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Geriatr Gerontol Int 2014; 14 (Suppl. 1): 102–108
ORIGINAL ARTICLE
Association of cognitive impairment, depressive symptoms and sarcopenia among healthy older men in the veterans retirement community in southern Taiwan: A cross-sectional study Ying-Hsin Hsu,1,2,3 Chih-Kuang Liang,1,2,3 Ming-Yueh Chou,1,3,4 Mei-Chen Liao,1,3,5 Yu-Teh Lin,1,2,3 Liang-Kung Chen3,6 and Yuk-Keung Lo1,2,3 1 Geriatric Medicine Center, 2Division of Neurology, Department of Internal Medicine, Departments of 4Family Medicine and 5Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, 6Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, and 3 National Yang Ming University School of Medicine, Taipei, Taiwan
Aim: To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan Methods: This cross-sectional study recruited 353 men aged 65 years and older. In addition to demographic characteristics, all participants were measured for gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA). The diagnosis of sarcopenia was made according to the European Working Group on Sarcopenia in Older People criteria. Slow walking speed was defined as ≤0.8 meter/second. Low muscle strength was defined as the handgrip strength less than 22.5 kg which was adjusted according to Taiwanese norms. A heightadjusted muscle mass of 8.87 kg/m2 from a previous Taiwanese study was defined as low muscle mass. Cognitive function was evaluated by the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15) was used for screening of depressive symptoms. Results: Among the 353 participants (mean age 82.7 ± 5.3 years), 30.9% (109/353) were classified as sarcopenic. Multivariate logistic regression showed that sarcopenia was independently associated with cognitive impairment (adjusted OR 3.03, 95% CI 1.63–5.65, P < 0.001) and depressive symptoms (adjusted OR 2.25, 95% CI 1.03–4.89, P = 0.04). Conclusions: Sarcopenia was significantly associated with cognitive impairment and depressive symptoms among otherwise healthy older men living in the veterans retirement community. Further outcome study is required to explore the interrelationship of cognition, depressive symptoms and sarcopenia in older adults. Geriatr Gerontol Int 2014; 14 (Suppl. 1): 102–108. Keywords: cognitive impairment, depressive mood, elderly, men, sarcopenia.
Introduction Sarcopenia was first introduced in 1989 by Rosenberg who highlighted the importance of low muscle mass in the health of older people and the importance of sarcopenia in the care of elderly.1 “Sarcopenia” originated from the Greek “sarx” (flesh) and “penia” (loss),2
Accepted for publication 26 November 2013. Correspondence: Dr Ming-Yueh Chou MD, Geriatric Medicine Center, Department of Family Medicine, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Rd. Zuoying District, Kaohsiung, Taiwan 813. Email: [email protected]
102 |
doi: 10.1111/ggi.12221
and to establish the well-accepted operational definition is challenging. The European Working Group on Sarcopenia in Older People (EWGSOP) defined sarcopenia as the combination of low muscle mass plus low muscle function (either muscle strength or physical performance).3 The reported prevalence of sarcopenia ranged from 8 to 40% in people aged over 60 years and progressively increased as people aged.4–6 Sarcopenia has been shown to result in functional impairment, physical disability, frequent falls and higher mortality risk in the elderly population.6–8 Although the association between sarcopenia and adverse health outcomes has been described, little was known regarding the association of cognition, © 2014 Japan Geriatrics Society
Sarcopenia, cognition and depression
depressive symptoms and sarcopenia.9,10 A previous study has shown that weight loss might precede the occurrence of cognitive impairment of the elderly,11 and lower body mass index in the elderly was associated with a more severe degree of Alzheimer’s disease pathology on post-mortem examinations,12 and more rapid cognitive impairment.13 In contrast, aging alone features lean mass loss, which is related to cognitive impairment and brain atrophy,14 as well as sarcopenia.5,15 However, the Epidemiologie de l’Osteoporose (EPIDOS) cohort study did not identify a significant association between sarcopenia and cognitive impairment.9 Atrophy in the hippocampus, anterior cingulate and dorsolateral prefrontal cortex of the brain is associated with depression.16,17 A prospective community-based cohort study disclosed that obesity increased the risk of depressive moods in older men,18 but another study showed that older men with lowest height-adjusted appendicular skeletal muscle mass tended to be more depressive.19 Nevertheless, the interrelationship among cognition, depressive symptoms and sarcopenia of older people remained unclear. The main aim of the present study was to explore the association of cognitive impairment, depressive symptoms and sarcopenia among older men in the veterans retirement community in southern Taiwan.
