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. 2019 Oct 3;24(1):83–90. doi: 10.1007/s12603-019-1267-x

Differences in the Prevalence of Sarcopenia in Community-Dwelling, Nursing Home and Hospitalized Individuals. A Systematic Review and Meta-Analysis

SK Papadopoulou 1, P Tsintavis 1, G Potsaki 1, Dimitrios Papandreou 2
PMCID: PMC12879112  PMID: 31886813

Abstract

Background

Sarcopenia is an age-related disease which leads to a decline in muscle mass and function and is one of the most important health issues in elderly people with a high rate and variety of adverse outcomes.

Objective

The current systematic review and meta-analysis study was carried out to estimate the overall prevalence of sarcopenia in both males and females in different regions around the world and to show the major differences in its occurrence among different populations.

Design

A systematic review and metaanalysis of studies published in PubMed (Medline) and Scopus.

Participants

Community dwelling, nursing home and hospitalized older adults aged over 60 years.

Measurements

Sarcopenia was defined by the major validated diagnostic criteria, such as the European Working Group on Sarcopenia in Older People (EWGSOP), the Asian Working Group for Sarcopenia (AWGS) and the International Working Group on Sarcopenia (IWGS). The model used was the random effect model for estimating the prevalence of sarcopenia. The sex-specific prevalence of sarcopenia as well as 95% CI (Confidence interval) were calculated using MetaXL (version 5.3). Heterogeneity assessment was carried out by subgroup analysis.

Results

We included 41 studies with a total of 34955 participants. The prevalence of sarcopenia in community-dwelling individuals in the included studies were 11% (95% CI: 8–13%) in men and 9% (95% CI: 7–11%) in women. The prevalence of sarcopenia in nursing-home individuals in the included studies were 51% (95% CI: 37–66%) in men and 31% (95% CI: 22–42%) in women and in hospitalized individuals were 23% (95%, CI: 15–30%) in men and 24% (95% CI: 14–35%) in women.

Conclusions

Despite the differences encountered between the studies, regarding diagnostic tools used to measure of muscle mass, different regions around the world and different populations and clinical settings, this systematic review revealed that a significant proportion of old people has sarcopenia (major in nursing homes), even in populations healthy in general. However, sarcopenia is caused by the aging progress, early diagnosis and individualized care, including physical activity and nutrition, can prevent some adverse outcomes in all populations.

Key words: Sarcopenia, nursing home, elderly, reduced muscle mass

Background

Sarcopenia is a geriatric syndrome associated with ageing that is characterized by a loss of muscle function and a progressive loss of skeletal muscle mass. It is known to increase the risk of disability, falls and fall-related injuries, loss of independence, hospitalization, and mortality (1). Characteristics of the population in study (such as age, sex, race and body composition differences in ethnic groups), living situation (hospitalized, community-dwelling and living in nursing homes) and the used methodology to assess sarcopenia's parameters cause a significant variation in the rate of this disease.

In order to improve the early recognition, diagnosis, and management of sarcopenia, as well as to stimulate further research, there have been published several guidelines. In 2010, the European Working Group on Sarcopenia in Older People (EWGSOP) introduced the first and most popular consensus, which suggested cut-offs of muscle mass, muscle strength, and physical performance for assessing and diagnosing sarcopenia (2). In 2011, the International Working Group on Sarcopenia (IWGS) published a consensus similar to that of the EWGSOP (3). The American Foundation for the National Institutes of Health (FNIH) Sarcopenia Project published their official consensus in 2014 (4). As a result of differences in ethnicity, genetic background, and body size, the EWGSOP and IWGS criteria might not apply to Asians (5); therefore, sarcopenia experts and scientists from Taiwan, Japan, Hong Kong, South Korea, China, Malaysia, and Thailand established the Asian Working Group for Sarcopenia (AWGS), which published guidelines for diagnosing sarcopenia in 2014 (6).

It is worth mentioning that in early 2018, the Working Group met again (EWGSOP2) to update the original definition in order to reflect scientific and clinical evidence that has built over the last decade. The new consensus (1) focuses on low muscle strength as a key characteristic of sarcopenia, uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia; (2) updates the clinical algorithm that can be used for sarcopenia case-finding, diagnosis and confirmation, and severity determination and (3) provides clear cut-off points for measurements of variables that identify and characterize sarcopenia (3).

