Abstract
Objectives
We aimed to evaluate the comparative effectiveness and applicability of using calf circumference (CC), strength, need for assistance with walking, rising from a sitting position, climbing stairs, and the incidence of falls (SARC-F), as well as SARC-F plus CC (SARC-CalF) and the Ishii test, for assessing sarcopenia in older adult nursing home occupants.
Method
In this cross-sectional study, the diagnostic criteria of the AWGS2019 were used as the standard, and the accuracy of the four screening methods determined by indicators, including sensitivity, specificity, receiver operating characteristic (ROC) curve, positive predictive values (PPV), and negative predictive values (NPV).
Results
One hundred and ninety-nine older adults, 97 male and 102 female, were included. The prevalence of sarcopenia was 48.7%. Over all the participants, the sensitivity and specificity of CC were 74.22% and 51.96%, respectively, and 40.21% and 83.33%, respectively, for SARC-F. The use of SARC-CalF raised the SARC-F sensitivity (71.14%) while reducing the specificity (60.78%). The Ishii test had a sensitivity of 89.7% and a specificity of 74.51%. The PPV and NPV of CC, SARC-F, SARC-CalF, Ishii test were 0.6/0.68, 0.7/0.59, 0.55/0.63, and 0.77/0.88, respectively. The areas under the curve for CC, SARC-F, SARC-CalF, and the Ishii test were 0.67(95%CI, 0.59–0.74), 0.71(95%CI, 0.64–0.79), 0.71(95%CI, 0.64–0.79), and 0.86 (95% CI,0.81–0.92), respectively. The sensitivity and specificity of CC, SARC-F, SARC-CalF, and the Ishii test for sarcopenia screening in males were 71.69%/56.41%, 29.31%/79.49%, 67.24%/64.10%, and 94.83%/56.41%, respectively, and in females were 79.49%/49.21%, 56.41%/85.71%, 76.92%/58.73%, and 82.05%/85.71%, respectively. The PPV and NPV of CC, SARC-F, SARC-CalF, and the Ishii test in males were 0.71/0.56, 0.68/0.43, 0.74/0.57, and 0.76/0.88, respectively, while in females the values were 0.49/0.79, 0.71/0.76, 0.54/0.8, and 0.78/0.89, respectively. The areas under the curve for CC, SARC-F, SARC-CalF, and the Ishii test in males were 0.7(95%CI, 0.59–0.8), 0.63(95%CI, 0.52–0.75), 0.68(95%CI, 0.57–0.8), and 0.86(95% CI, 0.78–0.94), respectively, and in females 0.69(95%CI, 0.58–0.8), 0.81(95%CI, 0.72–0.89), 0.76(95%CI, 0.67–0.86), and 0.85 (95%CI, 0.77–0.94), respectively.
Conclusion
The overall screening ability of the Ishii test for sarcopenia was superior to that of the CC, SARC-F, and SARC-CalF in older adults in nursing homes.
Key words: Older adults, sarcopenia, screening, nursing home
Introduction
Sarcopenia is characterized by both reduced muscle strength and mass (1). It is more prevalent in older people (2), and can cause serious problems such as poor quality of life, fractures, falls, dysphagia, disability, cognitive impairment, even death (3, 4). It is, therefore, important to recognize sarcopenia in its early stages. Diagnosing sarcopenia requires checking both the mass and the functioning of muscles. Currently, there are many diagnostic tools for checking muscle mass, including DXA (5), BIA (6), CT (7), and MRI (8). Muscle function is usually recognized by the performance and strength of muscles, using parameters such as grip, walking speed, and chair-standing tests. However, the above methods used for determining muscle mass require specialized equipment and professional operators, which may be difficult in a nursing home setting. Therefore, a simple screening method or simple screening scale may be more appropriate.