Methods Study participants All residents living in the Gangshan Veterans Home, a veterans retirement community in southern Taiwan,20 were invited to participate in the study and were screened for study enrolment if informed consent was obtained. Of the 389 residents being screened, one woman and 11 people aged younger than 65 years were excluded from the study. Among those eligible residents (n = 377), 14 residents could not complete the full examinations, because they were too weak to complete the walking test or were unable to communicate, had a severe hearing impairment or blindness. The remaining 353 residents were enrolled for the study.
Data collection The results of the minimum data set (MDS) for the participating residents were retrieved for analysis. The MDS (Nursing Home 2.1, Chinese/Taiwanese version) contained 95 items of health-related characteristics, including sociodemographics, physical function, communication, health conditions, nutrition and previous drug history. In addition to MDS, the Mini-Mental State Examination (MMSE) and 15-item Geriatric Depression Scale (GDS-15) were carried out for each participant at the same time. The MMSE has been © 2014 Japan Geriatrics Society
translated into Chinese and has been sufficiently validated in Chinese populations.21 The GDS-15, consisting of 15 yes/no questions, has been proven to be as effective as the complete GDS in depression screening, which is also true in the Chinese version.22 Physical function of the study participants was evaluated by using the MDS resource utilization group activity of daily living (MDS RUG ADL) scale, which is composed of four items ADL; that is, bed mobility, toileting, transferring and eating.23 The total score of MDS RUG ADL ranged from 4 to 18. Participants who were classified as independent in all four items were considered physically independent, so a score of 4 was considered to show physical independence.
Assessment of sarcopenia From July to September of 2011, the sarcopenia status of the study participants was evaluated by the EWGSOP recommendation.3 All participants carried out a 6-m walk at their usual pace, and a cut-off point of ≤0.8 m/s was considered as low physical performance. Muscle strength was assessed by handgrip strength by using a digital dynamometer (TTM-YD, Tokyo, Japan). Three trials for each hand were carried out, and the best reading was used for sarcopenic diagnosis. Low muscle strength was defined as a handgrip strength less than 22.5 kg, which was adjusted according to Taiwanese norms.24,25 Skeletal muscle mass was measured by bioimpedance analysis (BIA; In Body 220 body composition analyzer, Seoul, Korea). A recent study reported that BIA eventually provided accurate estimates of skeletal muscle mass,3,26 and low muscle mass was defined as the height-adjusted skeletal muscle mass lower than 8.87 kg/m2 from a previous Taiwanese study.26
Determination of cognition and depressive symptoms The MMSE is a widely used instrument for cognitive function evaluation that has been used as a screening tool for cognitive impairment.27 The Chinese version of the MMSE has been validated,21 and a score of 0.8 m/s (n=159)
Measure handgrip strength
Normal
No sarcopenia (n =128)
Low (n =31)
Measure muscle mass
Low
sarcopenia (n =109)
carried out by Student’s t-test, and comparisons between categorical data were carried out by χ2-test or Fisher’s Exact test when appropriate. Multivariate logistic regression was used to evaluate independent associative factors for sarcopenia, and age, body mass index (BMI), physical function, chronic obstructive pulmonary disease, cognitive impairment, and depressive symptoms would be entered in the regression model. For all tests, a P-value
Geriatr Gerontol Int 2014; 14 (Suppl. 1): 102–108
ORIGINAL ARTICLE
Association of cognitive impairment, depressive symptoms and sarcopenia among healthy older men in the veterans retirement community in southern Taiwan: A cross-sectional study Ying-Hsin Hsu,1,2,3 Chih-Kuang Liang,1,2,3 Ming-Yueh Chou,1,3,4 Mei-Chen Liao,1,3,5 Yu-Teh Lin,1,2,3 Liang-Kung Chen3,6 and Yuk-Keung Lo1,2,3 1 Geriatric Medicine Center, 2Division of Neurology, Department of Internal Medicine, Departments of 4Family Medicine and 5Emergency Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, 6Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, and 3 National Yang Ming University School of Medicine, Taipei, Taiwan
