Open Access Research BMJ Open: first published as 10.1136/bmjopen-2015-008281 on 25 July 2016. Downloaded from Impact of physical function impairment and multimorbidity on mortality among community-living older persons with sarcopaenia: results from the ilSIRENTE prospective cohort study Francesco Landi, Riccardo Calvani, Matteo Tosato, Anna Maria Martone, Roberto Bernabei, Graziano Onder, Emanuele Marzetti To cite: Landi F, Calvani R, ABSTRACT Strengths and limitations of this study Tosato M, et al. Impact of Objective: Sarcopaenia and physical function physical function impairment impairment may have a greater effect on survival than ▪ and multimorbidity on The association between sarcopaenia and other clinical characteristics, including multimorbidity. mortality among community- adverse health outcomes was explored in a well- living older persons with In this study, we evaluated the impact of sarcopaenia characterised and relatively large cohort of older sarcopaenia: results from the on all-cause mortality and the interaction among persons living in the community. ilSIRENTE prospective cohort muscle loss, physical function impairment and ▪ The association between sarcopaenia and mortal- study. BMJ Open 2016;6: multimorbidity on mortality risk over 10 years in older ity was assessed over a long follow-up and e008281. doi:10.1136/ community-dwellers. adjusted for several possible confounders. bmjopen-2015-008281 Design: Prospective cohort study. ▪ The observational design of the study allowed Setting: Population-based study. the enrolment of community-living older persons ▸ Prepublication history for Participants: All persons aged 80+ years living in the without restrictive selection criteria, such as this paper is available online. community in the Sirente geographic area (L’Aquila, those adopted in randomised clinical trials. To view these files please Italy) (n=364). Participants were categorised in the ▪ The estimation of muscle mass was based on visit the journal online sarcopaenic or non-sarcopaenic group based on the anthropometric parameters rather than on http://bmjopen.bmj.com/ (http://dx.doi.org/10.1136/ European Working Group on Sarcopenia in Older imaging techniques, such as dual X-ray absorpti- bmjopen-2015-008281). People criteria. ometry, computerised tomography or magnetic Received 23 March 2015 Primary and secondary outcome measures: resonance imaging. Revised 24 July 2015 (1) All-cause mortality over 10 years according to the Accepted 30 July 2015 presence of sarcopaenia and (2) impact of physical function impairment, assessed using the Short INTRODUCTION Physical Performance Battery (SPPB), and The age-related loss of muscle mass and func- multimorbidity on 10-year mortality risk in persons tion (sarcopaenia) is increasingly recognised with sarcopaenia. on September 27, 2021 by guest. Protected copyright. as an important risk factor for several nega- Results: Sarcopaenia was identified in 103 tive health-related outcomes.1 Indeed, sarco- participants (29.1%). A total of 253 deaths were paenia is associated with poor endurance, recorded over 10 years: 90 among sarcopaenic 1 participants (87.4%) and 162 among non-sarcopaenic slow gait speed and decreased mobility. The persons (65.1%; p<0.001). Participants with muscle decline that accompanies ageing has sarcopaenia had a higher risk of death than those also been indicated as a major factor in the without sarcopaenia (HR=2.15; 95% CI 1.02 to 4.54). development of physical frailty and its pos- When examining the effect of sarcopaenia and physical sible biological substrate.23It is therefore not function impairment on mortality, participants with low surprising that sarcopaenia conveys increased physical performance levels showed greater mortality. risk of incident disability, higher healthcare – Conversely, the mortality risk was unaffected by costs and all-cause mortality.4 6 Department of Geriatrics, multimorbidity. Remarkably, the association between sarco- Neurosciences and Conclusions: Our findings show that physical paenia and mortality appears to be inde- Orthopaedics, Catholic function impairment, but not multimorbidity, is University of the Sacred pendent of age, cardiovascular or respiratory predictive of mortality in older community-dwellers Heart, Rome, Italy 4 with sarcopaenia. Hence, in sarcopaenic older persons, diseases, or the comorbidity burden. This finding suggests that the physical function Correspondence to interventions against functional decline may be more Dr Francesco Landi; effective at preventing or postponing negative health impairment intrinsic to sarcopaenia could [email protected] outcomes than those targeting multimorbidity. underlie the link between muscle loss and Landi F, et al. BMJ Open 