Since the AWGS2019 consensus update, the use of calf circumference (CC), strength, the need for support while walking, the ease of standing from a sitting position, stair-climbing, and the tendency to fall (SARC-F), as well as the SARC-F-CC combination (SARC-CalF) has been recommended for screening in community-based primary medical institutions (9). Based on the AWGS2019 consensus, most studies on CC focus on older adults in the community (1, 10). SARC-F (11) is a commonly used screening questionnaire and includes five simple questions. The questionnaire, however, has low sensitivity and high specificity, and, to improve its sensitivity, the SARC-CalF screening scale was developed (12). Although one study has investigated the efficacy of the CC, SARC-F, and SARC-CalF parameters in the prediction of sarcopenia among elderly people in assisted living conditions (13), the sample size was small. To date, there have been few reports on using these parameters for determining sarcopenia in residents of nursing homes based on the AWGS2019 consensus. An additional measure, the Ishii test, is based on the EWGSOP consensus (14) has high sensitivity and specificity (15). We have shown in a previous study based on the AWGS2019 consensus that although the Ishii test is strongly predictive of sarcopenia in community-based elderly (10), its accuracy and efficacy in nursing home situations has not been investigated.
Therefore, based on current research, we aimed to evaluate the comparative effectiveness of CC, SARC-F, SARC-CalF, and the Ishii test in screening nursing home-based older adults to determine the most suitable and effective screening tool under these conditions.
Methods
Study design and patient recruitment
Adult residents over the age of 60 years from two nursing homes were included. Exclusion criteria included people with contraindications for BIA, with severe cognitive dysfunction limiting cooperation, those who had received surgery to legs, feet, or hands in the previous three months, those diuretics (with the exception of diuretics used to treat hypertension and where the dose had been stable for at least 21 days), or having other disorders or diseases deemed unsuitable for the study by the investigator. The study was conducted in accordance with the Declaration of Helsinki, and the the protocol was approved by the Institutional Review Board of the Zigong Medical Foundation (IRB number: 20191001). All participants or their legal guardians provided written informed consent.
Measurement of muscle mass
BIA and an Inbody 770 Body Composition Analyser (Inbody 770, Biospace China Inc.) were used to evaluate muscle mass. The values of appendicular skeletal muscle mass (ASM), the amount of muscle in both legs and arms, were used, together with the height, to calculate the ASM index (ASMI) (kg/m2) (9).
Measurement of muscle strength
The handgrip was evaluated using a digital grip strength dynamometer (Camry EH101, Camry, El Monte, CA, USA). Three measurements were taken for each hand and the maximum measurement was used.
Measurement of physical performance
The speed of walking over a 6 m distance was determined to 0.01 s. The average of two assessments was used.
Additional measurements
The average of two CC measurements was used for analysis. The CC values were expressed in cm (0.1 cm).
Cut-off values of the four screening tools for sarcopenia screening
The following cut-off values suggest the possibility of sarcopenia: CC, <34 cm for males and < 33 cm for females (9); SARC-F, ≥4 points(9); SARC-CalF, ≥11 points (9); Ishii test for males, ≥105 points and ≥ 120 points for females (14).
Statistical analysis
SPSS 26.0 (IBM Corp, NY, USA) was utilized for all analyses. Data are represented as means ± SD or medians with interquartile ranges (IQR). Continuous variables were compared via the one-way ANOVA test. Categorical variables are represented as numbers (percentages) and differences determined using chi-squared tests. The area under the ROC curve (AUC) was used as a measure of precision of the screening tools in determining sarcopenia; the differences across the ROC curves were examined using the DeLong method (16). The AUC was usually between 0.5 and 1, with AUC values of greater than 0.8 indicating good prediction. The accuracy of the screening methods was evaluated by specificity, sensitivity, positive predictive value (PPV), and negative predictive value (NPV).
Results
One hundred and ninety-nine people aged 60 years and older were included. Of these 51.3% were women and 48.7% were men. The proportions of the group under 70 years old and the group greater than or equal to 70 years old were 42.7% and 57.3%, respectively. The overall prevalence of sarcopenia was 48.7%, while the sarcopenia incidence was 59.8% and 38.2% for males and females, respectively (Table 1).
Table 1.