Because of the different measurement tools, cutoff points and sarcopenia criteria, prevalence results may be difficult to interpret. In addition, the major differences in the prevalence of sarcopenia according to the population (community dwelling, hospitalized and living in nursing homes), makes it more difficult to establish preventative routines and therapeutic protocols and it requires a more personalized approach.

This meta-analysis aims to show the variations in the prevalence of sarcopenia in adults aged 60 years according to different populations (community-dwelling, hospital, nurse homes) and to provide awareness of such a serious, multifactorial and often undiagnosed disorder (3).

Methods

The pre-defined review protocol was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO — registration number: CRD42019130570).

Search Strategy

The search was carried out in the electronic database of PubMed (Medline) and Scopus between January 2009 and January 2019. The pre-defined search terms were: “sarcopenia” and “prevalence” or “frequency” or “incidence” or “muscle strength” or “muscle mass” or “muscle wasting”. The list of references of articles was also reviewed for any additional papers. Search was not limited by language.

Inclusion and Exclusion Criteria

We included only studies that had enrolled participants aged 60 years and older within well-defined populations (such as those in community-dwelling, hospital and nursing home/geriatric settings). We included studies that prevalence of sarcopenia had been assessed according to the EWGSOP, AWGS or IWGS definitions of sarcopenia, i.e. based on muscle mass (adjusted appendicular muscle mass for height) and muscle strength (handgrip strength) or physical performance (the usual gait speed). We excluded studies that focused on patients with diseases, such as cancer patients and hemodialysis patients.

Research papers were selected based on titles and abstracts. The full texts of all chosen publications were assessed for pertinence. The process initially performed by two investigators. A third investigator adjudicated discrepancies between the two reviewers.

Data Extraction

Two reviewers extracted the information from all studies included using an excel form that we developed using a modified STROBE checklist. The following information was included: study design and methods, country, number of study settings, diagnostic criteria of sarcopenia, study outcomes, the prevalence of sarcopenia, results and conclusions. Another reviewer verified the extracted information.

Statistical Analysis

The pooled prevalence of sarcopenia with 95% confidence intervals (CIs) was estimated using a random effects model.

Heterogeneity was assessed by subgroup analysis. Severe heterogeneity was indicated as the heterogeneity of studies was greater than 50%. Publication bias was assessed using Doi plots. All meta-analysis methods were performed using MetaXL 5.3.

Results

The literature searches yielded 2102 studies (including 32 duplicates). According to inclusion criteria, we assessed titles and abstracts and 108 studies were selected. After reviewing full texts, 41 studies were suitable for the meta-analysis (Figure 1).

Figure 1.

Figure 1

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PRISMA diagram for study selection

A total of 34955 individuals, 15599 (45%) men and 19347 (55%) women; respectively, from the general population were examined through these studies. 30287 individuals were community-dwelling individuals, whereas 3802 and 886 individuals were from hospitals and nursing homes accordingly. Thirteen studies were distributed in Asia and there were also 28 studies from non-Asian countries, 21 of them being from Europe. A total of 15 studies used the Dual Energy X-Ray Absorptiometry (DXA) to assess muscle mass, 21 studies used the Bio-electrical Impedance Analysis (BIA) and 6 studies used anthropometric equations. In a study both DXA and BIA were used to assess muscle mass (7). The PRISMA diagram for study selection is shown in Figure 1.

Figure 2.

Figure 2

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Forest plot on the prevalence of sarcopenia in community-dwelling Men — total and divided in three subgroups (Asian, non-Asian and European)

Meta-analysis

The overall prevalence of sarcopenia in the included studies were 14% (95% CI: 11–17%) in men and 12% (95% CI: 10–15%) in women. Substantial heterogeneity observed in men (Q=1186.45, p=0.00, 12=96%) and women (Q=1188.18, p=0.00, 12=96%).

Because of the major differences in the prevalence of sarcopenia among community-dwelling individuals (10% prevalence), nursing-home individuals (38% prevalence) and hospitalized individuals (23% prevalence) as shown in figure 6, we examined these populations separately analyzing extensively only the community-dwelling group.

Figure 6.

