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Geriatric Nursing xx (2014) 1e4

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Geriatric Nursing

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Feature Article

Sarcopenia influences fall-related injuries in community-dwellingolder adults

Namhyun Woo, BSN, RN, Su Hyun Kim, PhD, RN *

College of Nursing, Kyungpook National University, South Korea

a r t i c l e i n f o

Article history:Received 1 November 2013Received in revised form25 February 2014Accepted 3 March 2014Available online xxx

Keywords:Accidental fallsElderlySarcopenia

This research was supported by Kyungpook Nation2011.* Corresponding author. College of Nursing, Daegu,

sity, Korea 700-422. Tel.: þ82 53 420 4928.E-mail address: suhyun_kim@knu.ac.kr (S.H. Kim)

0197-4572/$ e see front matter � 2014 Mosby, Inc. Ahttp://dx.doi.org/10.1016/j.gerinurse.2014.03.001

a b s t r a c t

This study aimed to determine the relationship between sarcopenia and fall-related injuries incommunity-dwelling older adults in Korea. The study population comprised 2848 subjects aged 65 yearsor older who participated in the Korea National Health and Nutrition Examination Surveys during 2010e2011. Sarcopeniawas considered to be present if the subject’s appendicular skeletal muscle mass dividedby his or her weight was less than 29.9% in men, or less than 25.1% inwomen. The incidence of fall-relatedinjuries during the past year among all the respondents was 4.3%, and the prevalence of sarcopenia was32.2%. After controlling for sociodemographic variables and morbidity due to chronic diseases, the inci-dence of fall-related injuries remained significantly elevated among older adults with sarcopenia (oddsratio ¼ 1.61, 95% confidence internal ¼ 1.01e2.54). Sarcopenia should be considered when investigatingmeans of preventing of fall-related injuries in community-dwelling older adults. To prevent falls amongthese persons, it is vital to implement intervention programs that increase muscle mass.

� 2014 Mosby, Inc. All rights reserved.

Introduction

Among older adults, falls are one of the most common accidentsthat can cause disability or impairment.1,2 Approximately 28%e35%of older adults are reported to fall each year, worldwide.3 Further, ithas been reported that 21%e48% of older adults in Korea experi-ence falls each year.4,5 Of these individuals who experienced falls,80% developed an injury and 63% received treatment at a hospital.5

In the United States, falls are the second largest contributor to theeconomic burden of injuries (in terms of lifetime costs).2 Similarly,health care expenditure associated with fall-related injuries isexpected to rise in Korea, accompanying rapid increases in the sizeof the elderly population.

Accidental falls among community-dwelling older adults havebeen shown to contribute to hospital visits, nursing home place-ments, and functional decline.6,7 Therefore, it is critical to identifyrisk factors for accidental falls in the community.8e10 In a system-atic review, muscle strength, gait, and balance impairments werefound to be the strongest risk factors for falls among community-dwelling older adults.1 In particular, lower or upper extremitymuscle weakness significantly increased the odds ratio (OR) for

al University Research Fund,

Kyungpook National Univer-

.

ll rights reserved.

injurious falls.11 However, limited information is availableregarding the independent effect of loss of skeletal muscle masswith aging and its association with muscle strength and falls.12

The loss of skeletal muscle mass that occurs with aging is knownas sarcopenia. Previous investigations have shown that sarcopeniais closely associated with declining muscle quality13 and musclestrength in the older population.14 Sarcopenia is considered to playa crucial role in the frailty process, leading to poor outcomes,including falls, multiple trauma, functional decline, disability, poorquality of life, nursing home placement, and mortality.12 None-theless, findings regarding the relationship between sarcopeniaand falls have been inconsistent.15e17 Thus, it is essential to clarifythe independent relationship between sarcopenia and falls. Indeed,doing so may lay the groundwork for interventions that success-fully prevent falls among community-dwelling older adults.

Therefore, the aim of the current study was to assess theinfluence of sarcopenia on fall-related injuries in community-dwelling older adults in Korea. To increase the validity of ourfindings, we used the Korea National Health and Nutrition Exami-nation Survey (KNHANES), which is nationally representative.

Methods

Study population and data collection

Data on subjects were obtained from KNHANES V-1 and V-2.KNHANES is a nationwide survey on health and nutrition status,

Table 1Characteristics of participants (N ¼ 2848).

