Saudi Journal of Biological Sciences 28 (2021) 1213–1217

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Saudi Journal of Biological Sciences

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Original article

Frailty, sarcopenia and health related outcomes among elderly patients

in Saudi Arabia
Abdulaziz A. Alodhayani a,⇑, Saad M. Alsaad a, Nourah Almofarej b, Njoud Alrasheed b, Badriah Alotaibi c
a
Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
b
King Saud University, Saudi Arabia
c
Department of Pharmaceutical Science, College of Pharmacy, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the prevalence of frailty and sarcopenia among elderly patients in Saudi Arabia
Received 20 October 2020 and explore if there are significant association between frailty and sarcopenia.
Revised 12 November 2020 Methods: A total of 498 patients from public tertiary hospital in Saudi Arabia participated in this descrip-
Accepted 15 November 2020
tive cross-sectional study between March 2019 to June 2019. All participants answered a 5-part question-
Available online 24 November 2020
naire, which includes demographic data, Edmonton Frail Scale, SARC-F and questions related to Activities
of Daily living.
Keywords:
Results: The mean age of the participants was 69.98 ± 6.28. Of the 498 participants, 67.7% were aged 61–
Frailty
Sarcopenia
70 years and 42% had a BMI of greater than < 30 kg/m2. The prevalence of patients with mild frail, mod-
Activities of daily living erate frail and severely frail were 22, 12, and 4%, respectively. The analysis showed that majority of
Saudi Arabia patients who had sarcopenia were females (84%). The analysis show that the level of frailty of patients
were significantly different between age, marital status, educational level and patients’ needs of home
care, activities of daily living, presence of comorbidity and sarcopenia (p = 0.001). In the logistic regres-
sion analysis, the pre-frailty group was significantly likely to have sarcopenia (OR 0.02 95% 0.01–0.23p =
0.001) than nonfrailty patients.
Conclusion: In conclusion, this research highlights the high prevalence of sarcopenia among elderly
patients and the increasing percentage of frail patients in Saudi Arabia. In addition, significant difference
and association were found with sarcopenia and frailty with many sociodemographic and clinical com-
ponents of elderly patients in Saudi Arabia.
Ó 2020 The Authors. Published by Elsevier B.V. on behalf of King Saud University. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction decline, unplanned hospitalizations, surgery, and mortality

(Clegg, 2013; Shimada, 2013; Pel-Little, 2009). Even though frailty
Frailty is a clinical syndrome associated with aging character- is associated with age or its prevalence, it not similar or synonym
ized by loss of physiologic and cognitive reserves (Clegg 2013). It with aging and different from the definition of ‘‘healthy aging”
is also associated with poorer health related quality of life and (Sacha, 2017; Xue, 2008). The assessment of frailty or identifying
increases vulnerability to adverse outcomes such as functional frail individual is emerging as a critical issue because it may help
clinicians to recognized high-risk patients of procedural complica-
tions, disability, institutionalization and death (Sacha, 2017; Xue,
⇑ Corresponding author at: Family and Community Medicine Department, 2008; Boyle, 2010; Chen, 2014).
College of Medicine, King Saud University, P.O. Box 7805, Riyadh 11472, Saudi Several tools have been developed and the most often frailty
Arabia.
assessments are the Edmonton Frailty Scale, Frailty Phenotype
E-mail addresses: Aalodhayani@gmail.com (A.A. Alodhayani), salsaad@ksu.edu.
sa (S.M. Alsaad), Nouralmofarej@gmail.com (N. Almofarej), Njoud.r@gmail.com (N. (FP) and Frailty Index (FI) (Rolfson, 2006; Pereira, 2017; Clegg,
Alrasheed), bsalotaibi@pnu.edu.sa (B. Alotaibi). 2016). These tools are extensively published on for the assessment
Peer review under responsibility of King Saud University. of frailty. Frailty phenotype instruments measures and assess
motor and activity that predominate and lead to an aggregate score
that spans from robust to frail (Rolfson 2006). Meanwhile, frailty
index instruments, assess factors like social, psychological condi-
Production and hosting by Elsevier tions, co-morbidities and cognitive decline (Pereira, 2017; Clegg,

https://doi.org/10.1016/j.sjbs.2020.11.058
1319-562X/Ó 2020 The Authors. Published by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.A. Alodhayani, S.M. Alsaad, N. Almofarej et al. Saudi Journal of Biological Sciences 28 (2021) 1213–1217

