Poređenje nekih funkcionalnih i antropometrijskih parametara kao faktora rizika za fragilnost među polovima kod starih osoba Comparison of some functional and anthropometric parameters as risk factors for gender fragility in the elderly people

Introduction. A specific characteristic of the elderly is brittleness or fragility, and due to its prevalence, fragility needs to be understood as a public health priority. The aim of the study was to examine the association of functional and anthropometric parameters with fragility in persons over 65 years of age. Method. The study was designed as a cross-section al study and included 446 elderly people. As research in -struments, a general questionnaire was used to assess the functional status of the Tinetti test and, of anthropometric parameters, the circumference of the upper arm and the cir cumference of the middle part of the lower leg. We used the χ2 test and Pearson’s correlation analysis as statistical tests. Results. Females had poorer functional status, walking, and balance compared to males (χ2 = 4.125; p <0.127). It was observed males subjects had higher values of upper arm circumference (26.96 ± 3.44) compared to females, while fe males had higher values of the middle circumference of the lower leg (32.66 ± 6.29). Analyzing the correlation of anthro pometric measurements with the total score of the Tinetti test and in relation to subjects` gender, it was noticed there is a correlation analysis between the parameters. Conclusion. A high percentage of people over the age of 65 have poor functional status, as well as lower values of anthropometric markers, suggesting that they may be poten tial risk factors for the fragility in the elderly.


Introduction
Over the past decades, the age structure of the population has changed with the increase in the number of elderly people over 65. A specific characteristic of the elderly is fragility, and due to its prevalence, fragility should be understood as a priority of public health, because it not only negatively affects the quality of life of the elderly but also brings along numerous economic and social consequences. It is thought fragility is very common in the elderly population and carries a high risk of poor health outcomes, including increased mortality, institutionalization, falls, and hospitalization. As a result, interest in this topic has grown over the last decade (1). The main reason is the belief that early identification of risk factors could help delay or prevent negative fragility outcomes. Despite considerable research, there is still debate about the nature, definition, prevalence, and characteristics of older people in different "phases" of fragility (2). In the geriatrics domain, fragility is increasingly defined as a biological syndrome of reduced reserve and resistance to stressors, which is the result of a cumulative decline in several physiological systems leading to the above-mentioned poor outcomes. Although often equated to a disability, the fragility syndrome can be a physiological precursor and etiological factor of disability due to its main characteristics of weakness, reduced endurance, and slow performance (3). When talking about fragility, we rarely fail to mention sarcopenia and malnutrition, which are closely related to this syndrome. We can freely say sarcopenia and fragility overlap in three characteristics: low muscle strength, walking speed, and muscle mass, which would imply sarcopenia and fragility, in these segments, coincide because they share three of the same characteristics. According to previous research, a person with sarcopenia is always fragile, but not necessarily the other way around, while malnutrition may be associated with both of these conditions (4).
Fragility correlates with aging but is not its inevitable consequence. Fragility is present in approximately 10% of people over the age of 65, while in those over 85 this percentage is significantly higher and amounts to between 25% and 50% (5,6,7,8). It is higher in women than in men and is prevalent in people with lower education and income, poorer health, chronic diseases, and those with poorer functional status (9). The prevalence of fragility occurs worldwide and ranges from 4 to 59,1% (10). As there is still no clear consensus for a detailed assessment of fragility or sarcopenia indicators, further research in this area is urgently needed.

Objective
The study aimed to examine the association of functional and anthropometric parameters with fragility in persons over 65 years of age.
Comparison of some functional and anthropometric parameters as risk factors for gender fragility in the elderly people General Practice 2022;28(1-2):27-36

Examinees
The cross-sectional study was conducted with elderly people, and the sample consisted of 446 subjects of both genders. The criterium for inclusion was time orientation, and exclusion criteria were individuals with acute illnesses, recent hospitalization, disorientation, inability to establish cooperation, chronic renal failure, individuals with hip fractures, and the presence of mental illness, dementia, malignancy. disease, stroke, etc. The survey was conducted by researchers at health centers in Foca, Rogatica, and East Sarajevo from November 2020 to March 2021. Each respondent was asked to sign a written consent stating his/her voluntary participation in the research. The research was conducted in accordance with the Declaration of Helsinki, with the consent of the Ethics Committee of the Medical Faculty in Foča, and the Health Centers included in the research.

