Association between bone mass and functional capacity among elderly people aged 80 years and over

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w w w . r b o . o r g . b r

Original

Article

Association

between

bone

mass

and

functional

capacity

among

elderly

people

aged

80 years

and

over

夽

Vanessa

Ribeiro

dos

Santos

a

_,

_Diego

_Giulliano

_Destro

_Christofaro

b

_,

Igor

Conterato

Gomes

c

_,

_Jamile

_Sanches

_Codogno

b

_,

_Lionai

_Lima

_dos

_Santos

b

_,

Ismael

Forte

Freitas

Júnior

a,b,∗

a_Postgraduate_Program_on_Motricity_Sciences,_Universidade_Estadual_Paulista,_Rio_Claro,_SP,_Brazil b_Department_of_Physical_Education,_Universidade_Estadual_Paulista,_Presidente_Prudente,_SP,_Brazil

c_Doctoral_Program_on_Epidemiology_in_Public_Health,_Universidade_de_São_Paulo,_São_Paulo,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17August2012

Accepted28November2012

Keywords:

Aged80andover

Bonedensity

Femur

a

b

s

t

r

a

c

t

Objective:Analyzedtheassociationofbonemasswiththefunctionalcapacityofelderlyaged

80ormore.

Methods:Thesampleconsistedof93elderlyaged80and91years(83.2±2.5years)being61

women(83.3±2.7years)and32men(83.1±2.2years)livinginthecityofPresidentePrudente–

SãoPaulo/Brazil.Theassessmentofbonemasswasrealizedbyabsorptiometrydual-energy

X-ray(DXA),wherehavebeenmeasuredvaluesbonemineralcontent(BMC)andbone

min-eraldensity(BMD)ofthefemurandspine(L1–L4).Thefunctionalcapacitywasevaluatedby

meansofwalkingspeedtests,staticequilibriumandstrengthoflowerlimbscontainedinthe

questionnaireWellnessHealthandAging(SABE).Thevariablesofbonemassandfunctional

capacitywerecategorizedaccordingtothemedianvaluesandscoretests,respectively.For

statisticalanalysiswecarriedoutthechi-squaretest,thesoftwareusedwasSPSS(13.0)and

thesignificancelevelwassetat5%.

Results:Elderlymalewithhigherperformanceinthefunctionaltestsshowedhigherfemur

BMCcomparedtolowerperformance,resultnotfoundwhenevaluatedwomen.

Conclusion:Thus,theboneofthefemurfortheoldestoldmaleisassociatedwithfunctional

capacity.Theconstantassessmentofthebonemineralmassandpractiveofphysicalactivity

throughoutlifewouldbemeasurestopreventfallsintheelderly.

Ltda.Allrightsreserved.

Associac¸ão

entre

massa

óssea

e

capacidade

funcional

de

idosos

com

80 anos

ou

mais

Palavraschave:

Idosode80anosoumais

r

e

s

u

m

o

Objetivo:Analisaraassociac¸ãoentreamassaósseaecapacidadefuncionaldeidososcom

80anosoumais.

夽

WorkperformedattheSchoolofSciencesandTechnology,UniversidadeEstadualPaulista,PresidentePrudente,SP,Brazil.

∗ _{Corresponding}_author.

E-mail:ismael@fct.unesp.br(I.F.FreitasJúnior).

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Conteúdomineralósseo Fêmur

Métodos: Aamostrafoicompostapor93idososentre80e91anos(83,2±2,5anos),61

mul-heres(83,3±2,7anos)e32 homens(83,1±2,2anos)dacidadedePresidentePrudente.A

avaliac¸ãodamassaósseafoifeitapelaabsorptiometriadeduplaenergiaderaiosX(DXA),

naqualforammensuradososvaloresdeconteúdomineralósseo(BMC)edensidade

min-eralóssea(BMD)dofêmuredacoluna(L1–L4).Acapacidadefuncionalfoiavaliadapormeio

dostestesdevelocidadeparacaminhar,equilíbrioestáticoeforc¸ademembrosinferiores

contidosnoquestionárioSaúde,Bem-EstareEnvelhecimento(Sabe).Asvariáveisdamassa

ósseaecapacidadefuncionalforamcategorizadasdeacordocomosvaloresdemedianae

apontuac¸ãoobtidanostestes,respectivamente.Paratratamentoestatísticofez-seoteste

qui-quadrado,osoftwareusadofoiSPSS(13.0)eoníveldesignificânciaestabelecidofoide

5%.