2016). Several frailty instruments are suitable for identifying related to activities of daily living and Edmonton Frail scale, Basic
patients or individuals at high risk for adverse outcomes and for demographic information includes age, sex, marital status, educa-
risk division to assist in clinical decision making (Walston 2018). tional level and BMIs.
The prevalence of frailty in general and specific population has Frailty will be measured using the Edmonton frailty scale (EFS),
been reported by previous studies in Saudi Arabia, however, asso- a validated tool will be scored the patients level of frailty from 0 to
ciated factors in frail individuals such as sarcopenia and other fac- 17 (not frail to very frail) [8]. The degree of frailty will determine
tors remains unknown. Sarcopenia is a condition in which presence from the following cutoff; 0–5 = not frail, 6–7 = vulnerable; 8–
of low skeletal muscle mass plus and strength with poor physical 9 = mild; 10–11 = moderate; and 12–17 = severely frail. The EFS
disability (Santili 2014). Because of the similarities in etiology tool assess 9 domains related to frailty such as general health sta-
and definition which can be present in the same patient, the occur- tus, cognition, social support, functional dependence, continence,
rence of both condition may have implication and consequence for mood, nutrition and medical use (Rolfson 2006).
treatment and outcome of elderly patients. Identifying the preva- The SARC-F questionnaire was developed as a rapid diagnostic
lence of frailty and may likely to take advantage of preventive tool for sarcopenia. Five components closely related to functional
actions in these certain population. Thus, we aim to answer the fol- status were self-reported by the older individuals: strength, assis-
lowing question: first, what is the prevalence of frailty and sar- tance with walking, rising from a chair, climbing stairs, and falls,
copenia among elderly patients in Saudi Arabia? Second, is there which were scored between 0 and 2, with higher scores being sug-
are significant difference between baseline characteristics of gestive of sarcopenia. The score ranged from 0 to 10 (Yang 2018).
elderly patients and other factors with frailty and sarcopenia and The Katz Activities of Daily Living (ADL) scale is an instrument
lastly, to determine association of level of frailty in elderly patients that developed to assesses six primary and psychosocial functions:
with sarcopenia. bathing, dressing, going to toilet, transferring, feeding, and conti-
nence (Ibrahim 2018). Katz and collaborators found that these
six activities have a hierarchical order in which the most complex
2. Methods
functions are lost first. Each ADL is scored on a 3-point scale of
independence. Items are ordered by difficulty. The scoring reflects
2.1. Design and setting
this, although some variation in the hierarchy of difficulty is
allowed with a score range of 0–6.
A descriptive cross-sectional study will be performed in one of
The Lawton IADL scale can be scored in several ways, the most
the largest tertiary-level hospital in Saudi Arabia from March 2019
common method is to rate each item either dichotomously (0 = less
to June 2019. The selected hospital is a multi-disciplinary facility
able, 1 = more-able) or (1 = unable, 2 = needs assistance, 3 = inde-
and referral hospital in Riyadh, Saudi Arabia which is facilitated
pendent) and sum the eight responses (Potkin, 2002). The higher
by Ministry of Health. Ethical approval from the Institutional Board
the score, the greater the person’s abilities. Women are scored on
of the selected hospital will be sought prior to distribution of sur-
all 8 areas of function, but, for men, the areas of food preparation,
vey questionnaire.
housekeeping, laundering are excluded. Clients are scored accord-
ing to their highest level of functioning in that category. A sum-
2.2. Participants mary score ranges from 0 (low function, dependent) to 8 (high
function, independent) for women, and 0 through 5 for men.
For this study, all patients attending outpatients’ clinics in a The Charlson Comorbidity Index (CCI) was originally developed
public tertiary hospital, aged 50 and above, Saudi national and able to predict 1-year mortality in a mixed population of internal med-
to walk independently were included in the study. Physically icine patients using comorbidity derived from chart review. The
impaired or has sensory impairment and patients with existing CCI consists of 19 selected conditions that are weighted and
comorbidities such as stroke, dementia and Parkinson’s disease summed to an index on a 0–33 scale. Patients were divided into
as well as incomplete data on frailty were excluded from this three groups: mild, with CCI scores of 1–2; moderate, with CCI
study. The caregiver of the patients will also be invited to partici- scores of 3–4; and severe, with CCI scores  5. CCI was calculated
pate and answer in behalf of the patients. Calculating a sample size according to the scoring system established by Charlson et al
for estimating prevalence of both frailty and sarcopenia in a group (D’Hoore 1996).
of elderly patients:
P Frailty = 0.27 2.4. Data collection procedure
Alpha level = 0.05 (corresponding to 95% confidence level)
