Sarcopenia in older adults: Prevalence and links to depression and physical activity

Abstract

BACKGROUND

Sarcopenia, a common debilitating geriatric syndrome, is frequently accompanied by depression and physical inactivity, forming a detrimental cycle that accelerates functional decline. However, hospital-based data on these interrelationships among Chinese older adults remain limited. This study aimed to determine the prevalence of sarcopenia in geriatric in- and out-patients and to test the hypothesis that sarcopenia is independently associated with higher depression scores and lower objectively measured physical activity.

AIM

To determine sarcopenia prevalence and its associations with depression and physical activity in older adults.

METHODS

In this cross-sectional study, 346 adults aged ≥ 60 years were recruited via convenience sampling from geriatric departments of hospitals. Data were analyzed using SPSS 26.0. Descriptive statistics, t-tests, χ² tests, Spearman correlation, and binary logistic regression were employed to examine group differences, variable associations, and independent predictors of sarcopenia.

RESULTS

Sarcopenia was identified in 62/346 participants (17.92%). Significant inter-group differences emerged for age, body mass index (BMI), coronary artery disease, hypertension, appendicular skeletal muscle mass index (ASMI), grip strength, and 6-m gait speed (P < 0.05). Individuals with sarcopenia reported markedly lower physical activity: A higher prevalence of low activity and lower Physical Activity Scale for the Elderly (PASE) scores (P < 0.001). Spearman correlations revealed ASMI, grip strength, and gait speed were inversely related to depressive symptoms, while positively linked to physical activity (P < 0.01). Logistic regression confirmed 30-item Geriatric Depression Scale and PASE scores independently predicted sarcopenia after adjustment for age, BMI, coronary artery disease, and hypertension (P < 0.05).

CONCLUSION

Sarcopenia is linked to depression and physical inactivity in elderly inpatients, supporting the need for integrated screening and comprehensive management in clinical practice.

Key Words: Elderly people; Sarcopenia; Epidemiology; Depression; Physical activity level; Correlation

Core Tip: This study explores the relationship between sarcopenia, depressive symptoms, and physical activity levels in older adults. It highlights the high prevalence of sarcopenia and its association with mental health and lifestyle factors. Depressive symptoms may worsen muscle loss, while appropriate physical activity, especially resistance and aerobic exercises, can help prevent and alleviate the condition. The findings aim to support early detection and targeted interventions, offering important insights for public health strategies.

INTRODUCTION

As the global aging process accelerates, sarcopenia has become an important public health issue in the domain of elderly medicine[1,2]. Global data indicate sarcopenia affects roughly 10%-27% of adults aged ≥ 60 years and up to 50% of those ≥ 80 years[3,4]. Currently, over 50 million people live with the condition, and projections suggest this figure could exceed 200 million by 2050[5]. China, home to the world’s largest older population, faces an especially pressing challenge in sarcopenia prevention and care[6]. Relevant epidemiological survey results show that there are obvious regional and racial differences in the frequency of sarcopenia in seniors in China. The overall prevalence stands at about 19.31%, and it shows a significant upward trend with age[7].

The connection between sarcopenia and lifestyle and mental health has been the subject of an increasing number of research in recent years[8,9]. One of the most prevalent psychological issues among the elderly is depression. It not only affects the emotional state and cognitive function of the elderly, but also may further aggravate muscle loss and functional degeneration by affecting appetite, activity willingness and social participation. Research has indicated that individuals with sarcopenia had a much higher prevalence of depressive symptoms than those without the condition, which may indicate a reciprocal or interacting relationship between the two[10].

In addition, physical activity, as an important protective factor for maintaining muscle mass and function, has been widely recognized to have a preventive effect on sarcopenia. Physical activity refers to all physical behaviors that promote skeletal muscle contraction and thus increase resting energy consumption. Low, medium, and high are the three intensity levels into which it can be separated. It can also be divided into two types according to nature: Non-leisure types such as work, housework, and commuting, and leisure types such as physical exercise. The risk of sarcopenia can be decreased by engaging in appropriate physical activity, particularly resistance training and frequent aerobic exercise, which helps preserve or build muscle mass, improve muscle strength, and enhance physical function[11,12].

