215 ORIGINAL ARTICLE Acta Med Indones - Indones J Intern Med • Vol 49 • Number 3 • July 2017 Factors Related with Handgrip Strength in Elderly Patients Nur Riviati1, Siti Setiati2, Purwita W. Laksmi2, Murdani Abdullah2 1 Geriatric Subspesialist Fellow, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia. 2 Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia. Corresponding Author: Prof. Siti Setiati, MD., PhD. Division of Geriatrics, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro 71, Jakarta 10430, Indonesia. email: s_setiati@yahoo.com. ABSTRAK Latar belakang: proses penuaan menyebabkan penurunan fungsi pada berbagai organ. Otot rangka merupakan salah satu organ yang dipengaruhi oleh proses penuaan. Hal ini dikenal sebagai sarkopenia. Sarkopenia didefinisikan sebagai suatu sindroma yang ditandai oleh hilangnya massa dan kekuatan otot secara progresif. Pemeriksaan kekuatan genggaman tangan seringkali diterapkan sebagai teknik penapisan sarkopenia. Penelitian ini bertujuan untuk menentukan hubungan usia, status gizi dan penyakit kronik seperti stroke, hipertensi (HT), diabetes melitus (DM), penyakit jantung koroner (PJK) dan penyakit paru obstruktif kronik (PPOK) dengan kekuatan genggaman. Metode: ini adalah studi potong lintang untuk menentukan faktor- faktor yang berhubungan dengan kekuatan genggaman tangan pada pasien usia lanjut. Penelitian dilaksanakan di poliklinik Geriatri, Rumah Sakit Cipto Mangunkusumo dan Rumah Sakit Mohammad Hoesin sejak Agustus hingga Oktober 2015. Terdapat 352 subjek yang memenuhi kriteria penelitian ini dan direkrut dengan teknik pengambilan sampel secara berurutan (consecutive sampling). Variabel-variabel independen penelitian ini terdiri atas usia, jenis kelamin, status gizi, penyakit kronik (stroke, hipertensi (HT), diabetes melitus (DM), penyakit jantung koroner (PJK) dan penyakit paru obstruktif kronik (PPOK) dan lingkar pinggang; sedangkan variabel dependen adalah kekuatan genggaman tangan. Hasil: usia >75 tahun dan malnutrisi merupakan faktor risiko yang mempengaruhi lemahnya kekuatan genggaman tangan. Usia >75 tahun akan meningkatkan risiko rendahnya kekuatan genggaman tangan sebanyak 2-3 kali lipat. Malnutrisi meningkatkan risiko rendahnya kekuatan genggaman tangan sebanyak 1,9 kali. Kesimpulan: usia >75 tahun dan malnutrisi akan meningkatkan faktor-faktor risiko menurunnya kekuatan genggaman tangan pada pasien usia lanjut. Kata kunci: kekuatan gengaman tangan, usia lanjut, faktor. ABSTRACT Background: the aging process causes decreasing in the function of various organs. Skletal muscle is one of the organs affected by aging process. It is known as sarcopenia. Sarcopenia is defined as a syndrome characterized by progressive loss of muscle mass and strength. The handgrip strength examination is often applied as a sarcopenia filtering technique. This study aimed to determine the relationship between age, nutritional status, and chronic diseases such as stroke, hypertension (HT), diabetes mellitus (DM), coronary heart disease (CHD), and chronic obstructive pulmonary disease (COPD) with handgrip strength. Methods: a cross-sectional study to determine factors related to the handgrip strength in elderly patients was conducted in Geriatric outpatient clinic of Cipto Mangunkusumo Hospital and Mohammad Hoesin Hospital from August to October 2015. There were 352 eligible subjects in this study recruited with consecutive sampling. The independent variables in the study consisted of age, sex, nutritional status, chronic disease (stroke, hypertension (HT), diabetes mellitus (DM), coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD)), waist circumference while Nur Riviati Acta Med Indones-Indones J Intern Med 216 INTRODUCTION The elderly population in the world is predicted increase by three-fold within 50 years, from 600 million people in 2000 to over two billion in 2050. The number of elderly population in Indonesia is ranked the top five in the world, reaching 18.1 million in 2010 and is estimated increase by two-fold to 36 million in 2025. Life expectancy of the population Indonesia (both male and female) reached 67.8 years in 2000- 2005 and is predicted increase to 73.6 years in 2020-2025.1,2 The increasing elderly population is accompanied by increasing health problems as one of the effects of the aging process. The aging process is associated