Resultados: Osidososdosexomasculinocommaiordesempenhonostestesfuncionais

apresentarammaioresvaloresdeBMCdefêmurcomparadoscomosdemenordesempenho,

resultadonãoencontradoquandoavaliadasasmulheres.

Conclusão: Dessaforma,amassaósseadofêmurparaidososlongevosdosexomasculino

estáassociadaàcapacidadefuncional.Aavaliac¸ãoconstantedamassamineralósseaea

práticadeatividadefísicaaolongodavidaseriammedidasparaprevenc¸ãodasquedasem

idosos.

EditoraLtda.Todososdireitosreservados.

Introduction

Withincreasinglifeexpectancyandlongevity,occurrencesof

healthcomplication havealsobeen increasing. These may

includediminishedbonemass,whichisgenerallycausedby

disproportionbetweentheactivitiesofosteoclastsinrelation

toosteoblasts,inwhichthereisgreaterconsumptionand/or

lowerproductionofbone.1_This_situation_may_lead_to

devel-opmentofosteoporosisinolderindividuals.

Diminished bone mass and advanced age can be

con-sidered to be two of the main risk factors for fractures.2

Bonefracturesareoneofthemaincausesofmorbidity,

mor-talityand hospitalization amongthe elderly and represent

oneofthe biggestpublic healthproblems.3 _However,_their

developmentandconsequencescanbereducedbyadopting

preventivestrategiessuchasexaminationusingthetechnique

ofdual-energy X-rayabsorptiometry(DXA),whichwas

cre-atedinthe1980s.4_This_has_the_capacity_to_provide_precise

bone mineral density (BMD) measurements and thus may

contributetowardsorganizingstrategiesformaintainingBMD

withinappropriatevalues.

Diminishedbonemassalsohasaninfluenceonthe

func-tionalstateofolderindividuals.5_One_of_the_options_for_easing

thephysiologicalalterationsthatoccurinthe

musculoskele-tal system due to the aging process, and for maintaining

functionalcapacity,istoregularlypracticephysicalexercise

throughoutlife.Exercisecausesweighttobeplacedon

spe-cificboneregions,whichgeneratestensionordeformationas

anexternalstimulusandprovidesanosteogeniceffect.6

For better diagnosis, it is important to choose the best

regionsfordetermining bonemass.The lumbarspineand

thetotalfemurarethemostpreciselocalities.7_It_also_needs

tobeemphasizedthatwithadvancingage,oneofthe

great-estfractureratesamongelderlypeopleisintheregionofthe

femur.7,8_However,_there_is_a_scarcity_of_studies_in_the

litera-tureinvestigatingtherelationshipbetweenbonemassinthe

totalfemurandlumbarspineregionsandfunctionalcapacity

amongelderlypeopleaged80yearsandover.Thus,theaim

ofthepresentstudywastoanalyzetheassociationbetween

bonemassandfunctionalcapacityamongelderlypeopleaged

80yearsandover.

Material

and

Methods

Sampling

Thiswasastudywithacross-sectionaldesignthatwas

con-ducted inthe city ofPresidentePrudente betweenOctober

2009andMay2010.Thiscityhas210,000inhabitants9_and_is

locatedinthewestofthestateofSãoPaulo,withaHuman

DevelopmentIndex(HDI)of0.846(ranked14thinthestate).10

AccordingtotheBrazilianInstituteforGeographyand

Statis-tics(IBGE),thenumberofBraziliansaged80yearsandover

waspredictedtobe2,653,060in2009,i.e.1.1%ofthecountry’s

population.Fromthisprinciple,thecurrentestimateforthe

numberofelderlypeoplewithinthisagegroupinPresidente

Prudenteis2100inhabitants.TheMunicipalHealth

Depart-mentsuppliednames,addressesandtelephonenumbersof

individualsaged80yearsandover.Fromthisinformation,226

individualswererandomlydrawnandwerecontactedby

tele-phone.Thosewhowereunabletowalk,werebedridden,lived

intheruralzone,wereinstitutionalizedorusedpacemakers,

andthosewhosedatainourdatabasewereincomplete,were

excludedfromthesample.Inthismanner,thesampleforthe

presentstudywascomposedof93individualsofbothsexes.