Evidence on how sarcopenia, depression, and physical activity intersect in older adults remains scarce, and hospital-based geriatric data are particularly sparse. So, we conducted a cross-sectional study of in- and outpatients aged ≥ 60 years in the geriatric unit of our hospital, mapping the prevalence of sarcopenia and its links to depressive symptoms and activity levels. The results are intended to inform earlier detection, targeted intervention, and improved management of sarcopenia in this population.

MATERIALS AND METHODS

General information

From January 2024 to June 2024, 346 patients who satisfied the inclusion criteria in the geriatric department of the Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University were chosen as research participants using the convenience sample method. Inclusion criteria: (1) Age ≥ 60 years old; (2) Able to perform basic daily activities; and (3) Voluntarily participate in the study and sign the informed consent. Exclusion criteria: (1) Those who have recently taken drugs that affect muscle function; (2) Those with cognitive impairment; or (3) Those who are unable to cooperate with this study due to physical limitations.

Research methods

General information: Baseline characteristics gathered encompassed age, sex, body mass index (BMI), education, marital and living arrangements, income, and histories of coronary artery disease, hypertension, and diabetes.

Diagnostic criteria and detection methods for sarcopenia: Following the Asian Working Group for Sarcopenia 2019 criteria[13,14], sarcopenia is identified when low muscle mass is accompanied by either weak strength or poor physical performance: (1) Low mass: Appendicular skeletal muscle mass (ASM) index (ASMI) < 7.0 kg/m² (men) or < 5.7 kg/m² (women); (2) Weak strength: Grip < 28 kg (men) or < 18 kg (women); and (3) Impaired performance: 6-m gait speed ≤ 1.0 meter/second. Diagnosis requires low mass plus at least one of the other two deficits.

ASMI measurement: The individuals' ASM was determined using a body composition analyzer (InbodyS10). Before the measurement, the subjects were required to avoid strenuous exercise, drinking or eating a lot of water, and emptying their bladder. The calculation formula was: ASMI = ASM (kg)/height² (m²).

Grip strength test: A CAMRY EH101 spring-type electronic handgrip dynamometer was used for the test. With their dominant arm hanging naturally at a 15° angle to the body and their feet naturally spaced apart, the individuals stood erect. They gripped the hand with the greatest possible strength. The test was conducted twice with an interval of 15 seconds. The larger value of the two measurements was taken as the maximum grip strength result. The result was accurate to 0.1 kg.

6-m gait speed test: The subjects walked through the test area twice at their normal walking speed, with an interval of 1 minute between the two times. The average value was taken as the final result, and the result was accurate to 0.01 meter/second.

Geriatric depression scale: The 30-item Geriatric Depression Scale (GDS-30) is a self-report screen for late-life depressive symptoms. Originally developed by Brink et al[15] and refined by Yesavage et al[16], its validated Chinese version[17] was employed here. Each yes/no item contributes 1 point-20 positively keyed, 10 negatively keyed-for a maximum of 30; higher scores indicate greater symptom severity. Cut-offs: (1) 0-10 = no depression; (2) 11-20 = mild depression; and (3) 21-30 = moderate-to-severe depression.

Physical activity scale: The Physical Activity Scale for the Elderly (PASE) scale, developed by Washburn et al[18] in 1993 for geriatric epidemiology, was translated and culturally adapted into Chinese by Ngai et al[19], who reported an intraclass correlation of 0.81 for test-retest reliability; the validated Chinese version was applied here to gauge older adults’ physical activity. The scale consists of three parts: Physical exercise, household physical activity, and occupational physical activity, with a total of 26 items. A weighted scoring system is used for calculation. The total score usually ranges from 0 to 400 points, and the score is positively correlated with the level of physical activity. In specific applications, researchers often use the average total PASE score of the survey sample as a benchmark to divide the physical activity level into three levels: Low level (< 50% of the average), medium level (50%-150% of the average), and high level (≥ 150% of the average).

Quality control: This study used strict quality control measures to ensure data reliability. All researchers were uniformly trained and used standardized assessment tools and processes. During the survey, the researchers clarified the goal of the investigation and the requirements for filling out the questionnaire in detail. After obtaining informed consent, trained investigators guided the elderly to fill out the questionnaire (face-to-face interviews were used to assist illiterate people). The questionnaires were collected and checked for completeness on the spot, and missing items were filled in in a timely manner. Data were entered by two people, and statistical analysis was independently verified by two researchers.