Power = 0.8 All patients attending from ambulatory clinics in a public ter-
Margin of error (m) = 0.05 tiary hospital in Riyadh Saudi Arabia were interviewed by two
N=Za researchers. The researchers asked and seek approval to patients’
2 [p(1-p)] / m 2 physician to set a time to interact with the participants for facilitat-
N = 1.96 2 [ 0.27*0.73] / (0.05) 2 = 302  303 ing the data collection. Written consent was sought prior to data
P sarcopenia = 0.443 collection in accordance with the guidelines of Institutional Review
Alpha level = 0.05 (corresponding to 95% confidence level) Board of King Saud Medical City. The researchers ensured the
Power = 0.8 patients about their confidentiality and their participation were
m = 0.05 voluntary.
N = 1.96 2 [0.443*0.557] / (0.05) 2 = 379.1  380
We expect the response rate will be 80%, then we adjust the 2.5. Statistical analysis
sample size to count for this assumed response rate: N
adjusted = N / response rate. All data were entered and analyzed using SPSS 23 (Chicago, IL,
USA). Patient characteristics were summarized using descriptive
2.3. Instrument statistics. Shapiro-Wilk (S-W) test was used to determine the nor-
mal distribution of variables. Means and standard deviation were
All consented participants answered a self-administered ques- used to present the results of normally distributed variables while
tionnaire that compose of sociodemographic questions, questions median with interquartile range was used for non-normal dis-
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tributed variables. The Chi-square test was applied to detect differ- cent had primary level of education and 12% of the participants had
ences between demographic characteristics and level of frailty. high education degree. The majority of the patients reported that
Logistic regression analysis was performed to determine the asso- they need home care (N = 372, 74.7%). The prevalence of frailty
ciation between level of frailty and sarcopenia. A p < 0.05 level was for the total sample is presented in Fig. 1. The prevalence of
considered statistical significant. patients with mild frail, moderate frail and severely frail were 22,
12, and 4%, respectively. According to the frail scale, 22% was vul-
3. Results nerable and 38% of the participants were not frail. Fig. 2 shows the
percentage of sarcopenic and nonsarcopenic patients according to
3.1. Demographic characteristic of the participants gender.
Table 2 shows the comparison of certain clinical and demo-
The study participants included 498 patients admitted in a graphic characteristics between the level of frailty of patients.
referral hospital in Riyadh, Saudi Arabia. The characteristics of There were 22 (4.4%) patients in the frailty group, 283 (56.8%)
the participants were shown in Table 1. The mean age of the par- patients in the prefrailty group and 193 (38.7%) patients in the
ticipants was 69.98 ± 6.28. Of the 498 participants, 67.7% were nonfrailty group. The analysis show that the level of frailty of
aged 61–70 years and 42% had a BMI of greater than <30 kg/m2. patients were significantly different between age, marital status,
>70% of the participants were females and nearly half of the partic- educational level and patients’ needs of home care, activities of
ipants had no formal education (N = 212, 42.6%). Twenty-five per- daily living, presence of comorbidity and sarcopenia (p = 0.001).
Logistic regression analysis was performed to assess the associ-
Table 1 ation of level of frailty and sarcopenia. As shown in Table 3, the
Demographic characteristic of the participants.
pre-frailty group was significantly likely to have sarcopenia (OR
Variable N = 498 % 0.02 95% 0.01–0.23P = 0.001). The odds ratio of 0.02 was<1, which
Age Mean 69.98 SD 6.28 indicated that for every prefrailty patients there were 0.02 times
51–60 years 3 0.6 less likely to have sarcopenia.
61–70 years 337 67.7
70 and above 158 31.7
BMI 4. Discussion
>30 kg/m2 194 53.6
<30 kg/m2 152 42.0 This study highlights the increasing prevalence of sarcopenia
Gender whereas 84% of sarcopenic were females. This is contrary to a study
Male 136 27.3 done in Western Europe in which prevalence of sarcopenia was
Female 362 72.7
Marital status
12.5% among subjects aged 80 years and over (Buckinx 2017). In
Single 151 30.3 another study in Europe, the prevalence of sarcopenia, among
Married 347 69.7 patients aged 65 years or more was. 13.7% (Martone 2017). The
Educational level findings in the present study shows that the prevalence of sarcope-
No formal education 212 42.6 nia is about 3 times higher compared with other countries that was
Primary 126 25.3 approximately 10 to 15%. The high prevalence can be explained by
Intermediate 42 8.4
the particular care setting of the study population which was home
Secondary 58 11.6
High education degree 60 12.0 setting. Previous study admitted that the prevalence of sarcopenia
increases and associated with the place of care of patients
Do you need home care
Yes 372 74.7 (Moreira, 2019; Landi, 2012). There is a strong association of the
No 126 25.3 degree of sarcopenia with dependence among residents (Bauer
2008). One multi-centered study in Spain show 37% prevalence
sarcopenia and comparable in the present study (Bravo-Jose