Variables Total(n ¼ 2848)

Fallers(n ¼ 120)

Non fallers(n ¼ 2728)

c2/t p

n (%)

Age, year (mean (SE)) 73.17 (0.14) 73.41 (0.49) 72.93 (0.13) 0.97 0.335GenderWomen 1675 (58.8) 85 (71.2) 1590 (58.3) 7.97 0.022Men 1173 (41.2) 35 (28.8) 1138 (41.7)

EducationLess than elementary

school graduate2047 (71.9) 89 (73.9) 1958 (71.8)

Middle schoolgraduate

313 (11.0) 14 (11.7) 301 (11.0) 2.05 0.574

High school graduate 327 (11.5) 14 (11.6) 313 (11.5)More than a college

graduate159 (5.6) 3 (2.7) 156 (5.8)

Income quartileLow 772 (27.1) 37 (31.2) 735 (27.0)Middle-low 722 (25.3) 27 (22.3) 695 (25.5) 1.33 0.764Middle-high 702 (24.7) 28 (23.1) 674 (24.7)High 652 (22.9) 28 (23.4) 624 (22.9)

Living arrangementLiving alone 478 (16.8) 25 (21.0) 453 (16.6) 1.66 0.287Living with others 2370 (83.2) 95 (79.0) 2275 (83.4)

Morbidity of diseaseStroke 103 (3.6) 9 (7.9) 94 (3.4) 7.04 0.013Arthritis 803 (28.2) 41 (33.8) 762 (28.0) 1.95 0.307Diabetes 501 (17.6) 24 (19.9) 477 (17.5) 0.46 0.499Depression 63 (2.2) 6 (4.7) 57 (2.1) 3.82 0.049Sarcopenia 1404 (49.3) 76 (63.3) 1328 (48.7) 5.97 0.008

Body mass index(mean (SE))

23.72 (0.10) 24.08 (0.33) 23.71 (0.10) 1.16 0.237

N. Woo, S.H. Kim / Geriatric Nursing xx (2014) 1e42

conducted by the Korea Centers for Disease Control and Prevention.It provides baseline data for developing health promotion pro-grams and health-related policies. Study subjects in the KNHANESwere randomly sampled according to stratified regions, gender, agecomposition, and average size and price of housing. Data werecollected throughout the year 2010 for KNHANES V-1 and 2011 forKNHANES V-2. In total, the survey was completed by 81.9% of theinterviewed subjects in KNHANES V-1 and 80.4% of those inKNHANES V-2. Of the 17,476 subjects in both surveys, 3076 whowere 65 years or older were selected for the current study. Afterexcluding 228 subjects who did not respond to the questionnaireon falls, a total of 2848 participants were included for analysis inthis study.

Assessment of fall-related injuries and sarcopenia

We defined fall-related injuries as unintentional injuries due tofalls or sliding accidents during the past year. Fall-related injurieswere assessed using the following questions. First, participantswere asked, “Have you ever experienced accidents that requiredtreatment at a hospital or emergency room?” Respondents whoanswered, “Yes,” were additionally asked, “How did the accidentoccur?” Older adults were considered to have experience with fall-related injuries if they reported accidental falls from high locationsor had accidentally slipped onto the ground and been treated byhealth care providers.18

To measure sarcopenia, we adopted a formula in which theappendicular skeletal muscle mass (ASM) is divided by totalweight.19,20 Appendicular muscle mass was measured using dual-energy X-ray absorptiometry (Discovery-W; Hologic Inc., Wal-tham, MA, USA) by determining differences in the transmittance ofeach subject’s body composition. As a component of KNHANES, adual-energy X-ray absorptiometry was performed on all studysubjects at a mobile examination center. According to a previousstudy in an older Korean population, members of the sarcopenicgroup were more likely to have cardiometabolic risk factors thanweremembers of the normal community-based elderly cohort.21 Inthat study, the sarcopenic group included subjects who met thedefined criteria for sarcopenia (ASM/weight, <29.9% in men and<25.1% in women).

Data analysis

Descriptive statistics were used to analyze subjects’ socio-demographic characteristics. In light of the inherent statisticalcomplications involved in multistage, complex survey designs, theinvestigators followed the guidelines of KNHANES for the analysisof sample weights. By using these weights appropriately, thestratification and clustering of the design were incorporated intothe analyses to ensure appropriate estimates and standard errors.22

t-tests and chi-square tests were employed to test differences be-tween subjects who had and had not experienced fall-relatedinjuries.