The individuals who were invited to participate in the

present studyweregivenexplanationsaboutthe objectives

ofthestudyandthemethodologyusedtogatherdata,and

theyweretoldthattheycoulddropoutofthestudyatany

time.Onlythosewhosignedthefreeandinformedconsent

statementformedpartofthesample.Alltheprotocolswere

reviewedandapprovedbytheResearchEthicsCommitteeof

UniversidadeEstadualPaulista(Proceduralnumber26/2009).

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participatinginthestudyhadaccesstotheresultsfromthe

teststhattheyunderwent.

BoneMass(FemurandSpine)

Toanalyzethebonemassofthetotalfemurandlumbarspine

(L1–L4),a dual-energyX-rayabsorptiometry(DXA)machine

wasused(Lunar,modelDPX-MD;software4.7).TheDXA

tech-niqueisbasedonmeasuringtheattenuationbythepatient’s

body,ofabeamofradiation generatedby anX-raysource

withtwo energylevels. Theexposureto radiation islower

thanthatofconventionalX-rayexaminations.Thetechnique

makesitpossibletoestimatethe bonemassforthe entire

bodyand perbody segment.Thedurationofthe

examina-tion isapproximately15min.Themeasurementmethod is

simpleanddoesnotrequireanyassistancefromthe

individ-ualunderevaluation,whoshouldremainpositionedindorsal

decubitus,withoutmakingmovements insidethemachine.

Theresultsweretransmittedtoacomputerthatwas

intercon-nectedwiththeapparatus.Thebonemineralcontent(BMC)

andbonemineraldensity(BMD)weresubsequentlyanalyzed

andcategorizedaccordingtomedianvalues.Elderly

individ-ualswhoseBMCandBMDwereabovethemedianvalueswere

consideredtohavehigherBMCandBMD,whilethosebelow

themedianwereconsideredtohavelowerBMCandBMD.

FunctionalCapacity

Functionalcapacitywasanalyzedbymeansofthe testson

staticbalance,walking speed and lower-limbstrength that

appearinsectionLoftheSABEquestionnaire.11_The_balance

testhadthreestages,whichweredoneinsequence(10seach).

Inthefirststage,theelderlyindividualneededtostandup,

withfeettogether;inthesecondstage,standwiththeheelof

onefootnexttothebigtoeoftheotherfoot;andinthethird

stage,standwithonefootinfrontoftheother.Thescores

fromthethreestagesweresummedandthefinalresultwas

obtainedfromthesum.

Inthewalkingtest,theelderlyindividualneededtowalk

forthreemetersatthesamespeedusedtoperformhisdaily

activities.Thetimetakenwasmeasuredandregisteredbythe

evaluators.

Toevaluatelower-limbstrength,the testofstandingup

from andsitting downon achairwasapplied. Inthis,the

elderlyindividualhadtokeephisarmscrossedonhischest

andthen,onasignalfromtheevaluator,hadtostandupfrom

andsitdownonachairasquicklyaspossible,fivetimes

with-outanypause.Individualswhowereunabletodothetestin

lessthan60sweredisqualified.

Thescoresforeachtestrangedfrom0to4points.To

clas-sifytheelderlyindividuals’performance,thesumofthescores

obtainedinthethreetestswasused.Individualswere

consid-eredtopresentlowerfunctionalcapacityiftheirscorewas0–2

points,andhighercapacityiftheirscorewas3–4points.

StatisticalAnalysis

For the numerical variables, the normality of the dataset

was analyzed using the Kolmogorov–Smirnov (K–S) test.

SincethedatafittedintoaGaussiandistributionmodel,the

Table1–Descriptionofthesample,accordingtosex.

