• Vol. 54 No. 1, 57–61
  • 23 January 2025
Accepted: 11 December 2024

Knowledge and attitudes towards sarcopenia among healthcare professionals

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Dear Editor,

Sarcopenia is the age-related loss of skeletal muscle mass as well as muscle strength and/or performance.1 Sarcopenia is an important public health issue as it has a significant impact on patient health outcomes, and personal and social economic outcomes. It leads to increased adverse outcomes such as increased risks of falls, fractures, postoperative complications, disability and increased mortality.2 It is associated with many chronic diseases such as heart failure, chronic kidney disease, chronic obstructive pulmonary disease, diabetes and cognitive impairment.2,4 The prevalence of sarcopenia is expected to dramatically increase in the next few decades, especially in ageing populations.6

Sarcopenia was recognised as a disease by the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) with the code M62.84 in 2016. Yet, many clinicians and healthcare professionals remain unaware of the condition and uncertain about diagnostic tools and management strategies.6

We conducted a study to describe the current knowledge and practice regarding sarcopenia among healthcare professionals and to identify potential gaps, if any. A structured survey was crafted and modified based on a previous study.7 Key survey results are shown in Table 1.

Table 1. Key survey results.

From 1 February to 1 August 2023, an online survey was completed by 108 healthcare professionals across 3 public hospitals in Singapore. An online survey link was sent to healthcare professionals from the institutions inviting them to participate in an anonymous survey via the FormsSG digital survey platform. This study received ethics approval from the National Healthcare Group Domain Review Board (2022/00781).

There was a total of 108 respondents. Majority of the respondents were nurses (56%) and doctors (36%). The rest of the allied health professionals respondents were therapists, dieticians and pharmacists. The majority of doctors were from internal medicine (40%) and geriatric medicine (35%). The remaining were from family medicine (7.5%), gastroenterology (5%), endocrinology (5%), dermatology (2.5%), palliative medicine (2.5%) and rehabilitation medicine (2.5%).

First, a set of questions were on participants’ attitudes regarding sarcopenia. Overall, most healthcare professionals strongly agreed that the recognition and management of sarcopenia was important. However, only 22.20% of participants diagnosed sarcopenia within the past 3 months. Common reasons cited for not diagnosing sarcopenia included lack of tools for diagnosis, and feeling that they are not the ones responsible for the diagnosis of sarcopenia.

Second, we assessed participants’ knowledge on sarcopenia. Only 13% (n=14) identified sarcopenia as a disease, and this was similar for both allied health professionals (13%, n=9) and doctors (12.5%, n=5). The majority of respondents correctly agreed that sarcopenia can be prevented (65.7%, n=71). We wanted to assess participants’ knowledge on diagnostic criteria of sarcopenia too, and the majority of participants correctly identified the following determinants in the diagnosis of sarcopenia: muscle mass (88.89%, n=96, muscle strength (86.11%, n=93) and physical performance (77.78%, n=84). However, there was also a high percentage of respondents who selected clinical impression (50.93%, n=55), nutritional status (63.89%, n=69), body mass index (BMI; 53.70%, n=58) and frailty criteria (57.41%, n=62) as part of diagnostic criteria for sarcopenia, even though current guidelines only recommend usage of muscle mass, muscle strength measurements and physical performance.1

Third, we aim to assess current practice for the diagnosis and management of sarcopenia. Based on the Singapore Clinical Practice Guideline for Sarcopenia,8 diagnosis is made via presence of low muscle mass and muscle function. Muscle mass can be measured by dual x-ray absorptiometry (DXA). Muscle strength can be measured via grip strength, and physical performance can be measured by gait speed, 5 times sit-to-stand test or short physical performance battery test. However, only 9.30% (n=10) of respondents used muscle mass to diagnose sarcopenia, and 19.4% (n=21) used muscle strength for the diagnosis of sarcopenia. Interestingly, 22.2% (n=4) of respondents used nutritional status for the diagnosis of sarcopenia. Also, 16.17% (n=18) of respondents used BMI and 28.70% (n=31) used frailty criteria in the diagnosis of sarcopenia, even though they are not part of the recognised diagnostic criteria for sarcopenia. Only 5.6% (n=6) of respondents indicated that there was a protocol for the diagnosis of sarcopenia, and only 4.6% (n=5) indicated the existence of a protocol for the management of sarcopenia in their institutions.

With the rise in research for sarcopenia and increased resources for diagnosis and management of sarcopenia, there should be a corresponding increase in awareness of this disease. Based on this survey, the majority of respondents demonstrated a positive attitude towards sarcopenia. However, there is significant heterogeneity in how sarcopenia is being diagnosed. Less than 20% (n=21) of participants used muscle strength and mass for the diagnosis of sarcopenia, even though it was included in a standardised diagnostic criteria put forth by the Asian Workgroup for Sarcopenia and Singapore clinical practice guidelines.9,8 Interestingly, up to 38.9% (n=42) of participants uses clinical impression for the diagnosis of sarcopenia, despite presence of standardised guidelines. This can lead to risks of misdiagnosis and undertreatment, especially in patients who may appear to have larger body habitus due to obesity or fluid overload states. Obesity and sarcopenia are not mutually exclusive entities.