Characteristics of the Study Population
| Characteristics | N0n-Sarcopenia (n=102) | Sarcopenia (n=97) | P |
|---|---|---|---|
| Sex,n(%) | 0.002 | ||
| male | 39(38.2) | 58(59.8) | |
| female | 63(61.8) | 39(40.2) | |
| Age,year,n(%) | <0.001 | ||
| 60–69 | 58(56.9) | 27(27.8) | |
| ≥70 | 44(43.1) | 70(72.2) | |
| Gait speed,m/s,n(%) | <0.001 | ||
| ≥1 | 71(69.6) | 19(19.6) | |
| <1 | 31(30.4) | 78(80.4) | |
| Handgrip strength,male<28kg,female<18kg,n(%) | <0.001 | ||
| no | 80(78.4) | 11(11.3) | |
| yes | 22(21.6) | 86(88.7) | |
| ASMI,kg/m2,mean(SD) | 6.3(0.9) | 5.6(0.8) | <0.001 |
| CC,male<34cm,female<33cm,n(%) | <0.001 | ||
| no | 53(52) | 25(25.8) | |
| yes | 49(48) | 72(74.2) | |
| SARC-F score,n(%) | <0.001 | ||
| <4 | 85(83.3) | 58(59.8) | |
| ≥4 | 17(16.7) | 39(40.2) | |
| SARC-CalF score,n(%) | <0.001 | ||
| <11 | 62(60.8) | 28(28.9) | |
| ≥11 | 40(39.2) | 69(71.1) | |
| Ishii test,male≥105,female≥120, n(%) | <0.001 | ||
| no | 76(74.5) | 10(10.3) | |
| yes | 26(25.5) | 87(89.7) | |
Note:ASMI:appendicular skeletal muscle mass index; CC:calf circumference. SARC-F:strength, assistance in walking, rising from a chair, climbing stairs, and falls; SARC-CalF:SARC-F combined with CC.
Over all the participants, the CC had a sensitivity of 74.22% and a specificity of 51.96%; the parameters for SARC-F were 40.21% and 83.33%, respectively, for SARC-CalF, 71.14 % and 60.78%, respectively, and for the Ishii test, 89.70% and 74.51%, respectively. The PPV/NPV values of the CC, SARC-F, SARC-CalF, and the Ishii test were 0.6/0.68, 0.7/0.59, 0.55/0.63, and 0.77/0.88, respectively. The AUCs of the CC, SARC-F, SARC-CalF, and Ishii test were 0.67 (95% CI, 0.59–0.74), 0.71(95% CI, 0.64–0.79), 0.71(95% CI, 0.64–0.79), and 0.86 (95% CI, 0.81–0.92), respectively. The ROC curves differed significantly between the CC and the Ishii test, SARC-F and the Ishii test, and SACR-CALF and the Ishii test. However, the ROC curve differences did not differ significantly for the CC, SARC-F, and SACR-CalF screening methods. The sensitivity/specificity of CC, SARC-F, SARC-CalF, and Ishii test in screening for sarcopenia in males were 71.69%/56.41%, 29.31%/79.49%, 67.24%/64.10%, and 94.83%/56.41%, respectively, and in females were 79.49%/49.21%, 56.41%/85.71%, 76.92%/58.73%, and 82.05%/85.71%, respectively. The PPV/ NPV values of the CC, SARC-F, SARC-CalF, and the Ishii test in males were 0.71/0.56, 0.68/0.43, 0.74/0.57, and 0.76/0.88, respectively, and in females were 0.49/0.79, 0.71/0.76, 0.54/0.8, and 0.78/0.89, respectively. The AUCs of the CC, SARC-F, SARC-CalF, and Ishii test in males were 0.7 (95%CI, 0.59–0.8), 0.63(95%CI, 0.52–0.75), 0.68(95%CI, 0.57–0.8), and 0.86 (95%CI, 0.78–0.94), respectively, and in females were 0.69 (95%CI, 0.58–0.8), 0.81(95%CI, 0.72–0.89), 0.76(95%CI, 0.67–0.86), and 0.85(95%CI, 0.77–0.94), respectively. The Ishii test showed superior sensitivity and AUC in evaluating sarcopenia in males over CC, SARC-F, and SARC-CalF according to the AWGS 2019 criteria (Table 2 and Figures 1 and 2). In females, the Ishii test showed superior sensitivity, specificity, and AUC compared with the other three screening tools (Table 2 and Figure 3).
Table 2.