Variables Mean± SD P

Male(n=32) Female(n=61)

Age(years) 83.1±2.2 83.3±2.7 0.684

Weight(kg) 71.5±15.6 57.4±11.1 ≤0.001

Height(cm) 164.3±7.1 149.8±6.8 ≤0.001

FemoralBMC(g) 33.1±6 23.0±5.6 ≤0.001

SpinalBMC(g) 73.3±19.3 45.1±12.5 ≤0.001 FemoralBMD(g/cm2₎ _0.89_±_0.14 _0.74_±_0.15 _≤_0.001 SpinalBMD(g/cm2₎ _1.16_±_0.24 _0.93_±_0.17 _≤_0.001

BMC:bonemineralcontent;BMD:bonemineraldensity.

descriptive statistical analysiswas composed ofmean val-ues(centraltrend)andstandarddeviations(dispersion).The individualsweredistributedaccordingtosexandthemean values for each variable were compared according to sex, withanalysis bymeansofStudent’st-testforindependent samples.

The chi-square test was used to test the association between performance in the functional capacity tests and bonemass.ThestatisticaltreatmentwasdoneusingtheSPSS software(SPSSInc.,Chicago,IL,USA),version13.0,and the significancelevelwassetat5%.

Results

The values presented in Table 1 are expressed as means

and standard deviationsof the generalcharacteristics and

variables ofthebonemassofthesamplestudied,stratified

accordingtosex.Therewasnodifferenceregardingtheage

oftheelderlypeopleparticipatinginthestudy.Thevariables

of weight, height, femoral BMC, spinal BMC, femoralBMD

and spinalBMD (P≤0.001)presented significant differences

betweenthegroups.

In Table 2, the percentage values of the associations

betweenthevariablesofbonemassandperformanceinthe

threefunctional tests,according tosex,arepresented.The

elderlymenwithbetterperformanceinthefunctionaltests

presented higher femoralBMC valuesthan did those with

worseperformance(P≤0.001),whiletherewerenosignificant

differences relatingtothe variablesofspinalBMC,femoral

BMDorspinalBMD.Inthefemalegroup,therewereno

differ-encesinperformanceinthefunctionaltestsinrelationtothe

bonemassvariables.

betweenthebonemassvariablesandtheperformanceineach

ofthefunctionaltestsinthemalegrouparepresented.The

elderlymenwithbetterperformanceinthespeedandbalance

testspresentedhigherfemoralBMCvaluesthandidthosewith

worseperformance(P=0.009and0.006,respectively).The

vari-ables ofspinalBMC,femoralBMDand spinalBMDdidnot

presentsignificanceinanyofthetests.

betweenthevariablesofbonemassandtheperformancein

eachofthefunctionaltestsinthefemalegrouparepresented.

Therewerenodifferencesinperformanceinthefunctional

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Table2–Associationbetweenbonemassandperformanceinthethreefunctionaltestsonelderlypeopleofbothsexes.

Bonemass Male Female

Performanceinthetests P Performanceinthetests P

Worse Better Worse Better

FemoralBMC(g)

Low 81.3% 18.7% ≤0.001 54.8% 45.2% 0.705

High 18.8% 81.2% 50% 50%

SpinalBMC(g)

Low 56.3% 43.7% 0.480 61.3% 38.7% 0.160

High 43.8% 56.2% 43.3% 56.7%

FemoralBMD(g/cm2₎

Low 64.7% 35.3% 0.077 55.3% 44.7% 0.573

High 33.3% 66.7% 47.8% 52.2%

SpinalBMD(g/cm2₎

Low 50% 50% 1.000 57.6% 42.4% 0.311

High 50% 50% 44.4% 55.6%

Discussion

Decreasesinbonemassinhumansstarttooccuraroundthe ageof40years.12_If_no_preventive_action_is_taken,_this_process

maycontributetowardsdevelopmentofosteoporosis.13

BMDistheindicatormostusedforanalyzingbonemass

andfordiagnosingosteoporosis.7,14,15_However,_in_addition_to

BMD,BMC isalsoagoodindicator forboneloss.Itsuse is

important,becauseittakesintoconsiderationmorethanjust

themorphologicalbasisofboneloss(diminutionofperiosteal

appositionandendostealboneloss,whichrelatestolossfrom

thetrabecular, endocorticalandintracorticalsurfaces).16 _In

thestudybyGuptaet al.12 _on_{postmenopausal}_women,_the

BMCreducedsignificantlywithage.Inourstudy,thefemoral

BMCoftheveryelderly oldmenwas thebonecomponent

thatwasmostassociatedwithfunctionalcapacity.Oneofthe

possiblefactorsisthatthefemuristhebiggestboneofthe

lowerlimbsinhumansandthusaidsinlocomotion,posture

andbalance.Withtheboneinthisimportantregion

compro-mised,performingsomemotoractivitieslikewalkingbecame

moredifficult,therebyincreasingtheriskoffallsandfractures.

