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ORIGINAL ARTICLES

Screening sarcopenia through SARC-F in postmenopausal women: a single-center study from South America

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Pages 627-631 | Received 16 Jan 2019, Accepted 09 Jun 2019, Published online: 28 Aug 2019

Abstract

Objective: This study aimed to estimate the prevalence of postmenopausal women at high risk of sarcopenia and to compare their quality of life (QOL) with those at low risk using the SARC-F questionnaire.

Methods: We performed a cross-sectional study of postmenopausal women who attended a menopause clinic in Colombia. The risk of sarcopenia was determined through the SARC-F questionnaire; a score ≥4 was considered high risk. The Menopause Rating Scale, the International Physical Activity Questionnaire, and the Short Physical Performance Battery (SPPB) tool were applied.

Results: A total of 112 postmenopausal women with an average age of 68.4 ± 8.5 years were included. The prevalence of women at high risk of sarcopenia was 15.2% (n = 17) (95% confidence interval: 9.7; 23.0). Among the high-risk group there was a higher proportion of women with severe symptoms in the three domains when compared to the low-risk group (somatic 7% vs. 24%, psychological 15% vs. 44%, and urogenital 28% vs. 53%; p < 0.05). A tendency to a lower physical performance was found in the high-risk group (SPPB: 8 [interquartile range: 6–11] vs. SPPB: 10 [interquartile range: 8–11), p = 0.059).

Conclusion: Our results suggest that women with high risk of sarcopenia have a poor QOL. The SARC-F questionnaire is a brief and non-invasive screening tool to detect postmenopausal women at high risk of sarcopenia.

摘要

目的:本研究旨在评估绝经后妇女肌肉减少症高风险的患病率, 并使用SARC-F调查问卷比较其与低风险妇女的生活质量(QOL)。方法:我们对哥伦比亚的更年期门诊就诊的绝经后妇女进行了横断面研究。通过SARC-F问卷评估肌肉减少症的风险;得分≥4被认为是高风险。应用更年期评定量表, 国际体力活动问卷和简易机体功能评估法(SPPB)。结果:本研究纳入112名绝经后女性, 平均年龄为68.4 ± 8.5岁。妇女肌肉减少症高风险的患病率为15.2%(n = 17)(95%的置信区间:9.7; 23.0)。与低风险人群相比, 高风险人群以下三个方面有严重症状的比例更高(躯体7%比24%, 心理15%比44%, 泌尿生殖道28%比53%; p <0.05)。高风险组中体能呈现降低的趋势(SPPB:8 [四分位间距:6-11] vs SPPB:10 [四分位间距:8-11), p = 0.059)。结论:我们的结果表明, 患有肌肉减少症的女性的QOL评分较差。 SARC-F调查表是一种用于筛查绝经后妇女肌肉减少症风险的简便、非侵入性的工具。

Introduction

Menopause is defined as the permanent cessation of the menstrual cycle, which results in the loss of ovary follicular activity and marks the end of a woman’s reproductive life. It is preceded by a period of irregular menstrual cycle, also known as postmenopausal transition, which usually begins approximately at age 40 yearsCitation1. A decrease in estrogen levels contributes to a drop in bone mass density and a redistribution of subcutaneous fat to visceral areas, associated with a high risk for cardiovascular disease and a decrease in quality of life (QOL)Citation2.

Irwin RosenbergCitation3 defined sarcopenia as a combination of wasting muscle mass and a decline in physical performance that occurs as people age. Recently, various definitions of sarcopenia haven been suggested including a functional measurement (e.g. limited movement) and the estimate of appendicular lean muscle mass adjusted by height through computerized tomography, magnetic resonance, or dual-energy X-ray absorptiometryCitation3,Citation4. There is an estimated prevalence of sarcopenia in women of 5–24.2%Citation5. Janssen et al.Citation6 found an increase in the prevalence of sarcopenia associated with significant change in the hormonal state. In addition, postmenopausal women have been reported to have twice the amount of tissue of non-contractile muscle and greater intramuscular fat in comparison with younger womenCitation2.

The challenge to measure appendicular lean muscle mass through expensive tests has impaired the implementation of globally accepted definitions, as proposed by the European Working Group on Sarcopenia in Older People (EWGSOP)Citation3. This has allowed the development of simple screening tools for sarcopenia like the five-item SARC-F questionnaire that evaluate: strength, assistance walking, difficulty to rise from chair, difficulty to climb stairs, and risk of fallCitation7,Citation8. Ida et al.Citation9 reported a sensitivity of 21% and a specificity of 90%, exhibiting a high capacity to identify healthy subjects. The SARC-F has been identified as an ideal tool to determine which subjects need a confirmatory test to make the diagnosis of sarcopeniaCitation9.