2016;6:e008281. doi:10.1136/bmjopen-2015-008281 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2015-008281 on 25 July 2016. Downloaded from adverse health outcomes.7 Notably, the functional cap- status variables, as well as major clinical diagnoses and acity of an older person is a powerful predictor of nega- an extensive array of signs, symptoms, syndromes and tive events, independent of the presence and number of treatments.10 The MDS items have shown excellent inter- disease conditions.8 As such, the functional status is pro- rater and test-retest reliability when completed by nurses posed to be a critical target for interventions to restore performing usual assessment duties (average weighted robustness, improve the quality of life and (possibly) κ=0.8).11 Additional information about lifestyle habits, extend survival in late life.7 Whether the physical function physical activity and physical function was collected impairment intervenes in the relationship between sarco- through questionnaires and tests shared with the paenia and mortality has yet to be clearly established. ‘Invecchiare in Chianti Study’ (InCHIANTI study).12 The present study was therefore undertaken to assess the impact of sarcopaenia on all-cause mortality over Identification of sarcopaenia 10 years of follow-up in a population of frail octogenar- The presence of sarcopaenia was established according ians and nonagenarians enrolled in the to the criteria released by the European Working Group ‘Invecchiamento e Longevità nel Sirente’ (Aging and on Sarcopenia in Older People (EWGSOP).13 Longevity in the Sirente geographic area, ilSIRENTE) Specifically, the identification of sarcopaenia was based study. The influence of physical function impairment on the documentation of low muscle mass plus either and multimorbidity on mortality among sarcopaenic par- low muscle strength or low physical performance. ticipants was also explored. Muscle mass was estimated via the mid-arm muscle cir- cumference (MAMC). MAMC was calculated using the standard formula:14 METHODS The ilSIRENTE study is a prospective cohort study con- MAMC ¼ mid - arm circumference ð3:14 ducted in the mountain community living in the Sirente Â Þ geographic area (L’Aquila, Abruzzo) in Central Italy. triceps skinfold thickness The study was designed by the Department of Geriatrics, The measurement of triceps skinfold thickness was Neurosciences and Orthopaedics of the Catholic obtained using a Harpenden Skinfold Caliper, while University of Sacred Heart (Rome, Italy) and developed mid-arm circumference was measured using a standard ‘ by the teaching nursing home Opera Santa Maria della flexible measuring tape. All measurements were taken on ’ ’ Pace (Fontecchio, L Aquila, Italy), in a partnership with the right arm unless conditions were present that could local administrators and primary care physicians of interfere with the assessment (eg, amputation, lymphoe- Sirente Mountain Community Municipalities. dema, neurological diseases, recent upper extremity frac- All participants signed an informed consent form at ture, severe osteoarthritis with functional limitation). http://bmjopen.bmj.com/ ilSIRENTE the baseline visit. The study protocol is fully In the absence of accepted cut-off values of MAMC 9 described elsewhere. for the European population, MAMC tertiles calculated in all ilSIRENTE study participants were considered.15 Study population The lower tertile was considered for identifying partici- A preliminary list of persons living in the Sirente area was pants with low muscle mass. Low muscle mass was there- obtained at the end of October 2003 from the Registry fore defined as an MAMC smaller than 21.1 and 19.2 cm Offices of the 13 municipalities involved in the study. in men and women, respectively.15 fi Potential participants were identi ed by selecting all Walking speed was evaluated measuring the partici- on September 27, 2021 by guest. Protected copyright. persons born in the Sirente area before 1 January 1924 pant’s usual gait speed (m/s) over a 4 m course. As sug- and living locally at the time of the survey. Among the eli- gested by the EWGSOP,13 a gait speed slower than gible persons (n=429), the prevalence of refusal was very 0.8 m/s was adopted as the defining criterion for low low (16%). Age and gender distribution were not differ- physical performance. Finally, muscle strength was ent between people who refused to participate and the assessed by using a North Coast handheld hydraulic enrollees. The overall sample population enrolled in the dynamometer (North Coast Medical, Morgan Hill, CA). ilSIRENTE study consisted of 364 persons. The present Participants performed one familiarisation trial and one analysis was conducted in 354 participants, after excluding measurement