Figure 6

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Forest plot on the prevalence of sarcopenia divided in subgroups by population. The prevalence of sarcopenia in community-dwelling individuals is 10%, in nursing-home individuals is 38% and in hospitalized individuals is 23%

Community Dwelling individuals

The prevalence of sarcopenia in community dwelling individuals in the included studies were 11% (95% CI: 8–13%) in men and 9% (95% CI: 7–11%) in women. Substantial heterogeneity observed in men (Q= 770.68, p=0.00, I2=95%) and women (Q= 652.35, p=0.00, I2=94%).

According to the Doi plot and the value of the LFK index equaled 0.93 (no asymmetry) in men and 0.00 (no asymmetry) in women, there is no publication bias being identified.

Figure 3.

Figure 3

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Forest plot on the prevalence of sarcopenia in community-dwelling Women — total and divided in three subgroups (Asian, non-Asian and European)

Subgroup Analysis

Muscle mass assessment methods

According to the muscle mass assessment method (DXA, BIA and anthropometrics), the prevalence of sarcopenia in community dwelling men was 11%, 9% and 9% accordingly and in women was 8%, 10% and 13%.

Countries

Community dwelling individuals living in non-Asian countries were found more likely to be sarcopenic than those living in Asian countries. This was true among both genders (13% vs 9% in men, 11% vs 8% in women). The prevalence of sarcopenia in Europe was 13% for men and 14% for women.

Criteria

There is a small difference in the prevalence of sarcopenia in community dwelling men and women according to the criteria used. In community dwelling men the prevalence ranges from 11%, 12% and 8% using EWGSOP, AWGS and IWGS criteria accordingly and in women ranges from 10%, 11% and 5% using EWGSOP, AWGS and IWGS criteria accordingly.

Nursing home/hospitalized individuals

The prevalence of sarcopenia in nursing-home individuals in the included studies were 51% (95% CI: 37–66%) in men and 31% (95% CI: 22–42%) in women and in hospitalized individuals were 23% (95%, CI: 15–30%) in men and 24% (95% CI: 14–35%) in women.

Figure 4.

Figure 4

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Forest plot on the prevalence of sarcopenia in community-dwelling Men divided in subgroups by criteria (EWGSOP, AWGS, IWGS)

Figure 5.

Figure 5

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Forest plot on the prevalence of sarcopenia in community-dwelling Women divided in subgroups by criteria (EWGSOP, AWGS, IWGS)

Discussion

Sarcopenia is considered to be an independent risk factor for various adverse outcomes, including difficulties in basic and instrumental ADL, osteoporosis, falls, length of stay at the hospital and re-admission as well as death (46).

The prevalence of sarcopenia in the literature varies widely and is likely to be affected by the population studied (community-dwelling, nursing homes and hospitals), the criteria used (EWGSOP, AWGS, IWGS) and the different methods utilized to assess muscle mass, muscle strength and physical performance.

In our study we found that in non-Asian countries, the prevalence of sarcopenia was more likely than in the Asian community dwelling individuals (13% vs 9% in men, 11% vs 8% in women). These results can be attributed to various factors such as racial characteristics, body size, cultural background, dietary regimes, and life quality of the elderly between the Asian and non-Asian individuals in different countries. Also, the cut-off points for the Asian populations are lower than for the non-Asian individuals in both genders, with young people of the same ethnic group as reference (47).

Table 1.