with decreasing function of various organs. Skletal muscle is one of the organs affected by aging, which is well known as sarcopenia. Sarcopenia is a syndrome characterized by progressive loss of muscle mass and strength.3-5 The Prevalence of sarcopenia in the age of 60 to 70 years old was reported from 5% to 13% while in those aged >80 years is 11% to 50%. For the time being, the total number of sarcopenia cases is estimated to have reached at least 50 million cases, and in the period of 40 years the number can soar up to 200 million.6 A loss in muscle mass and strength would affect physical performance, functional status, mobility, the occurrence of impairment as well as increase the risk of death. Decreasing muscle strength occurs more rapidly than that of the muscle mass. The loss of muscle strength can not be prevented by maintaining or increasing muscle mass.7,8 Muscle strength can be measured on the upper and lower extremities with a dynamometer. There is a correlation between hand grip strength and muscle strength in other body parts. The handgrip strength examination is often applied as a sarcopenia filtering technique in clinical setting such measurement is considered inexpensive, simple, easy, and can be done with portable measuring tool. Hand grip examinations conducted with Jamar dynamometers warrant a higher accuracy rate and greater force than any other measuring tools, hence Jamar dynamometers are more commonly used.9 Putrawan10 found a positive relation between waist circumference and hand grip strength. Meanwhile, Keevil et al.11 demonstrated a negative relationship between waist circumference and handgrip strength as well as the relationship between body mass index (BMI) and waist circumference. However, controversies are still rife when it comes to the relation between BMI and hand grip strength as described by Silva et al.,12 while Westrop et al.13 found the relationship between BMI and grip strength was to be weak. On the other hand, a contrasting result reported by Kamarul14 showed that the hand grip strength was not related with BMI. The BMI assessment is a crucial part of Mini Nutritional Assessment (MNA) examination. MNA is an effective instrument to assess the nutritional status of elderly. Moreover, a study by Rantanen15 showed that there was a relation between hand grip strength and chronic diseases such as stroke, hypertension (HT), diabetes mellitus (DM), coronary heart disease (CHD), and chronic obstructive pulmonary disease (COPD). This study aimed to determine the relationship between age, nutritional status, and chronic diseases such as stroke, hypertension (HT), diabetes mellitus (DM), coronary heart disease (CHD), and chronic obstructive pulmonary disease (COPD) with handgrip strength. METHODS This was a cross-sectional study to determine factors related to handgrip strength in elderly patients, conducted in Geriatric outpatient clinic of Cipto Mangunkusumo Hospital and the dependent variable was handgrip strength. Results: age of more than 75 years old and malnutriton were risk factors that affected hangrip strength. Age of >75 years increase the risk for having low handgrip strength by 2,3-fold. Malnutrition increased risk for low handgrip strength for 1,9-fold. Conclusion: ages of >75 years old and malnutrition will increase the risk of low handgrip strength in elderly patients. Keywords: handgrip strength, elderly, factor. Vol 49 • Number 3 • July 2017 Factors related with handgrip strength in elderly patients 217 Mohammad Hoesin Hospital from August to October 2015. The inclusion criteria were patients aged above 60 years old with comorbidity of chronic diseases. Exclusion criteria were cognitive deficits (abbreviated mental test of <8), depression (geriatric depression scales of >10), and acute condition of diseases. There were 352 eligible subjects in this study recruited with consecutive sampling. The independent variables in the study consisted of age, sex, nutritional status, chronic disease (stroke, hypertension (HT), diabetes mellitus (DM), coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD)), waist circumference while the dependent variable was handgrip strength. The collected data was processed with SPSS 20 for windows. Descriptive data was presented in the forms of text, tables, and images as appropriate. The bivariate analysis for