Statistical analysis

All analyses were performed with SPSS 26.0. Continuous variables are reported as mean ± SD and compared by independent-sample t-tests; categorical data are expressed as n (%) and compared with χ² tests. Associations among sarcopenia, depression, and physical activity were examined using Spearman correlation and binary logistic regression. Statistical significance was set at P < 0.05.

RESULTS

Current epidemiological status of sarcopenia

This study enrolled 346 older patients aged ≥ 60 years, with 62 (17.92%) identified as having sarcopenia, a finding consistent with the condition's real-world prevalence. Significant between-group differences were observed in age, BMI, coronary heart disease, hypertension, ASMI, grip strength, and 6-m gait speed (all P < 0.05). Patients with sarcopenia were predominantly aged 70-79 years (51.62%), and the proportion aged ≥ 80 years was larger than in the non-sarcopenia group (8.06% vs 3.87%), indicating that sarcopenia is more prevalent among the older old. Rates of low body weight (4.84% vs 0.70%), coronary heart disease (35.48% vs 20.42%), and hypertension (56.45 % vs 39.44 %) were also elevated in the sarcopenia group (Table 1).

Table 1 General conditions of both groups.

Project	Sarcopenia (n = 62)	Non-sarcopenia (n = 284)	χ2/t value	P value
Age (years)			14.133	0.001
60-70	25 (40.32)	187 (65.85)
70-79	32 (51.62)	86 (30.28)
≥ 80	5 (8.06)	11 (3.87)
Gender			0.078	0.780
Male	25 (40.32)	120 (42.25)
Female	37 (59.68)	164 (57.75)
BMI			33.777	< 0.001
Low body weight	3 (4.84)	2 (0.70)
Normal weight	45 (72.58)	108 (38.03)
Overweight or obese	14 (22.58)	174 (61.27)
Education			0.913	0.339
Primary school and below	47 (75.81)	198 (69.72)
Junior high school and above	15 (24.19)	86 (30.28)
Marital status			0.002	0.961
Married	45 (72.58)	207 (72.89)
Divorced/widowed/single	17 (27.42)	77 (27.11)
Income			2.678	0.102
Unable to afford daily life	5 (8.06)	46 (16.20)
Can afford a normal life	57 (91.94)	238 (83.80)
Living status			0.506	0.477
Living alone	8 (12.90)	28 (9.86)
Living with relatives	54 (87.10)	256 (90.14)
Coronary heart disease			6.494	0.011
Have	22 (35.48)	58 (20.42)
None	40 (64.52)	226 (79.58)
Hypertension			6.029	0.014
Have	35 (56.45)	112 (39.44)
None	27 (43.55)	172 (60.56)
Diabetes			0.133	0.715
Have	8 (12.90)	32 (11.27)
None	54 (87.10)	252 (88.73)
Sarcopenia evaluation index
ASMI (kg/m2)	5.23 ± 0.66	7.49 ± 0.69	23.591	< 0.001
Grip strength (kg)	18.19 ± 8.48	27.64 ± 7.89	8.428	< 0.001
6-m pace (meter/second)	0.61 ± 0.10	0.93 ± 0.22	17.539	< 0.001

Data were showed as n (%) or mean ± SD. BMI: Body mass index; ASMI: Appendicular skeletal muscle mass index.

Depression in the elderly

Regarding depressive symptoms, the proportion of mild depression was higher in the sarcopenia group than in the non-sarcopenia group (32.26% vs 16.55%), and the proportion of moderate-to-severe depression remained higher in the sarcopenia group (14.52% vs 7.39%). The GDS-30 scores in the sarcopenia group were significantly higher than those in the non-sarcopenia group (P < 0.001), indicating that sarcopenia patients are more prone to depressive symptoms. This result suggests that there may be a close relationship between sarcopenia and depression, and sarcopenia patients need more psychological attention and intervention (Table 2).

Table 2 Depression in both groups.

