37 | 41.81 ± 5.09 | < 0.001 |
EFS Edmonton Frail Scale
Sway and stability area values, effect sizes, and changes due to positions of eyes were given in Table 3. According to the sway areas, male participants’ anteroposterior and mediolateral sways with eyes open on the perturbated stability were statistically higher (p < 0.05). Additionally, female participants’ forward, right, and left stability areas were statistically lower than male participants (p < 0.05). The ES was large for forward (ES = 0.80) and moderate for right (ES = 0.59) and left (ES = 0.67).
Table 3.
Sway and stability area values and changes due to positions of eyes
| Total (n = 68) X ± SD |
Female (n = 32) X ± SD |
Male (n = 36) X ± SD |
Effect size | p | |
|---|---|---|---|---|---|
| Balance, sway area (cm) | |||||
| Anteroposterior | |||||
| NSEO | 0.47 ± 0.18 | 0.43 ± 0.17 | 0.51 ± 0.19 | 0.44 | 0.140 |
| NSEC | 0.80 ± 0.32 | 0.75 ± 0.33 | 0.84 ± 0.31 | 0.28 | 0.255 |
| PSEO | 0.74 ± 0.31 | 0.64 ± 0.27 | 0.83 ± 0.32 | 0.64 | 0.017 |
| PSEC | 1.37 ± 0.55 | 1.27 ± 0.56 | 1.46 ± 0.52 | 0.35 | 0.186 |
| Mediolateral | |||||
| NSEO | 0.31 ± 0.17 | 0.30 ± 0.18 | 0.32 ± 0.16 | 0.12 | 0.639 |
| NSEC | 0.35 ± 0.23 | 0.36 ± 0.29 | 0.34 ± 0.15 | 0.08 | 0.720 |
| PSEO | 0.78 ± 0.42 | 0.66 ± 0.32 | 0.89 ± 0.47 | 0.57 | 0.024 |
| PSEC | 1.04 ± 0.55 | 1.01 ± 0.64 | 1.07 ± 0.47 | 0.10 | 0.640 |
| Balance, stability area (cm) | |||||
| Anterior | 5.57 ± 2.74 | 4.50 ± 2.39 | 6.55 ± 2.70 | 0.80 | 0.002 |
| Posterior | 3.13 ± 1.70 | 2.81 ± 1.52 | 3.42 ± 1.81 | 0.36 | 0.168 |
| Right | 6.90 ± 3.50 | 5.82 ± 3.12 | 7.82 ± 3.62 | 0.59 | 0.023 |
| Left | 6.44 ± 3.16 | 5.37 ± 3.10 | 7.41 ± 2.94 | 0.67 | 0.015 |
NSEO Normal stability eyes open, NSEC Normal stability eyes closed, PSEO Perturbated stability eyes open, PSEC Perturbated stability eyes closed
The correlation analysis between frailty scores of older adults with sarcopenia and the variables was presented in Table 4. Frailty scores were moderately positively associated with usual gait speed, fall risk, and kinesiophobia scores (r = 0.510–0.516). Moreover, frailty scores were weakly negatively associated with forward and right stability scores (p < 0.05) (Table 4).
Table 4.
Relationship of various variables with EFS score
| Correlation coefficients (r) | p | |
|---|---|---|
| Age | 0.361** | 0.002** |
| BMI | 0.052 | 0.676 |
| Usual gait speed (m/s) | 0.516** | < 0.001** |
| Hand grip strength (kg) | −0.301* | 0.013* |
| Skeletal muscle mass index (kg/m2) | 0.359** | 0.003** |
| Fall Risk Assessment Scale | 0.603** | < 0.001** |
| Kinesiophobia | 0.510** | < 0.001** |
| Balance, stability area (cm) | ||
| Anterior | −0.249* | 0.040* |
| Posterior | −0.236 | 0.053 |
| Right | −0.265* | 0.132 |
| Left | −0.185 | 0.030* |
*p < 0.05; **p < 0.01
Discussion
This study showed that females with sarcopenia were more frail and had more functional limitations than males. The prevalence of frailty in sarcopenic elderly individuals was 51.5%. Increasing frailty severity was associated with an increased risk of falls, kinesiophobia, and poor balance. Older females with sarcopenia were found to have a higher risk of falls and kinesiophobia, and poorer balance skills, compared to males.