categorical variables was done with chi-square analysis. The prevalence rate was displayed in the form of proportion (percentage) with its 95% of confidence intervals. Variables with p<0.25 in the bivariate analysis would be incorporated into the multivariate analysis. The multivariate analysis was performed with Cochran Mantel Haenzel analysis. Numerical data was analyzed with t-test. This study had been approved by the Ethical Committee of Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo Hospital on July 6th, 2015 (573/UN2.F1/ETIK/2015). RESULTS There were 352 eligible subjects in this study and the percentage of every variables is presented on Table 1. Table 2 shows factors related to handgrip strength in elderly patients. Age of >75 years old and malnutriton were the risk factors that were found to affect hangrip strength. Age of >75 years increased risk for low handgrip strength by 2.3-fold, while malnutrition increased the risk for low handgrip strength by 1.9-fold. DISCUSSION This study has obtained the relationship between age and the decrease of handgrip strength (PR 1.7; 95% CI 1.4 to 2.2). The results of this study was consistent with that of Forrest et al.16 and Budziareck17 which showed that decreasing muscle strength began to occur at the age of 50 years old. Decreasing handgrip strength in the elderly is associated with their fiber-type transformation, shifts in muscle fiber architecture and the process of Excitation-Contraction (EC) coupling, genetic factors, and oxidative stress (such as the increase in IL-6 and proapoptotic cytokines TNF-α).18 However, the decreasing muscle fiber tye II which plays an important role in anaerobic metabolism (i.e. glycolysis is high) is believed to be the main mechanism that initiates the declining muscle strength.19 The assessment of nutritional status with MNA in the study had showed a significant association with handgrip strength (p<0.001). The result was in line with the study by Karbarugi et al.20 which showed the correlation between MNA score and handgrip strength( (r=0.47), p<0.001). Despite many of the instruments utilized to assess the nutritional status such as BMI (body mass index), subjective global assessment, and the patient generated-subjective global assessment (PG-SGA); MNA remains to be a reliable instrument. Decreasing muscle Table 1. Baseline characteristics (n=352) Variables Values Sex, n (%) - Woman 212 (60.2) - Men 140 (39.8) Age (years), mean (SD) 69.7 (6.3) Age group, n (%) - ≤ 75 267 (75.9) - > 75 85 (24.1) Waist circumfrence (cm), mean (SD) 90.6 (10.7) Nutritional status, n (%) - Normal 304 (86.4) - Malnutrition 48 (14.6) Comorbidity, n (%) - Hypertension 277 (78.7) - Diabetes mellitus 156 (44.3) - Coronary heart disease 84 (23.9) - Stroke 30 (8.5) - COPD 15 (4.3) Handgrip strength (Kg), mean (SD) - Woman 19.8 (5.1) - Men 29.1 (6.9) Nur Riviati Acta Med Indones-Indones J Intern Med 218 strength in malnourished condition is due to decreasing muscle protein supply which is a useful alternative energy source.21 The aging process is associated with changes in quantitative and qualitative motor cortex and bone marrow. The aging process is caused by reduced neurotrophic factors such as serotonergic, cholinergic, adrenergic, dopaminergic, γ-aminobutyric acidergic and glutamatergic system. The change will cause a state of hypoexcitability in the cortex, reduced ability to braid the motor coordination, and reduction in cortical plasticity. It will affect the motor performance, especially in skeletal muscle strength.22 Denervation of type II fibers and the formation of collateral reinnervation to the motor unit type I (slow type) occurs in elderly patients. Some studies showed 57% decrease in muscle fiber tye II and 25% decrease in muscle fiber type I 22. Myofibrils tye II plays a pivotal role in type 2 anaerobic metabolism (i.e. glycolysis is high) for high voltage and short duration. Myofibrils tye I plays a role in aerobic metabolism (i.e. higher oxidation). CONCLUSION Age of >75 years old and malnutrition will increase the risk of handgrip strength in elderly patients. REFERENCES 1. Setiati S. Geriatric medicine, sarkopenia, frailty, dan kualitas hidup pasien usia lanjut tantangan masa depan pendidikan, penelitian dan pelayanan kedokteran di Indonesia. (Pidato Pengukuhan Guru Besar). Jakarta: Fakultas kedokteran Universitas Indonesia; 2013. 