In Colombia, according to the last census, of approximately 45.5 million habitants, 51.4% are women and 68.3% are between 15 and 64 years oldCitation10. In Latin America, the average age for menopause is 48.6 years, and in Colombia the average menopause age is between 49.8 and 53 yearsCitation11.

The aims of this work were to estimate the prevalence of postmenopausal women at high risk of sarcopenia and to compare their QOL with those at low risk using the SARC-F questionnaire.

Methods

This is a cross-sectional study of women who attended a menopause clinic in Cali, Colombia, between August and November 2017. Women over 40 years old with complete absence of the menstrual cycle in the last 12 months were included. This study was approved by the institutional review board of Centro Médico Imbanaco and each participant signed the informed consent.

The risk of sarcopenia was determined through the SARC-F questionnaire and a score of ≥4 was considered high riskCitation8,Citation12. This scale includes five questions that evaluate strength, assistance to walk, rise from chair, capacity to climb up and down stairs, and risk of fall. The scores for each component vary according to the difficulty to perform each task and range from 0 to 2 (0 = no difficulty, 1 = some difficulty, and 2 = a lot of difficulty or unable to do), with a global score between 0 and 10.

The participants were divided into two groups: ‘Low Risk of Sarcopenia (SARC-F < 4)’ and ‘High Risk of Sarcopenia (SARC-F ≥ 4)’. An interview was performed in order to gather information regarding comorbidities and the consumption of medications. In all cases, weight, height, and abdominal circumference were measured. The level of physical activity was assessed through the International Physical Activity QuestionnaireCitation13.

Physical performance

A performance test was carried out using the Short Physical Performance Battery. This tool consists of a balance test, a short walk at usual pace (gait speed), and standing up from a chair five times consecutively. For the balance test, participants were instructed to stand upright with their feet together and then in a semi-tandem and a tandem position. For gait speed, every participant performed a walk of 3–4 m of distance at their usual pace, recording the time in seconds. Finally, participants were asked to stand and sit in a chair five times with arms folded. The total score of the Short Physical Performance Battery tool was calculated by adding the three components evaluated with a range from 0 to 12 pointsCitation14.

Evaluating menopause symptoms

The Menopause Rating Scale (MRS) was used to evaluate menopausal symptoms and QOLCitation15. The scale consists of 11 items gathered in three domains: somatic, psychological, and urogenital. The somatic component evaluates the presence and severity of heat waves, heart discomforts, sleeping disorders, and hip and muscle pains. The psychological component assesses the presence and severity of depressive moods, irritability, anxiety, and physical and mental fatigue. Finally, the urogenital component evaluates the presence and severity of sexual problems, bladder complaints, and vaginal dryness. Each of the items is classified as 0 (absent), 1 (mild), 2 (moderate), 3 (severe), and 4 (very severe). The composite scores for each of the domains (sub-scales) is based on adding up the scores of the items of the respective dimensions. The composite score (total score) is the sum of the domain scores. The three domains, their corresponding questions, and their evaluation are detailed and summarized. The higher the total score, the greater the compromise of QOL. The scoring system is detailed in .

Table 1. Menopause Rating Scale scores according to domain.

Statistical analysis

The quantitative variables were summarized with mean ± standard deviation or median (interquartile range). Student’s t-test or the Mann–Whitney U-test were used to compare the scores between groups. Fisher’s exact test or the chi-squared test were used for categorical variables. The Cochran–Armitage tendency test was used to compare the proportion of women at high risk of sarcopenia according to age. All analyses were carried out with STATA 13.0® (StataCorp, College Station, TX, USA).

Results

One hundred and twelve postmenopausal women with an average age of 68.4 ± 8.5 years were included. The prevalence of women at high risk of sarcopenia was 15.2% (n = 17) (95% confidence interval: 9.7; 23.0). There was a tendency toward a higher proportion of women at high risk of sarcopenia with older age; 36.4% of women over 80 years old were in this group (Cochran–Armitage test p = 0.085) (). The characteristics of the groups are presented in .

Figure 1. Percentage of patients with high risk of sarcopenia according to age.

Figure 1. Percentage of patients with high risk of sarcopenia according to age.

Table 2. Characteristics according to the SARC-F questionnaire.