Fig. 1. Prevalence of Frailty among elderly patients in Saudi Arabia.

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A.A. Alodhayani, S.M. Alsaad, N. Almofarej et al. Saudi Journal of Biological Sciences 28 (2021) 1213–1217

Fig. 2. Sarcopenic vs nonsarcopenic patients according to gender.

Table 2
Difference regarding patients’ demographic characteristic with level of frailty.

Variable Total N = 498 Nonfrail (N = 193) Pre Frail (N = 283) Frail (N = 22) P value
Age
70 and below 340 (68.3) 148 (43.0) 183 (54.3) 9 (2.7) 0.001
71 and above 158 (31.7) 45 (28.5) 100 (63.3) 13 (8.2)
BMI [kg/m2]
BMI > 30 kg/m2 28.34 (21.78) 57 (32.2) 112 (63.3) 8 (4.5) 0.074
Gender
Male 136 (27.3) 64 (47.1) 66 (48.5) 6 (4.4) 0.061
Female 362 (72.7) 129 (35.6) 217 (59.9) 16 (4.4)
Marital status
Single 151 (30.3) 38 (25.2) 74 (49.0) 6 (4.0) 0.001
Married 347 (69.7) 155 (44.7) 96 (27.7) 16 (4.6)
Educational level
No formal education 212 (42.6) 69 (32.5) 132 (62.3) 11 (5.2) 0.002
Primary 126 (25.3) 38 (30.2) 82 (65.1) 6 (4.8)
Intermediate 42 (8.45) 17 (40.5) 24 (57.1) 1 (2.4)
Secondary 58 (11.6) 35 (60.3) 20 (34.5) 3 (5.2)
High education degree 60 (12.0) 34 (56.7) 25 (41.7) 1 (1.7)
Do you need home care
Yes 372 (74.5) 109 (29.3) 242 (65.1) 21 (5.6) 0.001
Activity of daily living: Katz index
<2 patient very dependent 64 (12.8) 3 (4.7) 49 (76.6) 12 (18.8) 0.001
Activity of daily living: Lawton Brody (less able)
Male 8 0 4 (50) 4 (50) 0.001
Female 36 2 (5.6) 27 (75.0) 7 (19.4)
Charlson Comorbidity Index
Severe 83 (22.9) 15 (12.7) 94 (79.7) 9 (7.6) 0.001
Sarcopenia
Sarcopenic 258 53 (20.5) 186 (72.1) 19 (7.4) 0.001

