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Physical Activity Scale for the Elderly (PASE) Score Is Related to Sarcopenia in Noninstitutionalized Older Adults

Curcio, Francesco MD1; Liguori, Ilaria MD1; Cellulare, Michele MD1; Sasso, Giuseppe MD1; Della-Morte, David MD, PhD2,3; Gargiulo, Gaetano MD4; Testa, Gianluca MD, PhD1,5; Cacciatore, Francesco MD, PhD1,6; Bonaduce, Domenico MD1; Abete, Pasquale MD, PhD1

Author Information

1Department of Translational Medical Sciences, University of Naples “Federico II,” Naples, Italy.

2Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.

3San Raffaele Roma Open University, Rome, Italy.

4Division of Internal Medicine, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy.

5Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy.

6Azienda Ospedaliera dei Colli, Monaldi Hospital, Heart Transplantation Unit, Naples, Italy.

Address correspondence to: Pasquale Abete, MD, PhD, Dipartimento di Scienze Mediche Traslazionali, Università di Napoli Federico II, Via S. Pansini, 80131 Naples, Italy ([email protected]).

Supported by Progetto AIFA COD, FARM7K7XZB and Fondazione Roma NCDS-2013-00000331—Sarcopenia and Insulin Resistance in the Elderly; Age-Associated Inflammation as a Shared Pathogenic Mechanism and Potential Therapeutical Target (They contributed to the purchase of materials utilized in the study.)The authors declare no conflicts of interest.Richard Bohannon was the Decision Editor.

Journal of Geriatric Physical Therapy: July/September 2019 - Volume 42 - Issue 3 - p 130-135
doi: 10.1519/JPT.0000000000000139
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Abstract

INTRODUCTION

Sarcopenia, previously defined as an age-related loss of muscle mass, is now considered as a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength.1,2 After the age of 50 years, muscle mass tends to be reduced at a rate of 1% to 2% per year, and this decline is mainly due to the progressive atrophy and loss of type II muscle fibers and motor neurons.3 This phenomenon is particularly prevalent in individuals older than 80 years and increases the risk of morbidity and mortality4,5 in older adults, especially in older individuals residing in nursing homes.6

The pathogenesis of sarcopenia is complex and several factors are involved. Indeed, hormonal, metabolic, nutritional, and inflammatory factors and, very importantly, physical inactivity are implicated.3

A sedentary lifestyle determines a greater and more rapid loss of muscle than an active one.7 Strong evidences suggest that disuse may be responsible for muscle atrophy and weakness more than aging.8 In addition, either acute conditions, such as hospitalization, or chronic conditions characterized by physical inactivity, such as cancer, diabetes and peripheral artery disease, seem to accelerate the progression of muscle atrophy.9

Nevertheless, the relationship between muscle mass and strength and physical activity levels is poorly investigated. One possible explanation for this phenomenon might be underutilization of valid measurement tools to quantify physical activity in older adults. In this regard, the Physical Activity Scale for the Elderly (PASE) is a reliable and valid self-reported questionnaire for older people, specifically conceived to assess the amount of occupational, household, and leisure physical activity carried out over the last week.10 The test can be easily administered and it is frequently incorporated into a comprehensive geriatric assessment.

Thus, in the present study we aimed to investigate the relationship between muscle mass and strength and physical activity, as assessed by PASE, in older adults who underwent comprehensive geriatric assessment.

METHODS

Study Population

This cohort study enrolled 420 older adults (≥65 years) consecutively admitted to the “Comprehensive Geriatric Assessment Center” of the Azienda Ospedaliera Universitaria Federico II (Naples, Italy) from January 2015 to December 2016. The study received full ethical approval from the “Research Ethics Committee” in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All participants signed an informed consent form, and the institutional review board approved the study. Anthropometric measurements including age, sex, body mass index (BMI), and waist circumference were collected.11