Project	n	No depression	Mild depression	Moderate to severe depression	GDS-30 score (points)
Sarcopenia	62	33 (53.23)	20 (32.26)	9 (14.52)	13.11 ± 6.88
Non-sarcopenia	284	218 (76.76)	46 (16.55)	20 (7.39)	9.10 ± 6.36
χ2/t value		14.159			4.224
P value		0.001			< 0.001

Data were showed as n (%) or mean ± SD. GDS-30: 30-item Geriatric Depression Scale.

Physical activity levels of the elderly

Sarcopenic participants were markedly less active: 27.42% recorded low activity vs only 2.46% of non-sarcopenic peers, whereas just 3.23% achieved high activity compared with 11.97% in the comparator group. Their mean PASE score was also significantly lower (P < 0.001), underscoring that reduced physical activity is both a likely risk factor for, and a potential target in, preventing or mitigating sarcopenia (Table 3).

Table 3 Physical activity levels between both groups.

Project	n	Low physical activity levels	Moderate physical activity level	High physical activity level	PASE score (points)
Sarcopenia	62	17 (27.42)	43 (69.35)	2 (3.23)	93.53 ± 39.93
Non-sarcopenia	284	7 (2.46)	243 (85.56)	34 (11.97)	125.24 ± 43.29
χ2/t value		51.046			5.296
P value		< 0.001			< 0.001

Data were showed as n (%) or mean ± SD. PASE: Physical Activity Scale for the Elderly.

Correlation analysis between sarcopenia, depression and physical activity level in the elderly

Spearman analysis revealed that, among older adults with sarcopenia, ASMI, grip strength, and 6-m gait speed were all inversely related to depression (r = -0.829, r = -0.749, and r = -0.331, respectively; P < 0.001, P < 0.001, and P = 0.009, respectively; Figure 1A). Conversely, the same three metrics were positively associated with physical activity (r = 0.804, r = 0.784, and r = 0.334, respectively; P < 0.001, P < 0.001, and P = 0.008, respectively; Figure 1B). All correlations were large in magnitude (|r| > 0.7) except for gait speed vs depression (r = -0.331, medium effect).

Figure 1 Correlation analysis between sarcopenia and depression and between sarcopenia and physical activity level. A: Sarcopenia and depression; B: Sarcopenia and physical activity level. ASMI: Appendicular skeletal muscle mass index; GDS-30: 30-item Geriatric Depression Scale; PASE: Physical Activity Scale for the Elderly.

Binary logistic regression analysis of sarcopenia, depression, and physical activity level in the elderly

The dependent variable in the univariate logistic regression analysis was whether the elderly developed sarcopenia, and P < 0.05 in the preceding table were included (Table 4). It was found that the GDS-30 score and PASE score were correlated with the occurrence of sarcopenia. This link maintained regardless of modifying for distracting factors such as age, BMI, hypertension, and coronary heart disease (Table 5).

Table 4 Univariate logistic regression analysis.

Variable	β	SE	Wald	OR (95%CI)	P value
Age (year)
60-70	-	-	1.640	1	0.440
70-79	0.156	0.564	0.076	1.168 (0.357-3.531)	0.783
≥ 80	1.075	1.229	0.766	2.930 (0.263-32.585)	0.382
BMI
Low body weight	-	-	50.061	1	< 0.001
Normal weight	-4.612	6.376	0.523	0.010 (0.001-26.110)	0.469
Overweight or obese	-9.631	6.463	2.221	0.001 (0.001-20.828)	0.136
Coronary heart disease	0.094	0.584	0.026	1.098 (0.350-3.449)	0.872
Hypertension	0.018	0.507	0.001	1.018 (0.377-2.752)	0.972
GDS-30 score	0.205	0.077	7.058	1.227 (1.056-1.427)	0.008
PASE score	-0.094	0.018	27.243	0.911 (0.879-0.943)	< 0.001

OR: Odds ratio; 95%CI: 95% confidence interval; BMI: Body mass index; GDS-30: 30-item Geriatric Depression Scale; PASE: Physical Activity Scale for the Elderly.

Table 5 Multivariate logistic regression analysis.

Variable	β	SE	Wald	OR (95%CI)	P value
GDS-30 score	0.495	0.213	5.401	1.640 (1.081-2.490)	0.020
PASE score	-0.027	0.008	10.870	0.973 (0.958-0.989)	0.001

OR: Odds ratio; 95%CI: 95% confidence interval; GDS-30: 30-item Geriatric Depression Scale; PASE: Physical Activity Scale for the Elderly.