There were no statistically significant differences between groups in body mass index, waist circumference, gynecological surgical history, and comorbidities. A higher proportion of women with insomnia, osteoarticular pain, depression, irritability, tiredness, and urinary discomfort was found in the high-risk sarcopenia group when compared to the low-risk sarcopenia group and this difference was statistically significant (p < 0.05). Among the group at high risk of sarcopenia, there was a higher proportion of women with severe symptoms in the three domains when compared to the low-risk group, and this difference was statistically significant (somatic 7% vs. 24%, psychological 15% vs. 44%, and urogenital 28% vs. 53%; p < 0.05) (). A positive relationship between the scores of the somatic and psychological domains was observed (Spearman’s rho: 0.531, p = 0.000).

Figure 2. Distribution of women according to risk of sarcopenia and severity of symptoms for each domain on the Menopause Rating Scale.

Figure 2. Distribution of women according to risk of sarcopenia and severity of symptoms for each domain on the Menopause Rating Scale.

A tendency toward low physical performance was reported in the high-risk group with a score of 8 (interquartile range: 6–11), in comparison with a score of 10 (interquartile range: 8–11) in the low-risk group (). The International Physical Activity Questionnaire survey showed that most of the patients carried out moderate physical activity without significant differences among the high-risk and low-risk groups (47.1% vs. 48.4%, respectively) ().

Table 3. Quality of life, performance, and physical activity according to the SCAR-F questionnaire.

Discussion

We found a prevalence of 15% of postmenopausal women with high risk of sarcopenia using the SARC-F questionnaire as a screening tool. Women in the group of high-risk sarcopenia displayed greater symptomatology on the somatic, urogenital, and psychological domains of the MRS. The SARC-F questionnaire has been suggested as a tool to detect patients at high risk of sarcopenia in primary care and is considered a first step during the diagnostic process to obviate the need for measurement of muscle mass in all cases. A higher score indicates the need for further testing to confirm the diagnosis, such as the physical performance test and the body composition assessmentCitation8,Citation9,Citation12,Citation16. This project represents the first approach to implementing the SARC-F questionnaire in postmenopausal women in Latin America.

Our estimation of patients at high risk of sarcopenia was similar to the frequency reported by Rolland et al.Citation16, who described a proportion of sarcopenia of 16.7% in a cohort of French postmenopausal women through the SARC-F questionnaire. However, when they confirmed the diagnosis of sarcopenia through measurement of lean muscle mass by dual-energy X-ray absorptiometry, a prevalence of 1.8% was found with a diagnostic performance of the SARC-F of 34% sensitivity and 85% specificityCitation16; this is similar to the findings of the meta-analysis reported by Ida et al.Citation9

The SARC-F questionnaire, according to various authorsCitation9,Citation16,Citation17, has low sensitivity and high specificity, which indicates an adequate capacity to detect women without sarcopenia; however, its capacity to detect women with this condition is limited. Nonetheless, Barbosa-Silva et al.Citation18 found that on combining the SARC-F with the measure of calf circumference, the sensitivity increased to 66.7%. Furthermore, the Spanish version applied to men and women over 60 years old in a community in a city of Mexico showed a Cronbach alpha of 0.641 with a reliability test–retest of 0.80 (coefficient of intraclass correlation), indicating an acceptable internal consistency. Also, those authors reported an adequate criterion of validity with a significant relationship between the scores of the SARC-F questionnaire and age, walking speed, strength, and QOLCitation19.

We also found that women with high risk of sarcopenia had a worse QOL when compared to the low-risk group. A higher percentage of these women manifested insomnia, osteoarticular pain, depression, irritability, fatigue, and urinary discomfort through the MRS. This creates a predisposition to falls, physical disability, and functional impairment, thus generating a significant use of hospital resources and determining the impact of sarcopenia on public healthCitation12.

The limitations encountered in this study were as follows. First, all women enrolled did not undergo measurement of the appendicular lean muscle mass. This did not allow calculation of the diagnostic performance of the SARC-F questionnaire in postmenopausal women. Second, the cases were enrolled from a single institution, which does not allow generalization and estimation of the proportion of postmenopausal women with high risk of sarcopenia with accuracy.

In summary, our results suggest that the SARC-F questionnaire is a brief, simple, and non-invasive screening tool to detect postmenopausal women at high risk of sarcopenia and that these women have a poor QOL.

Potential conflict of interest

No potential conflict of interest was reported by the authors.

Source of funding

Nil.

Acknowledgements

The authors thank the Research Institute of Centro Médico Imbanaco for their support during the development of this project.

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