Sensitivity/Specifificity Analyses and ROC Models for Calf Circumference, SARC-F, SARC-CalF and Ishii Validation Against the AWGS 2019 Criteria
| Sensitivity,% | Specificity, % | PPV | NPV | AUC | |
|---|---|---|---|---|---|
| Total | |||||
| CC | 74.22 | 51.96 | 0.6 | 0.68 | 0.67(0.59–0.74)d |
| SARC-F | 40.21 | 83.33 | 0.7 | 0.59 | 0.71(0.64–0.79)d |
| SARC-Calf | 71.14 | 60.78 | 0.55 | 0.63 | 0.71(0.64–0.79)d |
| Ishii test | 89.70 | 74.51 | 0.77 | 0.88 | 0.86(0.81–0.92)abc |
| Male | |||||
| CC | 71.69 | 56.41 | 0.71 | 0.56 | 0.7(0.59–0.8)d |
| SARC-F | 29.31 | 79.49 | 0.68 | 0.43 | 0.63(0.52–0.75)d |
| SARC-Calf | 67.24 | 64.10 | 0.74 | 0.57 | 0.68(0.57–0.8)d |
| Ishii test | 94.83 | 56.41 | 0.76 | 0.88 | 0.86(0.78–0.94)abc |
| Female | |||||
| CC | 79.49 | 49.21 | 0.49 | 0.79 | 0.69(0.58–0.8)d |
| SARC-F | 56.41 | 85.71 | 0.71 | 0.76 | 0.81(0.72–0.89) |
| SARC-Calf | 76.92 | 58.73 | 0.54 | 0.8 | 0.76(0.67–0.86) |
| Ishii test | 82.05 | 85.71 | 0.78 | 0.89 | 0.85(0.77–0.94)a |
Note:a Significantly different relative to the CC. b Significantly different relative to the SARC-F. c Significantly different relative to the SARC-CalF. d Significantly different relative to the Ishii test.
Figure 1.
The ROC curves of calf CC, SARC-F, SARC-CalF, and Ishii test in the total study population
Figure 2.
The ROC curves of calf CC, SARC-F, SARC-CalF, and Ishii test in the males study population
Figure 3.
The ROC curves of calf CC, SARC-F, SARC-CalF, and Ishii test in the females study population
Discussion
In our study, there was an overall 48.7% occurrence of sarcopenia among the nursing home residents. This is slightly higher than that observed in the previous study (17), possibly because we used the more stringent AWGS2019 diagnostic criteria.
This is the first time that the efficacy of CC, SARC-F, SARC-CalF, and the Ishii test were investigated for sarcopenia screening in nursing homes based on the AWGS2019 consensus criteria. For the overall participants, as well as the male and female subgroups, the AUC of the Ishii test was found to be the highest, with all above 0.8. In this study, we used the “rule-out” screening test (18), namely, that the sensitivity and NPV should be higher. In all categories (total participants, males and females), the sensitivity and NPV of the Ishii test was the highest. Therefore, we infer that the Ishii test is superior for assessing sarcopenia in nursing home residents.
The scoring of the Ishii test was originally designed by Ishii and associates based on the EWGSOP consensus. This screening tool uses inputs such as age (years), CC (cm), and grip strength (kg), as objective measures to mathematically calculate the likelihood and degree of sarcopenia (14). Hax et al. reported an ROC curve of the Ishii test for sarcopenia in patients with systemic sclerosis of 0.862, with sensitivity of 86.7% and a specificity of 73.4% (15). Although this study was based on the 2019 revised EWGSOP diagnostic criteria, the results are consistent with ours.
In our study, the ROC curve of CC was greater than 0.6, and the sensitivity was greater than 70% for all groups of participants (total, male, and female), indicating that CC is an accurate measure of sarcopenia in older nursing home adults. However, the specificity of the CC was found to be the lowest. A larger sample size is required in future studies.
Among the total study participants, as well as in male or female participants, the specificity of SARC-F was found to be highest and the sensitivity lowest. According to these results, the SARC-CalF can indeed enhance SARC-F sensitivity although with reduced specificity. However, both SARC-F and SARC-CalF ROC curves were greater than 0.6, indicative of good predictive value for assessing sarcopenia based on the AWGS2019 criteria in nursing homes.
Our research has several limitations. Firstly, our sample size was limited; a greater number of participants would be needed for verification. Secondly, the participants were relatively well physically and were able to stand up to complete the test, so it is possible that the actual sarcopenia prevalence may be higher.
Conclusion
The overall sarcopenia screening ability of the Ishii test was superior to that of the CC, SARC-F, and SARC-CalF in elderly nursing home occupants.
Declaration of conflicting interest
The authors declare that there are no conflicts of interest.
Funding
2020 Zigong City Key Technology Support Plan (Project No. 2020YLSF19).
Ethical standards
The study was conducted in accordance with the Declaration of Helsinki and the Institutional Review Board of Zigong Medical Foundation approved the study design protocol (IRB number:20191001).
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