Comprehensive Geriatric Assessment

Participants underwent a comprehensive geriatric multidimensional evaluation. Cognitive function and depression were assessed through the Mini-Mental State Examination (MMSE)12 and Geriatric Depression Scale (GDS), respectively.13 Comorbidity presence and severity were evaluated by means of the Cumulative Illness Rating Scale (CIRS-comorbidity and CIRS-severity)14 and drugs number count.15 The presence and degree of disability were examined via the number of lost basic (BADL)16 and instrumental activities of daily living (IADL).17 Nutritional assessment was performed using the Mini-Nutritional Assessment (MNA).18 The assessment of physical performance was carried out using 4-m gait speed (m/s) evaluation.19 Social support analysis was performed using the Social Support Assessment, scoring from 17 (participants with the lowest support) to 0 (participants with the highest support).20 Risk of falling was evaluated by Tinetti Mobility Test or Performance-Oriented Mobility Assessment.21 Frailty was assessed by Fried's method (≥3 of the following criteria were present: unintentional 10-lb loss in past year, self-reported exhaustion, weakness, slow walking speed, and low physical activity)22 and by Rockwood's methods (40 deficits including signs and/or symptoms routinely assessed in older adults).23

Assessment of Physical Activity

The PASE was used to assess participants' usual physical activity.10 The PASE scale is a brief and easily scored survey specifically designed to assess physical activity in epidemiologic studies involving persons 65 years and older. The PASE evaluates physical activity performed over a 1-week time frame. Participation in leisure activities, including walking outside the home, light, moderate, and strenuous sport and recreation, and muscle strengthening were recorded as never, seldom (1-2 days/week), sometimes (3-4 days/week), and often (5-7 days/week) performed. Duration was categorized as “less than 1 hour,” “between 1 and 2 hours,” “2 to 4 hours,” or “more than 4 hours.” Paid or unpaid work, other than work that involves mostly sitting activity, was recorded in total hours per week. Housework (light and heavy), lawn work/yard care, home repair, outdoor gardening, and caring for other people were recorded as “yes” or “no.” Frequency and duration of household activities were not requested. The total PASE score was computed by multiplying the amount of time spent in each activity (hours/week) or participation (yes/no) in an activity by the empirically derived item weights and summing over all activities. The PASE score was stratified in tertiles: 0 to 40 (sedentary), 41 to 90 (light physical activity) and more than 90 (moderate to intense activity).

Assessment of Muscle Mass and Strength

Muscle mass was measured by bioelectrical impedance analysis (BIA) using a Quantum/S Bioelectrical Body Composition Analyzer (Akern Srl, Florence, Italy). Whole-body BIA measurements were taken between the right wrist and ankle, with the participant in a supine position. Muscle mass was calculated using the BIA equation of Janssen and colleagues.24

Muscle strength was assessed by a handheld dynamometer held by a tester and applied to a participant (Mecmesin Advanced Force Gauge 500N, GDM, Italy).

Applying the algorithm of the European Working Group on Sarcopenia in Older People (EWGSOP) consensus, participants first performed a gait speed test. If they presented a slow gait speed (≤0.8 m/s), they underwent a grip strength measurement. Values of muscle strength (kg) for each range of BMI values were used as a cutoff point to classify “low muscle strength” (BMI ≤24 = ≤29 kg, BMI 24.1 to 28 = ≤30 kg, and BMI >28 = ≤32 kg for men, respectively; BMI ≤23 = ≤17 kg, BMI 23.1 to 26 = ≤17.3 kg, BMI 26.1 to 29 = ≤18 kg, and BMI >29 = ≤21 kg for women, respectively). Participants with low grip strength presenting low muscle mass (skeletal muscle index less than 8.87 and 6.42 kg/m2 in men and women, respectively) were classified as “sarcopenic.”25

Statistical Analysis

A sample size of a minimum 312 patients was calculated by considering a type I error rate of 0.05 and a type II error rate of 0.90, and by assuming a proportion of participants in the “sarcopenia-yes” group (exposed) of 15% (n = 47) and a proportion of participants in the “sarcopenia-no” group (unexposed) of 85% (n = 265) with an effect size of 0.5 and a standard deviation of the outcome in the population = 10. We enrolled 420 participants, and therefore exceeded the number of patients required to reach a sufficient sample size.

Baseline characteristics of the sample are expressed as mean (standard deviation). Participants were stratified by the presence or absence of sarcopenia and by tertiles of PASE (0-40, 41-90, and >90 points). Data on the presence or absence of sarcopenia were analyzed with “2-independent sample T tests.” When participants were stratified in tertiles of PASE, analysis of variance and Bonferroni's post hoc test was applied. Categorical variables were analyzed using χ2 testing, and continuous variables using a 1-way analysis of variance. A curvilinear relationship between PASE and muscle mass and strength was performed by applying the “1-phase association” model (y =y0 + (plateau −y0) × (1 − exp[−K × x]).