Research instruments
A standardized questionnaire was used to collect sociodemographic data on respondents in the study (gender, age, education, place of residence, incomes, social activity, and integration, socializing, hobbies, use of mobility aids).
The Tinetti Gait and Balance Instrument questionnaire was created to determine the risk of falls in the elderly over the next year. Using the questionnaire, we performed a physical examination of the patient and established the state of his balance, and calculated a special score, as well as the patient's gait for which we also calculated the score and got the final score. The final score may assess the risk of falling for the patient in the coming year. The instrument is very good, ie. reliable for assessing the functional status, and can be approached for further interpretation and generalization of results. The test is performed by the subject walking across the room, first in his "usual rhythm" and then in a "fast but safe" rhythm, using, if necessary, the usual walking aids such as a cane or walker. The maximum score for the balance is 16 points and for gait 12. The total score is 28. Respondents who score below 18 are at high risk for falling, those in the range of 19-23 have a moderate risk, and a score higher than 24 represents a low risk of fall (11).
Out of the anthropometric parameters, the circumference of the upper arm and the middle circumference of the lower leg were measured. The circumference of the upper arm (UAC) was measured using a centimeter tape in the middle of the upper arm, with the arm extended alongside the body, and the value was expressed in centimeters. Subjects would have the middle circumference of the lower leg measured in a standing position so that during the measurement Poređenje nekih funkcionalnih i antropometrijskih parametara kao faktora rizika za fragilnost među polovima kod starih osoba Opšta medicina 2022;28(1-2):27-36 Natalija P. Hadživuković et al.

Statistical analysis
In this research, the data were processed using the SPSS software statistical package. The χ2 square test, a nonparametric test, was used as a statistical test. The Pearson correlation analysis was used for the correlation analysis. The data are presented in tables. The usual value of p <0.05 was taken as the level of statistical significance of the difference, ie. all p values less than 0.05 were considered statistically significant.

Results
The study included 446 subjects over 65, of which 251 (56.3%) were women and 195 (43.7%) men, with an average age of 75.96 ± 7.41. When it comes to the age of the respondents, 50.0% belonged to the younger group aged 65-75, 39.0% were from 75-85, while 11% of the respondents were > 85. Most of the participants were married (47%), had primary education (67%), specific hobbies (56%), and pensions (87%). Almost all respondents (95.5%) were of the opinion that they like to hang out with friends and 70% did not use mobility aids (Table 1). By examining functional ability, using the Tinetti test, it was observed there was no statistically significant difference between male and female subjects when it comes to functional status. Females had lower functional status, gait, and balance compared to males (  Analizirajući povezanost antropometrijskih mjerenja sa ukupnim skorom Tinetti testa i u odnosu na pol ispitanika, uočeno je da postoji korelaciona analiza između parametara. Utvrđene su značajne negativne korelacije po pitanju obima nadlaktice i kod žena (p<0,001) i muškaraca (p<0,001). Značajne negativne korelacije kod muškaraca su utvrđene za obim nadlaktice (p<0,001), gdje je uočeno da su ispitanici sa nižim vrijednostima pomenutih mjerenja imali lošiji funkcionalni status. Takođe, ispitanici su imali lošiji funkcionalni status i u odnosu na vrijednosti obima srednje cirkumferencije potkoljenice (Tabela 4).  Analyzing the correlation of anthropometric measurements with the total score of the Tinetti test and concerning the subjects` gender, it was noticed there was a correlation analysis between the parameters. Significant negative correlations were found in upper arm circumference in both women (p <0.001) and men (p <0.001). Significant negative correlations in men were found for upper arm circumference (p <0.001) where it was observed the subjects with lower values of the mentioned measurements had poorer functional status. Also, the subjects had a poorer functional status concerning to the values of the middle circumference of the lower leg (Table 4).