To assess whether sarcopenia had an independent influence onfall-related injury (above and beyond the influences of potentialconfounders), we applied a hierarchical multiple logistic regressionanalysis. The regression analysis was used to estimate the rela-tionship between sarcopenia and the risk of fall-related injuriesafter adjusting for covariates.23 In model 1, we included de-mographic variables that may be associated with falls or sarcope-nia3,4,24: age, gender, educational difference, income, and maritalstatus. In model 2, we additionally incorporated covariates relatedto disease morbidity: stroke, arthritis, diabetes, and depression.1,25

Finally, model 3 included each covariate in model 2, as well assarcopenia status, which was thereby adjusted for demographic

variables and disease morbidity. In the multiple logistic regressionanalyses, education and income were treated as continuous vari-ables. Multicollinearity was ruled out using Spearman’s rho forcorrelation analyses, the results of which demonstrated low cor-relations between predictors (rho < 0.45 for all variables).23 Addi-tionally, the absence of multicollinearity was supported bymultiplelinear and logistic regression analyses, in which the low percentageof variance for each predictor was accounted for by the other pre-dictors (R2 or pseudo-R2 < 0.12 for all predictors). An alpha level of0.05 was selected for assessments of statistical significance. Datawere analyzed using SPSS 19.0 (SPSS, Inc., Chicago, IL, USA) complexsamples procedures.

Results

Table 1 shows the characteristics of the participants according tohistory of fall-related injuries. Of the 2848 participants, 120 (4.3%)had experienced one or more fall-related injuries in the past year.The mean (standard deviation) age was 73.17 (0.14) years, and58.8% of the participants were women.

In univariate analyses, the incidence of fall-related injuriesdiffered significantly according to gender. Women accounted for71.2% of the respondents who had experienced fall-relatedinjuries, and men accounted for 28.8% (c2 ¼ 7.97, p ¼ 0.022). Theincidence of falls however did not differ according to age, educa-tion, income, living arrangement, or body mass index. Older adultswho had experienced fall-related injuries had higher rates ofmorbidity in terms of stroke (7.9% vs. 3.4%, c2 ¼ 7.04, p ¼ 0.013)and depression (4.7% vs. 2.1%, c2 ¼ 3.82, p ¼ 0.049). However, nosignificant differences were observed for arthritis or diabetesmellitus. Of the total respondents, 1404 (49.3%) had sarcopenia.Subjects with sarcopenia were significantly more likely to haveexperienced fall-related injuries (63.3% vs. 48.7%, c2 ¼ 5.96,p ¼ 0.008).

N. Woo, S.H. Kim / Geriatric Nursing xx (2014) 1e4 3

We used hierarchical multiple logistic regression analysis toestimate the effect of sarcopenia on the risk of fall-related injuries,after adjusting for sociodemographic variables and chronic diseases(Table 2). According to model 1, the OR for fall-related injuries wassignificantly higher for women than for men (OR ¼ 1.78, 95%confidence interval [CI] ¼ 1.05e3.03). In model 2, morbidity interms of stroke significantly increased the OR for fall-related in-juries (OR ¼ 2.62, 95% CI ¼ 1.24e5.55); however, arthritis, diabetesmellitus, and depression were not significant predictors. Femalegender was not a significant predictor of fall-related injuries inmodel 2 (OR ¼ 1.77, 95% CI ¼ 0.99e3.16).

Finally, in model 3, which controlled for sociodemographic vari-ables anddiseasemorbidity, sarcopeniawas the significant predictoraffecting fall-related injuries. Among this older population, the riskof fall-related injuries was higher for individuals with sarcopeniathan for those without sarcopenia (OR ¼ 1.59, 95% CI ¼ 1.02e2.49).Morbidity in terms of stroke also significantly increased the OR forfall-related injuries (OR ¼ 2.63, 95% CI ¼ 1.05e6.59).

Discussion

In the current study, we evaluated the influence of sarcopeniaon fall-related injuries in older community-dwelling Korean adults.Our findings demonstrated a high prevalence of sarcopenia amongolder Korean adults, accounting for 49.3% of the population. OlderKorean adults with sarcopenia had a higher rate of fall-related in-juries than did their counterparts without sarcopenia. Consistentwith the results of a previous study among elderly Italians, sarco-penia was shown to have a strong effect on fall-related injuries,after adjusting for other sociodemographic variables and diseasemorbidity.16

In the current study, the incidence of fall-related injuries was4.3%, which was similar to the 4.9% incidence that was reported in arecent study conducted in the United States.26 However, the inci-dence was far lower than that reported by a previous study, whichfound that 15.2% of older Korean adults had received medicalattention and 28.9% had been hospitalized as a result of falls.4,5 Thediscrepancy between these fall-related injury rates may be attrib-utable to differences in the quantification of falls, such as theassessment of fall-related injuries treated by health care providersrather than the incidence of falls. Additionally, the discrepancy mayhave resulted from the current study’s use of representative com-munity samples.5,27

Table 2Hierarchical multiple logistic regression analysis on influence of sarcopenia on fallinjuries (N ¼ 2848).