All statistical analyses were performed with SPSS software (version 15.0, SPSS Inc, Chicago, Illinois). A P value less than .05 was considered statistically significant.

RESULTS

The sample consisted of 420 older adult participants, with a mean age of 82.4 ± 5.9 years; 241 (57.4%) were female and 179 (42.6%) were male. Table 1 shows anthropometric measurements and comprehensive geriatric assessment stratified for the presence and absence of sarcopenia, according to EWGSOP definition and diagnostic algorithm.26 Sarcopenic older adults had higher comorbidity, as showed by higher CIRS-comorbidity and severity score and drug number. Also, 4-m walking speed, MNA and Tinetti score and, more interestingly, PASE score along with muscle mass and grip strength significantly differed between nonsarcopenic and sarcopenic older adults, suggesting the presence of functional impairment in the latter (Table 1). As expected, both frailty by Fried's and frailty by Rockwood's were more prevalent in sarcopenic older adults (Table 1).

Table 1. - Baseline Characteristics of the 420 Patients Enrolled in the Study Stratified for the Presence and Absence of Sarcopenia
Characteristics Sarcopenia P Value
No (n = 365, 87%) Yes (n = 55, 13%)
Anthropometric data
Age, mean (SD), y 74.7 (8.2) 80.2 (7.3) .112
Female sex, n (%) 286 (68) 134 (32) .054
Body mass index, mean (SD), kg/m2 27.5 (3.2) 24.8 (4.7) .082
Waist circumference, mean (SD), cm 99.1 (11.8) 99.2 (12.6) .124
Geriatric evaluation
Mini-Mental State Examination, score, mean (SD) 23.3 (6.9) 21.8 (4.6) .064
Geriatric Depression Scale, score, mean (SD) 6.9 (4.2) 8.2 (5.5) .110
CIRS-comorbidity, score, mean (SD) 3.21 (1.69) 5.01 (2.06) .032
CIRS-severity, score, mean (SD) 1.65 (0.25) 2.28 (0.45) .042
Drug number, n., mean (SD) 2.0 (1.0) 4.0 (1.0) .020
BADL lost, n., mean (SD) 1.3 (1.8) 2.4 (1.8) .412
IADL lost, n., mean (SD) 3.0 (1.6) 4.4 (3.4) .621
Tinetti, score, mean (SD) 22.8 (4.6) 20.1 (2.6) .042
Mini-Nutritional Assessment, score, mean (SD) 15.0 (4.8) 22.6 (4.2) .024
4-m walking speed, mean (SD), m/s 0.90 (0.19) 0.64 (0.40) .05
PASE, score, mean (SD) 92.0 (52.4) 40.2 (89.1) .001
Social support, score, mean (SD) 7.3 (2.7) 9.2 (1.8) .05
Frailty by Fried, score, mean (SD) 2.6 (1.4) 4.0 (1.5) .05
Frailty by Rockwood, score, mean (SD) 16.5 (9.4) 25.2 (7.1) .05
Muscle measurements
Muscle strength, mean (SD), kg 32.7 (7.4) 23.6 (9.5) .05
Muscle mass, mean (SD), kg/m2 9.2 (1.7) 6.89 (1.4) .01
Abbreviations: BADL, basic activity of daily living; CIRS, Cumulative Illness Rating Scale; IADL, instrumental activity of daily living; PASE, Physical Activity Scale for the Elderly; SD, standard deviation.

In our sample, mean age and the proportion of female individuals progressively decreased as PASE score increased as well as MMSE score increased whereas depressive symptoms (GDS) decreased. Moreover, with increasing PASE score, we observed a reduction of the comorbidity severity score, lost BADL, MNA score, 4-m walking speed, and low social support. Interestingly, frailty scores decreased as PASE score increased, especially when frailty was assessed by means of the Rockwood index (Table 2).