Bonemassisoneofthemaindeterminantsoffractures,but

onlyafewstudiessofarhaveanalyzedthisinoldermen.16–18

Thisisanalarmingsituation,giventhattheBrazilian

Osteo-porosisConsensusof2002(PintoNetoetal.19₎_indicated_that

advancedageincreasestheriskofosteoporosisandfractures,

independentofsex.Thus,evaluationsonmenofadvanced

agebecomeessential.

Regarding evaluationof functional capacity, Kärkkäinen

et al.20_conducted_an_eight-year_follow-up_study _and_found

that therewas anassociation between functional

incapac-ity and increased risk offractures amongpostmenopausal

women. Although the incidence of fractures is greater in

Table3–Associationbetweenbonemassandfunctionalperformanceinmen.

Bonemass Performanceinthetests

Speed P Balance P Lower-limbstrength P

Worse Better Worse Better Worse Better

FemoralBMC(g)

Low 87.5% 12.5% 0.009 50% 50% 0.006 81.3% 18.8% 0.127

High 43.8% 56.3% 6.3% 93.8% 56.3% 43.8%

SpinalBMC(g)

Low 68.8% 31.3% 0.710 31.3% 68.8% 0.694 68.8% 31.3% 1.000

High 62.5% 37.5% 25% 75% 68.8% 31.3%

Low 76.5% 23.5% 0.169 29.4% 70.6% 0.863 76.5% 23.5% 0.316

High 53.3% 46.7% 26.7% 73.3% 60% 40%

Low 72.2% 27.8% 0.373 27.8% 72.2% 0.960 55.6% 44.4% 0.068

High 57.1% 42.9% 28.6% 71.4% 85.7% 14.3%

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Table4–Associationbetweenbonemassandfunctionalperformanceinwomen.

Bonemass Performanceinthetests

Speed P Balance P Lower-limbstrength P

Worse Better Worse Better Worse Better

FemoralBMC(g)

Low 71% 29% 0.717 41.9% 58.1% 0.332 77.4% 22.6% 0.510

High 66.7% 33.3% 30% 70% 70% 30

SpinalBMC(g)

Low 77.4% 22.6% 0.142 35.5% 64.5% 0.923 74.2% 25.8 0.939

High 60% 40% 36.7% 63.3% 73.3% 26.7

Low 68.4% 31.6% 0.925 39.5% 60.5% 0.476 76.3% 23.7% 0.561

High 69.6% 30.4% 30.4% 69.6% 69.6% 30.4%

Low 66.7% 33.3% 0.759 36.4% 63.6% 0.807 72.7% 27.3% 0.907

High 70.4% 29.6% 33.3% 66.7% 74.1% 25.9%

women,therelativeriskandtheconsequencessubsequent tothefracturearemoresevereinmen.21,22

InthestudyconductedbySakaietal.,23_it_was_found_that

performanceinthebalancetestonasinglefootwasassociated

withBMDamongJapanesewomenaged30–82years.Similar

resultswerealsofoundbyTaaffeetal.,24_who,_in_a_study_on

elderlypeopleofbothsexes,observedthattheirperformance

intestsonsittingdownonandgettingupfromchairsandon

balancingononefootwasonlyrelatedtofemoralneckBMD

andtrochantericBMD,respectively.Inourstudy,inthefemale

group,therewasnoassociationbetweenbonemassand

per-formance intestson sitting downon and gettingup from

chairsandonbalance.Thisresultmayindicatethatforelderly

womeninthisagegroup,othercomponentsofbody

composi-tion,suchasfat,aremoreassociatedwithfunctionalcapacity

(Rechetal.25_),_given_that_women_present_greater_quantities_of

bodyfat,whichgeneratesamechanicaloverloadonthebones

andmaycontributetowardsmaintainingBMD.26

Theusualwalkingspeedwasassociatedwithfemoralneck

BMDinWhite womenaged57–88, inastudy byBrownbill

etal.,27_and_with_forearm_BMD_in_{postmenopausal}_Japanese

womeninalongitudinalstudybyKwonetal.28_Lindsey_et_al.29

foundanassociationbetweenwalkingspeedandhip,spinal,

forearmandtotalBMDinagroupofwomenofmeanage68

years.Inthepresentstudy,noassociationwasfoundbetween

bone mass and performance inthe test on usual walking

speed,amongtheveryelderlyoldwomen.