In addition, there is a low rate of diagnosis for sarcopenia (22.2%) despite awareness of the disease. Sarcopenia can lead to adverse outcomes such as falls, fractures, disability and increased mortality. Similar to this study, a survey of healthcare professionals across Asia (in 2022) revealed that approximately 99.3% were aware of sarcopenia; and yet only 42.4% of them had screened for sarcopenia, while 42.9% diagnosed sarcopenia.10 This shows that the gap between awareness and diagnosis of sarcopenia is not unique to Singapore, but we may be falling behind in screening and diagnostic rates compared to rest of Asia. More work needs to be done to improve the screening and diagnosis rates for sarcopenia. Just having an awareness of sarcopenia is insufficient.

Possible strategies involve improving access to diagnostic tools such as bioelectrical impedance analysis or DXA machines. From this survey, 48.15% (n=52) of participants felt they did not have the tools for the diagnosis of sarcopenia. The most common equipment used in hospitals are dynamometers for testing of hand grip strength. Other equipment such as the bioelectrical impedance analysis machine or DXA machine may not be readily available. Investment in these  machines and education of staff on the interpretation of results will bridge this gap. Second, it is important to increase efforts in educating healthcare professionals on sarcopenia within each hospital, to streamline diagnostic processes. Third, implementing protocols involving multidisciplinary teams in the screening, diagnosis and management of sarcopenia is crucial. Doctors and allied healthcare play an important role in screening patients on the ground, and subsequently liaising with dieticians and physiotherapists for targeted interventions, tailored to the individual. Based on this survey, only 5.6% (n=6) of participants are aware of a protocol for sarcopenia diagnosis in their workplace. Perhaps a case finding approach can be performed, with administration of SARC-F (strength, assistance walking, rise from a chair, climb stairs and falls) questionnaires and grip strength or functional assessment offered to older adults in the clinic setting. This can be a good start to increase the screening and diagnostic rates. Fourth, creation of an Agency for Care Effectiveness clinical guideline on sarcopenia in Singapore may be useful for dissemination of information to clinicians on the ground.

There is a need to emphasise that sarcopenia is an important chronic disease, much like diseases such as hypertension or diabetes. Those with sarcopenia have higher odds of hospitalisation, and have increased hospital costs of around USD2315.70 (SGD 3,172.50) per person annually based on a cross-sectional study in US,3 on top of increased fall risks, fractures and disability. Proper interventions can lead to early identification of sarcopenia and reduce downstream complications, reduce healthcare costs and improve quality of life for older adults.

Overall, based on this survey, there is generally low adherence to Singapore clinical practice guidelines on sarcopenia, especially on screening and diagnosis of the disease. This inevitably results in reduced diagnosis or misdiagnosis, and inability to institute management early. Patient care is therefore affected, as we are not able to reduce risk of downstream effects such as falls, fractures, disability and increased postoperative complications. Sarcopenia is still relatively underdiagnosed and undertreated in tertiary hospitals. Institution of protocols for screening, diagnosis and management of sarcopenia in hospitals and community is needed. As suggested above, future efforts can be focused on education of healthcare professionals on the importance of sarcopenia detection, increasing accessibility to tools for the diagnosis of sarcopenia, and perhaps even direct efforts at the public health level to increase the public awareness of sarcopenia.


References

  1. Cruz-Jentoft AJ, Bahat G, Bauer J, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019;48:16-31.
  2. Beaudart C, McCloskey E, Bruyere O, et al. Sarcopenia in daily practice: assessment and management. BMC Geriatr 2016;16:170.
  3. Goates S, Du K, Arensberg MB, et al. Economic Impact of Hospitalizations in US Adults with Sarcopenia. J Frailty Aging 2019;8:93-9.
  4. Cruz-Jentoft AJ, Sayer AA. Sarcopenia. Lancet 2019;393:2636-46.
  5. Goates S, Du K, Arensberg MB, et al. Economic Impact of Hospitalizations in US Adults with Sarcopenia. J Frailty Aging 2019;8:93-9.
  6. Yao XM, Liu BB, Deng WY, et al. The Awareness and Knowledge Regarding Sarcopenia among Healthcare Professionals: A Scoping Review. J Frailty Aging 2022;11:274-80.
  7. Yeung SSY, Reijnierse EM, Trappenburg MC, et al. Current knowledge and practice of Australian and New Zealand health-care professionals in sarcopenia diagnosis and treatment: Time to move forward! Australas J Ageing 2020;39:e185-e193.
  8. Lim WS, Cheong CY, Lim JP, et al. Singapore Clinical Practice Guidelines For Sarcopenia: Screening, Diagnosis, Management and Prevention. J Frailty Aging 2022;11:348-69.
  9. Chen LK, Woo J, Assantachai P, et al. Asian Working Group for Sarcopenia: 2019 Consensus Update on Sarcopenia Diagnosis and Treatment. J Am Med Dir Assoc 2020;21:300-7e2.
  10. Yamada M, Lee WJ, Akishita M, et al. Clinical practice for sarcopenia in Asia: Online survey by the Asian Working Group for Sarcopenia. Arch Gerontol Geriatr 2023;115:105132.
Ethics statement

This study has been approved by National Healthcare Group (NHG) Domain Specific Review Board (2022/00781).

Declaration

No funding was received for this study. The authors have no affiliations or financial involvement with any commercial organisation with a direct financial interest in the subject or materials discussed in the manuscript.

Correspondence

Dr Jeremy Jun Wei Teng, Department of Healthy Ageing, Alexandra Hospital, 378 Alexandra Rd, Singapore 159964. Email: [email protected]