Table 2. - Baseline Characteristics of the 420 Older Adult Participants Enrolled in the Study
Characteristics All (n = 420) PASE Score P for Trend
0-40 (n = 135, 32.1%) 41-90 (n = 156, 37.2%) >90 (n = 129, 30.7%)
Anthropometric data
Age, mean (SD), y 82.4 (5.9) 82.9 (5.8) 81.9 (5.6) 80.3 (7.5)a .001
Female sex, n (%) 179 (42.6) 88 (65.5) 35 (22.4) 16 (12.1)a .001
Body mass index, mean (SD), kg/m2 27.5 (4.7) 27.7 (4.9) 27.3 (4.5) 26.8 (4.1) .249
Waist circumference, mean (SD), cm 99.7 (13.5) 100.1 (9.3) 98.7 (11.4) 98.3 (11.2) .456
Geriatric evaluation
Mini-Mental State Examination, score, mean (SD) 22.0 (6.5) 20.0 (6.8) 25.8 (3.5)a 26.5 (2.0)a .001
Geriatric Depression Scale, score, mean (SD) 6.1 (4.9) 7.4 (5.1) 4.0 (3.9)a 2.7 (2.0)a .001
CIRS-comorbidity, score, mean (SD) 3.4 (1.6) 3.5 (1.6) 3.2 (1.3) 3.1 (2.1) .629
CIRS-severity, score, mean (SD) 1.8 (0.3) 1.8 (0.3) 1.8 (0.5) 1.7 (0.4) .451
Drug number, n, mean (SD) 5.3 (3.2) 6.0 (3.4) 4.0 (2.0) 3.0 (1.4)a .175
BADL lost, n, mean (SD) 1.8 (1.8) 2.4 (1.8) 0.7 (0.9)a 0.0 (00) .001
IADL lost, n, mean (SD) 3.6 (2.9) 5.0 (2.4) 0.9 (1.0)a 0.7 (1.8)a .001
Tinetti, score, mean (SD) 18.0 (7.7) 15.1 (7.0) 22.9 (5.8) 25.3 (4.5) .001
Mini-Nutritional Assessment, score, mean (SD) 20.9 (4.1) 20.0 (4.0) 22.6 (3.8) 23.0 (4.0)a .001
4-m walking speed, mean (SD), m/s 0.33 (0.4) 0.62 (0.42)a 0.18 (0.4)a 0.04 (0.1) .001
PASE, score, mean (SD) 31.4 (42.1) 6.4 (10.9) 62.6 (13.9)a 124.6 (33.6)a .001
Social support, score, mean (SD) 7.1 (5.7) 7.9 (5.8) 6.2 (5.6) 3.5 (2.8)a .015
Frailty by Fried, score, mean (SD) 3.6 (1.5) 4.0 (1.5) 2.8 (1.2) 2.7 (1.0) .001
Frailty by Rockwood, score, mean (SD) 19.58 (9.49) 22.2 (9.1) 15.2 (8.2)a 12.0 (6.7)a .001
Abbreviations: BADL, basic activity of daily living; CIRS, Cumulative Illness Rating Scale; IADL, instrumental activity of daily living; PASE, Physical Activity Scale for the Elderly; SD, standard deviation.
aP < .01 versus PASE score = 0 to 40 at Bonferroni post hoc test; female sex was analyzed with χ2 test.

The relationship among muscle mass and strength and PASE score in noninstitutionalized older adults is shown in Figure 1. In our sample, both muscle mass (8.2 [1.0] to 15.5 [2.8] kg/m2) and muscle strength (22.1 [6.8] to 43.9 [8.5] kg) significantly increased as PASE score increased.

F1
Figure 1.:
Muscle mass and strength stratified by Physical Activity Scale for the Elderly 0 to 40, 41 to 90, and more than 90 in noninstitutionalized elderly people; P for trend .001 for both muscle mass and strength.

Finally, Figures 2A and 2B show the curvilinear relationships between skeletal muscle mass (A) and strength (B) and PASE that were found in our sample of noninstitutionalized older adults.

F2
Figure 2.:
Regression linear relationship among muscle mass (A) and muscle strength (B) and Physical Activity Scale for the Elderly in noninstitutionalized elderly people.