In studies such as that of Kärkkäinen et al.,30 _it _was

observedthat women withfemoralneck osteoporosis

pre-sented diminished functional capacity. In our study, no

association was observed between bone mass and

perfor-manceinany ofthe functional tests, inthe femalegroup.

Thisevidencemaysignify thatforelderly womenoverthe

ageof80years,bonemassmayhavelessinfluenceon

func-tionalcapacitythanforwomenoflowermeanage.Thiswas

observedbyMilleretal.31_in_a_study_on_men,_and_the_results

revealedthattherelationshipbetweenmusclestrengthand

aerobiccapacitywasstrongeramongmiddle-agedmenthan

amongoldmen.

Inthe presentstudy,thefunctional capacityofthe very

elderly oldmenwas associatedwiththe bonemassofthe

femur,butnotwiththebonemassofthespine.Whenthe

per-formanceofthemalegroupineachofthefunctionaltestswas

analyzed,thebonemassofthefemurwasfoundtobe

asso-ciatedwiththewalkingspeedandbalancetests.Kärkkäinen

etal.30_showed_this_relationship_between_the_balance_test_and

thefemoralandspinalbonemassinpostmenopausalwomen.

InthestudyconductedbyMilleretal.,31_the_BMC_of_some_body

regionssuchasthespine,pelvisandlegswascorrelatedwith

lower-limbstrengthamongmiddle-agedmen,buttherewas

nocorrelationbetweenthesevariablesamongelderlymen.In

ourstudy,therewasnoassociationbetweentotalfemurand

lumbarspinebonemassandperformanceinthelower-limb

strengthtestamongtheveryelderlyoldmen.

AccordingtoCawthonetal.,32_the_decrease_in_bone_mass

among men over the age of 85 years istwice as great as

among 65-year-old men. This finding explains our results,

sincesevere lossofbonemass(BMD andBMC)also

inten-sifies thediminution offunctionalcapacity. Another factor

thatreinforcesourfindingsisthatseverebonelossand

occur-rencesofosteoporosisarerelatedtohormonelevels.Whereas

women’s estrogenlossesbegin aroundthe ageof50years,

men’stestosteronepersistsatfunctionallevelsuntilthe

sev-enthdecadeoflife.33

Theprevalenceofosteoporosisandtheincidenceof

osteo-porotic fractures are less frequentinmenthan inwomen.

Thisis becauseBMDand bonesizeare greater, and

there-forebonesarestrongerinmenthaninwomen,34_as_observed

inoursample.However,increasingnumbersofmenare

pre-sentingosteoporosis,alongwiththecomplicationscausedby

thisdisease(falls,fracturesandfunctionalincapacity).

One of the limitations of our study was the absence

of other physical tests, such as tests on manual grip

strength, flexibility and coordination, in order to analyze

functional capacity. However, it is emphasized that there

is still a scarcity of studies aimed towards investigating

thesecharacteristicsamongelderlypeopleovertheageof80

(6)

Conclusion

Thus,thefemoralbonemassofveryelderlyoldmenwas

asso-ciatedwithfunctionalcapacity.Preventivemeasures,suchas

physicalactivitypracticethroughoutlifetargetingbonemass

preservation,shouldbeencouraged.Itshouldalsobe

empha-sizedthatassessmentofbonemineralmassamongelderly

peopleneedstobedoneconstantlywithadvancingage,since

thiswouldbeameansofworkingtowardspreventionoffalls,

whichhavehighprevalenceamongtheelderly.Althoughthere

wasnorelationshipamongfemales,limitationssuchasthe

absenceofothertestsandlackofassessmentofdietary

pro-cedures,suchastheuseofcalciumsupplementsamongsome

elderlywomen, may have contributed towardsthe present

findings.

Conflicts

of

Interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Theauthors thank the National Councilfor Scientific and

TechnologicalDevelopment(CNPq)forfinancialsupportfor

thisstudy.

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