Frailty reflects cumulative declines across multiple systems, leading to increased vulnerability in older adults [4]. Molecular, genetic, and environmental factors may contribute to sex differences in frailty [35]. Previous studies have shown that frailty levels tend to be higher in females [27, 36] although some have found no significant sex difference [37]. Evidence regarding sex-related differences in frailty among individuals with sarcopenia is still limited. In this study, females showed higher frailty levels than males. The reasons for this difference remain unclear and may involve factors such as comorbidities, hormonal status, or other physiological differences [4] which were not specifically analyzed in this study. Additionally, social roles and lifestyle factors such as lower lifetime physical activity levels, higher caregiving burdens, and differences in health-seeking behavior may also contribute to higher frailty in females [38]. Considering these results, sex is an important factor affecting frailty in sarcopenia and may be associated with progressively worsening physical and psychological capacity. Therefore, it should be taken into account during assessment.
Previous studies showed that sarcopenic patients were at an increased risk of falling and that individuals often had a history of falling in their daily lives [5, 11]. Moreover, a study reported that females with sarcopenia had a higher rate of falls than males [39]. Similar to the findings in the literature, this study also determined that females with sarcopenia had a 56.3% higher risk of falling. These results may also be related to the level of frailty. A systematic review linked the risk of falls to frailty and found that frail older adults had a 48% higher risk of falling than non-frail older adults [37]. In a meta-analysis examining the relationship between different frailty levels and frequency of falls, it was found that frail elderly individuals were more likely to experience recurrent falls [40]. In sarcopenia, the relationship between frailty levels and the risk of falling is unknown. This study found that increased frailty levels in sarcopenic individuals were associated with a higher risk of falling. In the literature it is known that sarcopenia physically affects females more [12]. This may be explained by the fact that frail sarcopenic females in this study showed a higher risk of falling than males. Additionally, previous studies showed that the level of frailty was associated with the risk of falling [37]. The higher frailty levels observed in female participants may help explain their increased fall risk. This association likely reflects sex-based physiological vulnerabilities, such as lower muscle mass and postural stability. Therefore, assessing the risk of falling in frail sarcopenic individuals is of great impormatance in preventing possible negative consequences in these individuals.
Decreased physical activity in sarcopenia is associated with a higher risk of falls and increased kinesiophobia [41]. Previous studies have reported that kinesiophobia and fear of falling are high in earthquake survivors and adults and elderly individuals with osteoporosis and osteopenia [42, 43] and kinesiophobia is associated with decreased physical activity [43]. In a study conducted by Telli et al. (2024), it was stated that kinesiophobia levels increased in individuals at risk of sarcopenia and that kinesiophobia levels were higher in females than in males [12]. This study showed that older adult females with sarcopenia had higher levels of kinesiophobia than males, with a large effect size, in line with studies in the literature. Frailty may also affect individuals in association with kinesiophobia. Frailty may also affect individuals associated with kinesiophobia, as confirmed in previous studies [6, 44, 45]. It was found that frail females who underwent coronary artery bypass surgery were found to have more anxiety in psychological domains, and this was associated with kinesiophobia [44]. As the level of frailty increased, the level of kinesiophobia also increased in elderly individuals with ischemic stroke [45]. Kinesiophobia levels were found to be higher in frail individuals with a history of COVID-19 than in non-frail individuals [6]. However, there is no study examining the relationship between frailty and kinesiophobia in individuals with sarcopenia. This study determined that increased frailty was associated with increased kinesiophobia, and older sarcopenic women exhibited higher kinesiophobia. Kinesiophobia is reported to be associated with balance and mobility issues, reduces functional ability and participation, and limits physical activity [46, 47]. Because frailty is also associated with decreased physical activity, increased frailty is likely to explain the increased levels of kinesiophobia. Furthermore, female gender has been reported to be associated with increased kinesiophobia and frailty in older individuals and has been reported as a risk factor for the development of frailty [46]. In this study, the indirect effect of frailty may have also contributed to the higher levels of kinesiophobia in women. Therefore, it is important to individually assess kinesiophobia and frailty, an important parameter that may be associated with it, in older individuals with sarcopenia.