Characteristics of studies included in this meta-analysis

Studies Region Population Sample (N) Total-Male-Female Criteria Assessment method for muscle mass Total N Male N Female N
Rossi A et al.2017 (8) Italy Community-dwelling 274-97-177 EWGSOP DXA 92 28 64
Wang H et al. 2018 (9) China Community-dwelling 865-427-438 AWGS BIA 61 28 33
Silva Neto L et al. 2016 (10) Brazil Community-dwelling 70-31-39 EWGSOP DXA 7 5 2
Hai S et al. 2017 (11) China Community-dwelling 834-415-419 AWGS BIA 88 47 41
Hu X et al. 2017 (12) China Community-dwelling 607-251-356 AWGS Anthropometric equation ASM 112 41 71
Bahat G et al. 2018 (13, 14) Turkey Community-dwelling 207-67-140 BIA
1 EWGSOP 8 7 1
2 FNIH 19 6 13
3 IWGS 4 3 1
4 SCWD 4 4 1
Lee W et al. 2013 (5) Taiwan Community-dwelling 386-223-163 DXA
1 IWGS 16 13 3
2 EWGSOP 30 24 6
3 IWGS 43 24 19
4 EWGSOP 63 33 31
Wen X et al. 20151 (4) China Community-dwelling 286-136-150 Anthropometric equation ASM
1 IWGS 17 10 7
2 AWGS 9 8 1
3 EWGSOP 1 1 0
Clynes M et al. 20151 (5) UK Community-dwelling 298-156-142 DXA
1 Community-dwelling EWGSOP 10 7 3
2 Community-dwelling IWGS 25 13 12
Wang H et al. 2016 (7) China Community-dwelling 636-316-320 AWGS DXA and BIA 66 26 40
Akune T et al. 2014 (16) Japan Community-dwelling 1000-349-651 EWGSOP BIA 129 48 81
Yoo J et al. 2017 (17) Korea Community-dwelling 4020-1698-2322 AWGS DXA 759 508 251
Yu R et al. 2014 (18) China Community-dwelling 4000-2000-2000 EWGSOP DXA 216 109 107
Dodds R et al. 2017 (19) UK Community-dwelling 719-282-437 EWGSOP BIA 149 59 90
Yang M et al. 2018 (20) China Community-dwelling 384-160-224 AWGS BIA 61 19 42
Lera L et al. 2017 (21) Chile Community-dwelling 1006-319-687 EWGSOP DXA 192 62 130
Gao L et al. 2015 (22) China Community-dwelling 612-254-358 AWGS Anthropometric measures 60 17 43
Patel H et al. 2013 (23) UK Community-dwelling 1787-765-1022 EWGSOP FFM 116 35 81
Bahat G et al. 2018 (24) Turkey Community-dwelling 242-77-165 EWGSOP BIA 2 1 1
Ohara D et al. 2018 (25) Brazil Community-dwelling 383-132-251 EWGSOP Equation TMM 48 14 34
Beaudart C et al. 2015 (26) Belgium Community-dwelling 534-212-322 EWGSOP DXA 73 25 48
Yoshida D et al. 2014 (27) Japan Community-dwelling 4811-2343-2468 EWGSOP BIA 360 192 168
Legrand D et al. 2013 (28) Belgium Community-dwelling 288-103-185 EWGSOP BIA 36 13 23
Zengin A et al. 2018 (29) Gambia Community-dwelling 486-238-248 EWGSOP DXA 59 37 22
Bianchi L et al. 2016 (30) Italy Community-dwelling 538-250-288 EWGSOP BIA 55 19 36
Beaudart C et al. 2014 (31) Belgium Community-dwelling 400-157-243 EWGSOP DXA
1 61 23 38
2 72 23 49
Hashemi R et al. 2016 (32) Iran Community-dwelling 300-146-154 EWGSOP DXA 54 30 24
Villada F et al. 2015 (33) Spain Community-dwelling 258-83-175 EWGSOP DXA 6 4 2
Phillips A et al. 2017 (34) Germany Community-dwelling 927-473-454 EWGSOP BIA 53 19 34
Christensen M et al. 2018 (35) Denmark Community-dwelling 80-28-52 EWGSOP DXA 21 8 13
Yoo J et al. 2016 (36) Korea Hospitalized 1614-664-950 AWGS DXA 174 107 67
Rossi A et al. 2014 (37) Italy Hospitalized 119-78-41 EWGSOP BIA 31 13 18
Bianchi L et al. 2017 (38) Italy Hospitalized 655-315-340 EWGSOP BIA 227 115 112
Smoliner C et al. 2014 (39) Germany Hospitalized 198-59-139 EWGSOP BIA 50 20 30
Buckinx Fanny et al. 2017 (40) Belgium Nursing home 662-182-480 EWGSOP BIA 252 78 174
Senior H et al. 201 (51) Australia Nursing home 102-31-71 EWGSOP BIA 41 15 26
Landi F et al. 2012 (41) Italy Nursing home 122-31-91 EWGSOP BIA 40 21 19
Jacobsen E et al. 2016 (42) Norway Hospitalized 120-44-76 EWGSOP anthropometric measures MAMC 36 3 33
Sousa A et al. 2015 (43) Portugal Hospitalized 193-112-81 BIA
1 EWGSOP 69 38 31
2 EWGSOP 72 46 26
3 EWGSOP 14 10 4
Martone A et al. 2017 (44) Italy Hospitalized 394-183-211 EWGSOP BIA 58 29 29
Cerri A et al 2015 (45) Italy Hospitalized 103-42-61 EWGSOP BIA 22 10 12
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Most of the studies we included used the Bio-electrical Impedance Analysis (BIA, 21 studies) to asses muscle mass, followed by the Dual Energy X-Ray Absorptiometry (DXA, 15 studies) and anthropometric equations (6 studies). The prevalence of sarcopenia varies according to the tool used to measure muscle mass. BIA is known to underestimate fat mass and overestimate muscle mass (49). Previous studies found that the BIA-based prevalence of sarcopenia was higher than the DXA- based approach (50, 51). In our study we found that according to the muscle mass assessment method (DXA, BIA and anthropometrics), the prevalence of sarcopenia in community dwelling men was 11%, 9% and 9% accordingly and in women was 8%, 10% and 13%.