DISCUSSION

The present study indicates that PASE score, one of the most appropriate tools for the assessment of physical activity in the older adults, is lower in sarcopenic than in nonsarcopenic, noninstitutionalized older adults. In these participants, moreover, there is a curvilinear relationship between PASE score and both muscle mass and strength. This evidence suggests that a reduction in physical activity identifies older adults at high risk of loss of muscle mass and strength, which are well-known specific markers of sarcopenia.

Sarcopenia and Physical Activity

Our conclusions seem consistent with previous observations using self-report and objective measures of physical activity.26,27 In community-dwelling Japanese individuals aged 65 to 84 years, participants with higher usual physical activity levels had higher lean mass over the 5 years of observation. In particular, a multivariate-adjusted proportional hazards model predicted that, over the next 5 years, men and women in the 2 lowest activity quartiles (<6700 and <6800 steps per day) were 2.3 and 3.0 times as likely to be sarcopenic compared with those in the highest activity quartile (>9000 and >8400 steps per day), respectively.26 It has been demonstrated that, in 2264 Korean community-dwelling older adults aged 65 years and older, moderate and high levels of physical activity were associated with a lower risk of sarcopenia.27 Accordingly, it is widely known that disuse and a sedentary lifestyle lead to greater and more rapid loss of muscle mass and strength, indicating that disuse may be more responsible for muscle atrophy and weakness than aging alone.8 Another classical example of disuse-induced sarcopenia is hospitalization: in this context the rate of sarcopenic muscle loss is exaggerated.27 Accordingly, physical inactivity may negatively influence muscle anabolism and catabolism and determine oxidative stress, muscle inflammation, muscle denervation, and excitation-contraction coupling alterations leading to a progressive fiber loss and fiber atrophy.28 Interestingly, recently it has been suggested that the surviving fibers are still prone to plasticity in response to functional demand such as exercise, in order to maintain optimal force-generating capacity.29

In contrast, exercise training has frequently been shown to preserve or improve muscle mass in healthy older individuals, which is also associated with functional improvements in muscle strength. In fact, quadriceps muscle volume was higher in parallel with increased fiber cross-sectional area in adults older than 75 years performing 12 weeks of aerobic exercise.30

Sarcopenia and PASE Score

To the best of our knowledge, this is the first report on the relationship between sarcopenia and PASE score. In our sample of noninstitutionalized older adults, the PASE score was lower in sarcopenic than in nonsarcopenic participants. The PASE score was also correlated with muscle strength and mass indices through a curvilinear relationship (R2 = 0.63 and R2 = 0.51, respectively), indicating that low PASE scores are strictly related to low muscle mass and strength. Interestingly, when stratified in tertiles, participants in the lowest tertile (0-40 PASE score) had several characteristics of frail older adults (ie, low MMSE score, high GDS score, and BADL and IADL lost), whereas in the highest tertile (ie, >90), these characteristics were absent. Accordingly, the frailty scores identified by Fried's and Rockwood's methods were 2.7 (1.0) and 12.0 (6.7) at the highest PASE tertile whereas were 4.0 (1.5) and 22.2 (9.1) at the lowest PASE tertile, respectively.

CONCLUSIONS

Scores from the PASE, one of the most appropriate tools for the assessment of physical activity in older adults, are lower in sarcopenic noninstitutionalized older adults, and are curvilinearly related to muscle mass and strength. Detection of sarcopenia with BIA methods and not with dual-energy x-ray absorptiometry (preferred tool for the diagnosis of sarcopenia) may represent a limitation of the study. However, the BIA method allows the identification of older adults at high risk of sarcopenia in the presence of a low PASE score.

ACKNOWLEDGMENT

PA is the initiator of the study and responsible for the concept and design, data acquisition, analysis, interpretation, and preparation of the article. DB and FC contributed to the concept and design, analysis, and interpretation, and preparation of the article. All authors contributed to the acquisition of the data, study concept and design and critical review of the article. All authors read and approved the final article and agree to be accountable for all aspects of the work.

The study was performed according to the Declaration of Helsinki, and was approved by the Committee for Medical and Health Research Ethics of University of Naples Federico II, Italy (n.17/2014). Informed consent was signed by the patients before entering the study. No experimental interventions were performed.

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Keywords:

older adults; physical activity; sarcopenia

© 2017 Academy of Geriatric Physical Therapy, APTA.