A general decline in balance performance was reported with advancing age in elderly individuals [48]. A study found that elderly females had lower static balance performance than men. Worsening of postural sway was reported more in females than in males [48]. Balance performance in individuals with knee osteoarthritis was found to be lower in sarcopenic individuals compared to the non-sarcopenic group [49]. In another study, anteroposterior and mediolateral sway speeds and sway circumference were found to be worse in sarcopenic elderly individuals compared to healthy individuals, indicating decreased balance stability. It has also been shown that females have lower static and dynamic balance performance than males. It was argued that males generally have stronger lower extremity muscles, which helps them maintain balance stability better than females [50]. According to this study, males with their eyes open had higher anteroposterior and mediolateral sways. Female’s forward, right, and left stability areas were also lower than male’s, with large to medium effect sizes. Additionally, sarcopenic older women had similar sway areas to older males. It has been reported that poor balance quality may be an early indicator of physical frailty and a predictor of frailty status in elderly individuals, including those with diabetes or sarcopenia [51, 52]. A study showing that sarcopenia negatively affected postural balance also linked it to frailty. It has also been reported that frail elderly individuals have worse stability domains than non-frail individuals [53]. In elderly individuals with type 2 diabetes, balance performance was found to be lower in frail elderly compared to non-frail elderly [14]. This study provides new evidence that balance deterioration increases with increasing frailty in older individuals with sarcopenia. The inverse relationship between frailty and balance performance may be due to age-related declines in proprioception and neuromuscular coordination, which worsen with increasing frailty [54, 55]. Since deterioration in balance can lead to falls, balance-related fragility should also be included in the clinical follow-up process to prevent possible injuries.
This study provides new evidence to the literature as it is one of the limited number of studies examining frailty and balance performance in patients with sarcopenia.
Limitation
Because the study was single-center and only included older adults, the results may not be generalizable to the entire adult population. A limitation of this study is the hospital-based sampling, which may not fully reflect community-dwelling older adults. Therefore, results should be interpreted with caution. Due to the limited sample size, multivariate regression analyses were not performed in this study; instead, analyses were conducted at the level of pairwise comparisons and correlations. This restricts the ability to control for potential confounding variables and should be considered a significant limitation of the study. Future research should utilize larger sample sizes and employ multivariate models that control for covariates. Despite using a validated BIA device and standardized measurement conditions, the potential influence of hydration status remains a limitation. Neurological and vestibular disorders were excluded to avoid confounding effects, but this limits generalizability. Since these conditions are common in frail elderly, excluding them may underestimate balance issues, fall risk, and kinesiophobia in this population. It should be noted that this study did not assess social, economic, or cultural factors, which may influence frailty, balance, and kinesiophobia. Finally, since this study had a cross-sectional design, it did not allow for causal relationships to be established between sarcopenia and frailty and other parameters; it is believed that prospective rehabilitation studies should be conducted on this subject.
Conclusion
In older individuals with sarcopenia, increased frailty severity is associated with increased risk of falls, kinesiophobia, and poorer balance. Being female may be related to higher levels of frailty, poorer balance stability performance, and higher rates of falls and kinesiophobia. These findings highlight the need to integrate frailty assessment into the rehabilitation processes of individuals with sarcopenia. Individualized approaches and sex-specific interventions should be developed, taking sex differences into account. Future research should examine sex-focused and more detailed interventions in the relationship between sarcopenia and frailty to develop more effective strategies to improve the quality of life of these individuals.
Acknowledgements
The authors did not receive support from any organization for the submitted work. We thank The Scientific and Technological Research Council of Türkiye (TUBİTAK) for their support.
Authors’ contributions
CRediT authorship contribution statement: Metehan Yana: Conceptualization, Data curation, Investigation, Methodology, Project administration, Writing – original draft, Writing – review and editing. Ecem Çoroğlu: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review and editing. Musa Güneş: Conceptualization, Investigation, Methodology, Formal analysis, Writing – original draft, Writing – review and editing. Gizem Mermerkaya: Investigation, Writing – original draft, Writing – review and editing. Nurhayat Özkan Sevencan: Data curation, Investigation, Writing – review and editing.
Funding
This study was supported by Turkish Scientific and Technical Research Council (2209-A -University Students Research Projects Support Program with acceptance number: 1919B012317290).
Data availability
The datasets are not publicly available due to ethical restrictions and the absence of participants’ consent for data sharing. For inquiries regarding the data, please contact the corresponding author. Asst.Prof. Metehan YANA (email: metehanyana@karabuk.edu.tr).
Declarations
Ethics approval and consent to participate
This study was conducted in accordance with the principles of the Declaration of Helsinki. The study was approved by the Karabuk University Non-Interventional Ethics Committee (Approval date: June 5, 2024, Approval number: 2024/1796).
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets are not publicly available due to ethical restrictions and the absence of participants’ consent for data sharing. For inquiries regarding the data, please contact the corresponding author. Asst.Prof. Metehan YANA (email: metehanyana@karabuk.edu.tr).