Model 1 Model 2 Model 3

OR (95% CI)

SociodemographicAge 1.02 (0.98e1.05) 1.02 (0.98e1.05) 1.01 (0.97e1.05)Gender (female

vs. male)1.78 (1.05e3.03)* 1.77 (0.99e3.16) 1.28 (0.67e2.45)

Education 1.08 (0.84e1.39) 1.08 (0.84e1.39) 1.10 (0.82e1.49)Income 0.98 (0.77e1.25) 0.99 (0.77e1.23) 0.97 (0.73e1.29)Living arrangement

(living alonevs. livingwith others)

1.16 (0.62e2.19) 1.21 (0.65e2.23) 1.11 (0.48e2.56)

Morbidity of chronic diseasesStroke 2.62 (1.24e5.55)* 2.63 (1.05e6.59)*Arthritis 0.99 (0.59e1.68) 0.94 (0.50e1.76)Diabetes 1.13 (0.71e1.79) 0.85 (0.46e1.58)Depression 0.49 (0.20e1.21) 0.41 (0.07e2.57)Sarcopenia 1.59 (1.02e2.49)*

*p < 0.05.

Using the indicator of ASM/weight, which reflects the relativequantity of muscle mass as a component of the total bodycomposition,19 the high prevalence of sarcopenia (49.3%) in thecurrent study was comparable to the results of previous studies inKorea and the United States. These previous studies reportedprevalence rates of 38% and 52% inmen and 63% and 69% inwomen,respectively.21,28 However, the prevalence of sarcopenia in ourstudy was much higher than that reported in studies measuringsarcopenia using the ASM/height2 indicator, which reflects theabsolute quantity of musclemass, disregarding body composition.15

The latter study concluded that only 6.3% and 4.1% of older Koreanmen and women, respectively, had sarcopenia.29

The relationship between sarcopenia and fall-related injuries inthe current studymay be explained by the critical role of sarcopeniain the frailty process. Frailty plays a role in the poor outcomes offalls, such as various traumas, functional decline, anddisability.12,13,28,30 Early seminal studies on sarcopenia reportedthat reduced muscle mass may result in low physical performance,a decline in mobility, and functional impairment,31e34 which can beregarded as distinctive characteristics of frailty. Therefore, webelieve that fall-related accidents may occur as results of decreasedagility, decreased flexibility, and delayed reactions, which them-selves result from sarcopenia.

Accordingly, the current study provides evidence of the need forfall prevention interventions that reduce risk factors for sarcopenia.In particular, there is a need for interventions promoting physicalactivities that increase muscle mass among older adults. Regardingthe successful prevention of fall-related injuries in the community,the current study’s findings underscore the importance of identi-fying older adults with sarcopenia and implementing targetedapproaches in this subgroup. The significant relationship betweensarcopenia and fall-related injuries provides suggestions for ele-ments that should be included in multi-factorial interventions,including physical activity and adequate nutrition programs.16,35

There are various means of slowing the decline in muscle massthat is associated with aging. Specifically, it may be valuable toincrease health care providers’ awareness of sarcopenia in olderadults. Further, it may be worthwhile to implement structuredexercise programs (including progressive resistance or powertraining) and nutritional interventions (including sufficient proteinand additional caloric intake).36

The current study had some limitations. First, it is possible thatthe findings would have differed if we had used a differentmethod to quantify sarcopenia. In the current study, we quantifiedsarcopenia using the ASM/weight indicator, which overcomesimportant limitations of the ASM/height2 indicator. Indeed, theASM/height2 indicator insufficiently accommodates reducedmobility in older adults37 and does not provide an appropriatedefinition of sarcopenia in Asians.21 Second, we employed sec-ondary data analysis, which might have made the measurement ofsome key variables difficult, possibly influencing the results.When assessing falls, we measured fall-related injury rather thanfall accidents because we could only obtain information on fall-related injuries from the existing KNHANES data. Despite theselimitations, our study has the advantage of using a representativesample of the Korean population. Our results suggest that sarco-penia is a critical problem among the elderly and must beconsidered by health care providers in preventing fall-relatedinjuries in the community.

In conclusion, sarcopenia is an important factor that contributesto the increased risk of fall-related injuries among community-dwelling elderly adults in Korea. Therefore, physical activity pro-grams, nutritional programs, and other such interventions shouldbe considered first for the prevention of fall-related injury.38e40

Further, interventions such as physical activity and nutritional

N. Woo, S.H. Kim / Geriatric Nursing xx (2014) 1e44

programs should be incorporated into fall-prevention programs inthe community setting.

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