DISCUSSION

This study was a cross-sectional survey, involving 346 patients aged 60 years and above in the geriatric department of our hospital. The prevalence of sarcopenia was 17.92%, which is similar to the results of most similar studies at home and abroad, but slightly higher than some community reports. This difference may be due to regional heterogeneity[20] and the high-risk characteristics of elderly patients in our hospital due to multiple comorbidities and limited activities. Intergroup comparison showed that sarcopenic patients were significantly worse than the non-sarcopenic group in terms of age, BMI, grip strength, gait speed, ASMI, etc., and had more severe depressive symptoms and lower physical activity levels. Correlation and binary logistic regression analysis further confirmed that depression level and physical activity level were independent related factors of sarcopenia.

The above findings reveal a close interactive relationship between sarcopenia, depression, and insufficient physical activity. Its internal mechanism may constitute a two-way loop pathway: On the one hand, the decline in physical function caused directly by sarcopenia will significantly limit the daily activities and social participation of the elderly, which can easily induce or aggravate their depression; on the other hand, the persistent depressive state will reduce the individual's appetite and intrinsic motivation for exercise, leading to insufficient dietary protein intake and a significant reduction in physical mechanical load, further exacerbating the loss of muscle mass and functional decline from the metabolic and behavioral levels[21]. This complex pathophysiological pathway has also been supported by many studies. For example, the study by Liu et al[22] revealed that depression plays a key mediating role between loneliness and sarcopenia; and a 12-year follow-up study by Veronese et al[23] further confirmed that sarcopenia itself is the main factor driving its association with osteosarcopenia and depression. Of course, it should be pointed out that the strength and manifestation of the association between depression and sarcopenia may also be potentially regulated by a variety of external and internal factors such as social support networks and comorbidity burden[24].

At the intervention and management level, this study clearly showed that there is a significant dose-response relationship between physical activity level and various indicators of sarcopenia. The study by Merchant et al[25] provides strong evidence for this, indicating that a structured dual-task exercise program can effectively improve gait speed and reduce the risk of impaired grip strength. Currently, the research paradigm in this field is undergoing a profound transformation, that is, from the previous training model that focused on single strength gain to a multidimensional intervention strategy that integrates "exercise factors-epigenetic-cognitive decline", and has begun to use artificial intelligence algorithms to generate highly personalized exercise load prescriptions[26]. Based on this trend, in clinical practice, medical staff should design a progressive multimodal program that integrates resistance training, balance exercises and cognitive stimulation for individuals based on the results of a comprehensive elderly physical fitness assessment; at the community support level, it is necessary to add infrastructure such as barrier-free trails, fitness corners equipped with elastic bands, and smart fitness stations that integrate feedback technology, aiming to effectively lower the participation threshold of the elderly from the environmental level and improve the compliance and feasibility of long-term intervention[27-30].

In summary, based on the core findings of this study, we recommend implementing combined screening for sarcopenia and depression in routine health assessments of elderly patients, and aim to develop a multidisciplinary, integrated management model that includes resistance training, personalized nutritional support, and necessary psychological interventions. However, several limitations of this study must be acknowledged: Its cross-sectional design and single-center sample size limit the inference of causal relationships and the ability to extrapolate conclusions to a wider population. Furthermore, some potentially important confounding variables were not included in the analysis, and the reliance on self-assessment scales such as the PASE and GDS-30 may be subject to recall and social desirability bias. Furthermore, the lack of biomarker data hinders in-depth exploration of potential mechanisms. Therefore, future studies are warranted to conduct multicenter, large-sample longitudinal investigations, employing both objective measurement indicators and biomarker analyses, and to provide high-level evidence for the effectiveness of comprehensive interventions through randomized controlled trials.

CONCLUSION

In short, sarcopenia is prevalent among seniors and tightly linked with indicators of depression and low physical activity. Depression appears to fuel sarcopenia’s onset and progression, whereas higher activity levels offer clear protection. These findings highlight the need for routine screening and targeted action, urging clinicians and policymakers to safeguard older people’s health and quality of life. Future work should clarify causal pathways and test the impact of combined interventions.