Note: Chi-square analysis was used in this table; p-value significant at p < 0.05

2018). In addition, in Turky, the prevalence of sarcopenia was iden-

tified at a percentage rate of 29%, while 40% of prevalence among
Table 3 Australian patients (Senior 2015).
Relationship between the level of frailty and sarcopenia. Another highlight of the study is the prevalence of frailty in
Sarcopenia Saudi population. The results highlight that among the prevalence
Frailty level OR (95% CI) P-value of patients with mild frail, moderate frail and severely frail were
22, 12, and 4%, respectively. This suggests that frail patients are
Nonfrailty 1(Reference)
Prefrailty 0.02 0.01–0.23 0.001
more at risk of being sarcopenic and it confirms the hypothesis that
Frailty 0.23 0.02–2.08 0.192 sarcopenia is a major factor in the development of frailty (Yalcin
2016). We found that the prevalence of sarcopenia increased when
Note: p-value significant at p < 0.05.

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getting older; however, the prevalence of sarcopenia often high in Bauer, J.M., Kaiser, M.J., & Sieber, C.C. (2008) Sarcopenia in nursing home residents. J
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None.
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Prevalence and risk factors of sarcopenia among adults living in nursing homes.
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All authors contributed to data analysis, drafting or revising the Shimada, H., Makizako, H., Doi, T., 2013. Combined prevalence of frailty and mild
article, gave final approval of the version to be submitted for pub- cognitive mpairment in a 6 population of elderly Japanese people. J. Am. Med.
Dir Assoc. 14 (518–524), 7 4.
lication and agree to be accountable for all aspects of work. Tamura, Y., Ishikawa, J., Fujiwara, Y., et al., 2018. Prevalence of frailty, cognitive
impairment, and sarcopenia in outpatients with cardiometabolic disease in a
Declaration of Competing Interest frailty clinic. BMC Geriatr. 18 (1), 264.
Walston, J., Buta, B., Xue, Q.L., 2018. Frailty screening and interventions:
considerations for clinical practice. Clin. Geriatr. Med. 34 (1), 25–38. https://
The author declare that there is no conflict of interest. doi.org/10.1016/j.cger.2017.09.004.
Xue, Q.L., Bandeen-Roche, K., Varadhan, R., et al., 2008. Initial manifestations of
frailty criteria and the 13 development of frailty phenotype in the Women’s
Acknowledgments
Health and Aging Study II. J. Gerontol. A Biol. Sci. Med. 14 Sci. 63, 984–990.
Yalcin, A., Aras, S., Cengiz, O.K., Varli, M., et al., 2016. Sarcopenia prevalence and
The authors extend their appreciation to the College of Medi- factors associated with sarcopenia in older people living in a nursing home in
cine Research Centre, Deanship of Scientific Research, King Saud Ankara Turkey. Geriatr. Gerontol. Int. 16 (8), 903–910.
Yang, M., Hu, X., Xie, L., et al., 2018. SARC-F for sarcopenia screening in community-
University, Riyadh, Saudi Arabia for funding this work. dwelling older adults: are 3 items enough?. Medicine (Baltimore). 97, (30).
https://doi.org/10.1097/MD.0000000000011726 e11726.
Yamada, M., Nishiguchi, S., Fukutani, N., et al., 2013. Prevalence of sarcopenia in
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