The overall pooled prevalence of sarcopenia among all populations in the included studies was higher in men (14%) and lower in women (12%). Epidemiological data for discordance in sarcopenia prevalence between older men and women have been conflicting. Several studies had suggested differential sex-specific rate of absolute muscle loss, being greater in men than in women, which could not be attributed merely to the larger initial muscle mass in men by interleukin-6 (IL-6) in women (48).

It is worth mentioning that we found a lower incidence of sarcopenia in the studies used the IWGS criteria in comparison with the EWGOP-based and AWGS-based studies. This was not surprising because EWGSOP and AWGS classify sarcopenia as low muscle strength with low muscle mass without low physical performance as IWGS does (5).

Our review is the first systematic review and meta-analysis to compare the differences in the prevalence of sarcopenia among different populations (community-dwelling, hospitalized, nursing home). Based on our findings, the most prevalent individuals to sarcopenia are the ones who live in nursing homes (38% incidence of sarcopenia) followed by the ones that are hospitalized (23% incidence of sarcopenia) and the least prevalent individuals who are community-dwelling (10% incidence of sarcopenia). One systematic review and meta-analysis done in 2018 found that the prevalence of sarcopenia in nursing homes is 41% (52, 53), which is close to our results of 38%. Another meta-analysis done in 2017 found that the prevalence of sarcopenia in community dwelling individuals is 10%(47) which completely agrees with our results of 10%.

Physical activity and nutrition

A lot of studies state that higher physical activity levels are associated with lower sarcopenic risk (18). The physical activity and the nutritional status are some of the major factors that we found such a difference in the prevalence of sarcopenia in nursing homes and hospitalized patients (38% and 23%), who spend a lot of hours in bed and often do not have a choice of what foods to eat, in comparison to community dwelling individuals (10%) that are more physically active and choose their own foods.

Sarcopenic individuals in nursing homes reported more sitting time, were less likely to report being currently physical active and also were more likely to be malnourished (1, 40, 41).

Hospitalized individuals might represent an additional risk factor for sarcopenia and functional decline because of reduced caloric intake, low physical activity or prolonged bed-rest, depressed mood, and social isolation (38, 44).

Community-dwelling individuals are more likely to be sarcopenic if they are less physically active and don't have a good nutritional status (7, 11, 12, 15, 18, 22).

It is also worth mentioning that sarcopenia may be less prevalent in Asian populations due to differences in lifestyle. These differences include better dietary aspect and higher levels of activity than the Western populations, which act as protective factors against sarcopenia (47).

Our review revealed that the currently available studies addressing sarcopenia in nursing homes and hospitals were generally small in sample size in comparison to the ones addressing community-dwelling individuals. Hence, there seem to be significant opportunities to expand our understanding of sarcopenia by carrying out further well-designed and well-reported studies to compare the various diagnostic criteria of sarcopenia on different populations for the prediction of death and other clinical outcomes (such as quality of life and hospitalization). It is also interesting to evaluate the use of targeted nutrition, nutritional supplements and exercise regimes on the outcomes of sarcopenia in nursing homes and hospitals.

Conclusion

Sarcopenia appears to be highly prevalent in older nursing home residents and hospitalized patients in comparison to community-dwelling individuals. Low physical activity and malnutrition may be two major factors associated with these results. Asian populations are less likely to be sarcopenic because of their different lifestyle than the Western populations. More well-designed RCTs are needed to determine the effects of nutritional supplements, exercise, and their combination for nursing home residents and hospitalized patients.

Conflict of Interest

None for all authors

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