2. World Population Ageing 2013. Department of Economic and Social Affairs. United Nations New York, 2013.[ Diunduh 29 Agustus 2014]. Diunduh dari:http://esa.un.org/wpp/sources/country.aspx and htpp : // esa.un.org /unpp/ index.asp? panel=4. Table 2. Factors related handgrip strength Variables Handgrip Strength, n (%) Prevalence Ratio (CI 95%) Adjusted Prevalence Ratio (CI 95%) P Low Normal Aged (years) - > 75 48 (56.5) 37 (43.5) 1.7 (1.4-2.2)* 2.3 (1.7-2.9)# 0.001 - ≤ 75 67 (25.1) 200 (74.9) Waist circumfrence (cm), mean (SD) 90,8 (11.3) 90,5 (10.4) 0.8** Nutritional Status - Malnutrition 27 (56.2) 21 (43.8) 1.6 (1.2-2.3)* 1.9 (1.4-2.6)# <0.001 - Normal 88 (28.9) 216 (71.1) Hypertension - Yes 90 (32.5) 187 (67.5) 0.9 (0.6-1.7)* 0.6 - No 25 (33.3) 50 (66.7) Diabetes mellitus - Yes 53 (34.0) 103 (66.0) 1.0 (0.9-1.2)* 0.6 - No 62 (31.6) 134 (68.4) Coronary heart disease - Yes 22 (26.2) 62 (73.8) 0.9 (0.8-1.0)* 0.1 - No 93 (34.7) 175 (65.3) Stroke - Yes 11 (36.7) 19 (63.3) 1.08 (0.7-1.7)* 0.748 - No 104 (32.3) 218 (67.7) COPD - Yes 5 (33.3) 10 (66.7) 1.0 (0.7-1.5)* 0.9 - No 110 (32.6) 227 (67.4) *Chi square test, # Cochran Mantel Haenzel, **T test Vol 49 • Number 3 • July 2017 Factors related with handgrip strength in elderly patients 219 3. Ryall.JG, Schertzer J.D, Lynch GS. Cellular and molecular mechanism underlying age-related skletal muscle wasting and weakness. Biogerontol. 2008;9:213-28. 4. Gale CR, Martyn CN,Cooper C,Sayer AA. Grip strength, body composition,and mortality. Int J Epidemiol. 2007;36:228-35. 5. Nair KS.Aging muscle. Am J Clin Nutr. 2005;81: 953- 63. 6. Cruz–Jentoff AJ, Baeyens JP, Bauer JM, et al. Sarcopenia: European consensus on definition and diagnosis. Report of the European Working Group on sarcopenia in older people. Age Ageing. 2010;39: 412-23. 7. Clark CB, Manini MT. What is dynapenia? Nutrition. 2012;28:495-503. 8. Delmonico MJ, Harris TB, Visser M, et al. Longitudinal study of muscle strength, quality, and adipose tissue infiltration. Am J Clin Nutr. 2009;90:1579-85. 9. Amaral JF, Mancini M, Junior JMN. Comparison of three hand dynamometers in relation to the accuracy and precision of the measurement. Rev Bras Fisioter. 2012;16(3):216-24. 10. Putrawan P, Kuswardhani T. Faktor-faktor yang menentukan kekuatan genggaman tangan pada pasien lanjut usia di Panti Wreda Tangtu dan Poliklinik Geriatri RSUP Sanglah-Denpasar [Tesis]. Denpasar: Universitas Udayana; 2008. 11. Keevil VL, Luben R, Dalzell N, et al. Cross sectional associations between different measures of obesity and muscle strength in men and women in a british cohort study. J nutr Health aging. 2015;19:3-11. 12. Silva NA, Mezanes TN, Melo RLP, Pedraza DF. Handgrip strength and flexibility and their association with anthropometric variables in elderly. Rev Assoc Med Bras. 2013;59(2):128-35. 13. Westropp NMM, Gill TK, Taylor AW, Bohannon RW, Hill CL. Handgrip strength :age and gender stratified normative data in a population-based study. BMC Res. 2011;4(127):2-5. 14. Kamarul T, Ahmad TS, Loh WYC. Handgrip strength in the adult Malaysian population. J Orthop Surg. 2006;14(2):122-7. 15. Rantanen T, Masaki K, Foley D, Izmirlian G, White L, Guralnik JM. Grip strength changes over 27 yr in Japanese- American men. Cited from http://www. jap.org. 16. Forest, Mitchell KW, Williams J, Atherton P, Larvin M, Lund J, Narici M. Sarcopenia, dynapenia and the impact of advancing age on human skeletal muscle size and strength;a quantitative review. Frontiers Physiol. 2012;3:1-18. 17. Budziarcek, Manini TM, Clark CB. Dynapenia and ageing: An update. J Gerontol A Biol Sci Med Sci. 2012;67A(1):28-40. 18. Clark BC, Manini TM. Sarcopenia dyanapenia. J Gerontol A Biol Sci Med Sci. 2008;63A(8):829-34. 19. Schwarts SR, Kohrt MW. Exercise :physiological and functional effect. In: Halter BJ, Ouslander GJ, Tinetti EM, Studenski S, High PK, Asthana S, ed. Hazard’s geriatric medicine & gerontology. 6th ed. New York: Mc Graw-Hill; 2009. p. 1381-95. 20. Karbarugi, Garatachea N, Lucia A. Genes physical fitness and ageing. Ageing Res Rev. 2013;12:90-102. 21. Meng JS, Yu Jiang L. Oxidative stress, molecular inflammation and sarcopenia. Int J Mol Sci. 2010;11:1509-26. 22. Artigas SB, Rolland Y, Zamboni M, Leheudre A. How to assess functional status: a new muscle quality index. J Nutr Health Aging. 2012;16(1):67-77.