Aim: To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan Methods: This cross-sectional study recruited 353 men aged 65 years and older. In addition to demographic characteristics, all participants were measured for gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA). The diagnosis of sarcopenia was made according to the European Working Group on Sarcopenia in Older People criteria. Slow walking speed was defined as ≤0.8 meter/second. Low muscle strength was defined as the handgrip strength less than 22.5 kg which was adjusted according to Taiwanese norms. A heightadjusted muscle mass of 8.87 kg/m2 from a previous Taiwanese study was defined as low muscle mass. Cognitive function was evaluated by the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15) was used for screening of depressive symptoms. Results: Among the 353 participants (mean age 82.7 ± 5.3 years), 30.9% (109/353) were classified as sarcopenic. Multivariate logistic regression showed that sarcopenia was independently associated with cognitive impairment (adjusted OR 3.03, 95% CI 1.63–5.65, P < 0.001) and depressive symptoms (adjusted OR 2.25, 95% CI 1.03–4.89, P = 0.04). Conclusions: Sarcopenia was significantly associated with cognitive impairment and depressive symptoms among otherwise healthy older men living in the veterans retirement community. Further outcome study is required to explore the interrelationship of cognition, depressive symptoms and sarcopenia in older adults. Geriatr Gerontol Int 2014; 14 (Suppl. 1): 102–108. Keywords: cognitive impairment, depressive mood, elderly, men, sarcopenia.
Introduction Sarcopenia was first introduced in 1989 by Rosenberg who highlighted the importance of low muscle mass in the health of older people and the importance of sarcopenia in the care of elderly.1 “Sarcopenia” originated from the Greek “sarx” (flesh) and “penia” (loss),2
Accepted for publication 26 November 2013. Correspondence: Dr Ming-Yueh Chou MD, Geriatric Medicine Center, Department of Family Medicine, Kaohsiung Veterans General Hospital, No. 386, Ta-Chung 1st Rd. Zuoying District, Kaohsiung, Taiwan 813. Email: [email protected]
102 |
doi: 10.1111/ggi.12221
and to establish the well-accepted operational definition is challenging. The European Working Group on Sarcopenia in Older People (EWGSOP) defined sarcopenia as the combination of low muscle mass plus low muscle function (either muscle strength or physical performance).3 The reported prevalence of sarcopenia ranged from 8 to 40% in people aged over 60 years and progressively increased as people aged.4–6 Sarcopenia has been shown to result in functional impairment, physical disability, frequent falls and higher mortality risk in the elderly population.6–8 Although the association between sarcopenia and adverse health outcomes has been described, little was known regarding the association of cognition, © 2014 Japan Geriatrics Society
Sarcopenia, cognition and depression
depressive symptoms and sarcopenia.9,10 A previous study has shown that weight loss might precede the occurrence of cognitive impairment of the elderly,11 and lower body mass index in the elderly was associated with a more severe degree of Alzheimer’s disease pathology on post-mortem examinations,12 and more rapid cognitive impairment.13 In contrast, aging alone features lean mass loss, which is related to cognitive impairment and brain atrophy,14 as well as sarcopenia.5,15 However, the Epidemiologie de l’Osteoporose (EPIDOS) cohort study did not identify a significant association between sarcopenia and cognitive impairment.9 Atrophy in the hippocampus, anterior cingulate and dorsolateral prefrontal cortex of the brain is associated with depression.16,17 A prospective community-based cohort study disclosed that obesity increased the risk of depressive moods in older men,18 but another study showed that older men with lowest height-adjusted appendicular skeletal muscle mass tended to be more depressive.19 Nevertheless, the interrelationship among cognition, depressive symptoms and sarcopenia of older people remained unclear. The main aim of the present study was to explore the association of cognitive impairment, depressive symptoms and sarcopenia among older men in the veterans retirement community in southern Taiwan.