Discussion
There is a decrease in muscle mass in old age. Skeletal muscles make up to 50% of total body protein. Significant loss of skeletal muscle mass threatens metabolism, immunocompetence, and strength. Loss of muscle mass, functional disability, and fragility are risk factors for falls, bone fractures, disability, sarcopenia, institutionalization, and hospitalization in the elderly. In the clinical setting, low muscle mass in hospitalized patients increases hospital stay and reduces their survival (13). In overweight individuals, low muscle mass can be masked by being overweight. It has been proven muscle mass decreases by about 30% at the age of 20 to 80 years, or about 6 kg ( 12).
Our results showed women had a higher percentage of injury risk, lower functional status, slower gait, and balance compared to men. Based on the results of our research, it can be concluded the analysis of data related to functional status showed individual differences between respondents. There are some older respondents with excellent functional status, but on the other hand, there are younger ones with lower functional status because their daily activities are lim- nika sa odličnim funkcionalnim statusom, ali sa druge strane postoje oni mlađi sa lošijim funkcionalnim statusom, jer su im aktivnosti dnevnog života ograničene. Slična zapažanja navodili su i drugi autori ukazujući na heterogenost populacije starih. Među starima postoje oni sa zadovoljavajućim funkcionalnim statusom i potpuno nezavisni od tuđe pomoći, ali i slabi i zavisni od tuđe pomoći, kao i oni sa različitim stepenom rizika od pogoršanja funkcionalnog stanja, slabosti, pa čak i smrti (14,15).
Based on the obtained results, analyzing the correlation of anthropometric measurements with the total score of the Tinetti test in relation to the sex of the subjects, it was noticed that there is a correlation analysis between some parameters. The results show that male and female subjects differ statistically in terms of anthropometric measurements, especially for upper arm circumference.
The concept of functional body composition integrates body parts into regulatory systems by connecting body components with appropriate metabolic processes. Age-related changes in body composition have implications for health and good physical function. Poor functional status has an impact on both nutritional status and cognitive status leading to a number of collaborative problems such as fragility and sarcopenia. Different phenotypes of sarcopenia must be observed in relation to functional and health aspects.
Muscle strength, muscle mass, and functional ability are three very important components for the assessment and diagnosis of sarcopenia. Studies have shown that the addition of essential amino acids and peptides to the diet can have a beneficial effect on the treatment of sarcopenia. Also, the positive effect of vitamin D intake on increasing muscle mass and strength is well known. To alleviate the effects of sarcopenia, a combination of physical activity, endurance exercise, and increased dietary amino acid intake have been shown to be best (16,17).
Disability can increase the risk of death, so there is a natural assumption that subjects with sarcopenia or sarcopenic obesity are at a higher risk of death. Insufficient physical activity is one of the leading risk factors for death in the world but also for the development of non-contagious diseases, such as cardiovascular disease, cancer and diabetes. Physical activity has significant health benefits and contributes to the prevention of the before mentioned non-contagious diseases (18). Regular physical activity, including aerobic and anaerobic activity, is a significant and variable factor in the prevention and treatment of obesity in the general population or sarcopenia in older adults. Physical activity prevents weight gain and reduces the proportion of adipose tissue in obese people, and while improving it, at the same time it increases muscle mass and strength in elderly people with sarcopenia (19). Leg and arm strength, agility, gait speed and balance in men, and agility and balance in women were more associated with the development of obesity sarcopenia. Similar results have been found in other studies, which indicate irregular physical activity is associated with a higher risk of develop-  (17,20). Loš kvalitet života, posljedice poput invalidnosti i fragilnosti,te nesamostalnost, samo su neke od niza obilježja sarkopenije. Korištenjem konceptualnog modela u prikazu ovakvog hroničnog oboljenja pojednostavljuje se i ukazuje na ozbiljnost problema (21,22,23,24,25).
ing sarcopenia. In addition to sarcopenia and chronic disease, they can also cause physical inactivity due to reduced ability to exercise (decreased cardiorespiratory form and muscle strength), physical limitations, and increased tiredness after exercise (17,20). Poor quality of life, consequences such as disability and fragility, and lack of independence are just some of the many features of sarcopenia. The use of a conceptual model in the presentation of such a chronic disease simplifies and indicates the seriousness of the problem (21,22,23,24,25).
Except for age, other risk factors for sarcopenia include a passive lifestyle, an unhealthy diet, and poor appetite. Adequate nutrition and physical activity during life are the most reliable public health interventions in combating this condition, and adequate intake of proteins, vitamin D, amino acids, and magnesium are of vital importance as well. Experience from practice shows that fragility in the elderly people in Bosnia and Herzegovina is poorly and inadequately tracked, and data on how frequent fragility is in the elderly population and what are the risk factors are very scarce. Regular and detailed assessment of fragility would provide a theoretical framework healthcare professionals could use to develop a comprehensive approach to the assessment and treatment of elderly patients with complex multimorbidity in a simple and acceptable way. Therefore, it is necessary to clearly define an internationally recognized diagnostic method for assessing fragility, define fragility indicators in the elderly people, show how their screening can be done in practice, and then determine which anthropometric biochemical marker will be clinically useful in practice, acceptable to a patient, have high sensitivity and high specificity for the expected outcome, as well as the promising potential for the recommended fragility diagnosis system. Considering we are aware of the importance of timely diagnosis of fragility, we believe the value of this research is extremely important for Bosnia and Herzegovina´s clinical practices.
The research had its shortcomings or weaknesses because the Katz Index of Daily Activities and the Lowton Scale of Instrumental Activities are most often used to assess functional ability, as a detailed assessment of a person's dependence or independence for life skills is used. In our study, the Tinetti test was used to assess gait and balance, on the basis of which potential risk factors for fragility can be determined.
Comparison of some functional and anthropometric parameters as risk factors for gender fragility in the elderly people General Practice 2022;28(1-2):27-36

Conclusion
The study showed a high percentage of people over the age of 65 have poor functional status related to gait and balance, as well as lower values of anthropometric parameters. Lower functional status increases the risk of disability and leads to increased health care needs and increased costs. Male participants had higher upper arm circumference values, while female participants had higher lower leg circumference values. The results obtained by correlation show the influence of anthropometric parameters on the motor abilities of the elderly. Lower functional status and unsatisfactory values of anthropometric parameters are potential risk factors for the development of fragility in the elderly. Prospective studies are necessary to analyze the trigger factors of disability of the elderly people and potential models of care that may contribute to the preservation of the functional capability of geriatric patients.
Comparison of some functional and anthropometric parameters as risk factors for gender fragility in the elderly people General Practice 2022;28(1-2):27-36