Methods Study participants All residents living in the Gangshan Veterans Home, a veterans retirement community in southern Taiwan,20 were invited to participate in the study and were screened for study enrolment if informed consent was obtained. Of the 389 residents being screened, one woman and 11 people aged younger than 65 years were excluded from the study. Among those eligible residents (n = 377), 14 residents could not complete the full examinations, because they were too weak to complete the walking test or were unable to communicate, had a severe hearing impairment or blindness. The remaining 353 residents were enrolled for the study.
Data collection The results of the minimum data set (MDS) for the participating residents were retrieved for analysis. The MDS (Nursing Home 2.1, Chinese/Taiwanese version) contained 95 items of health-related characteristics, including sociodemographics, physical function, communication, health conditions, nutrition and previous drug history. In addition to MDS, the Mini-Mental State Examination (MMSE) and 15-item Geriatric Depression Scale (GDS-15) were carried out for each participant at the same time. The MMSE has been © 2014 Japan Geriatrics Society
translated into Chinese and has been sufficiently validated in Chinese populations.21 The GDS-15, consisting of 15 yes/no questions, has been proven to be as effective as the complete GDS in depression screening, which is also true in the Chinese version.22 Physical function of the study participants was evaluated by using the MDS resource utilization group activity of daily living (MDS RUG ADL) scale, which is composed of four items ADL; that is, bed mobility, toileting, transferring and eating.23 The total score of MDS RUG ADL ranged from 4 to 18. Participants who were classified as independent in all four items were considered physically independent, so a score of 4 was considered to show physical independence.
Assessment of sarcopenia From July to September of 2011, the sarcopenia status of the study participants was evaluated by the EWGSOP recommendation.3 All participants carried out a 6-m walk at their usual pace, and a cut-off point of ≤0.8 m/s was considered as low physical performance. Muscle strength was assessed by handgrip strength by using a digital dynamometer (TTM-YD, Tokyo, Japan). Three trials for each hand were carried out, and the best reading was used for sarcopenic diagnosis. Low muscle strength was defined as a handgrip strength less than 22.5 kg, which was adjusted according to Taiwanese norms.24,25 Skeletal muscle mass was measured by bioimpedance analysis (BIA; In Body 220 body composition analyzer, Seoul, Korea). A recent study reported that BIA eventually provided accurate estimates of skeletal muscle mass,3,26 and low muscle mass was defined as the height-adjusted skeletal muscle mass lower than 8.87 kg/m2 from a previous Taiwanese study.26
Determination of cognition and depressive symptoms The MMSE is a widely used instrument for cognitive function evaluation that has been used as a screening tool for cognitive impairment.27 The Chinese version of the MMSE has been validated,21 and a score of 0.8 m/s (n=159)
Measure handgrip strength
Normal
No sarcopenia (n =128)
Low (n =31)
Measure muscle mass
Low
sarcopenia (n =109)
carried out by Student’s t-test, and comparisons between categorical data were carried out by χ2-test or Fisher’s Exact test when appropriate. Multivariate logistic regression was used to evaluate independent associative factors for sarcopenia, and age, body mass index (BMI), physical function, chronic obstructive pulmonary disease, cognitive impairment, and depressive symptoms would be entered in the regression model. For all tests, a P-value
