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THE AWARENESS AND KNOWLEDGE REGARDING SARCOPENIA AMONG HEALTHCARE PROFESSIONALS: A SCOPING REVIEW

 

X.M. Yao, B.B. Liu, W.Y. Deng, X.H. Wang

 

Central South University, Changsha, Hunan China

Corresponding Author: Xiuhua Wang, Central South University, Changsha, Hunan China, xiuhua203@csu.edu.cn

J Frailty Aging 2022;in press
Published online February 14, 2022, http://dx.doi.org/10.14283/jfa.2022.7

 


Abstract

Background: Sarcopenia is a prevalent and costly disease associated with serious negative health outcomes, and its prevalence will further grow as the percentage of elderly rises. Healthcare professionals play a crucial role in the prevention, identification and management of sarcopenia and in promoting the well-being of elders. Awareness and knowledge are the prerequisite and basis for these actions.
Objective: The objective of the review was to summarize available publications to identify the healthcare professionals’ awareness and knowledge about sarcopenia, and to identify knowledge gaps that interventions could address.
Design: The scoping review will be performed based on the Scoping Review guidelines published by JBI in Australia.
Methods: Six electronic databases, including PubMed, Embase, CINAHL, Web of Science, Cochrane Library and CNKI were searched systematically. Two researchers independently screened the retrieved articles and extracted the information.
Results: A total of 6 studies were identified, including 5 quantitative studies and 1 qualitative study. These studies mainly were conducted in Australia, Netherlands and Brazil, and none from Asia. The awareness and knowledge of healthcare professionals about sarcopenia varied in different studies. With exception of one study conducted in oncology clinicians, other studies suggested that awareness and knowledge among healthcare professionals was incomplete and limited.
Conclusion: The relatively few studies indicated that healthcare professionals had low awareness and limited knowledge of sarcopenia, which could influence and hinder the diagnosis and treatment of sarcopenia in practice. Future researches should develop a rigorously tested and valid sarcopenia knowledge assessment tool and researches conducted in larger samples are needed.

Key words: Sarcopenia, awareness, knowledge, healthcare professionals.


 

Introduction

Sarcopenia is an important muscle disease characterized by a progressive and generalized decline in skeletal muscle mass, as well as decrease in muscle strength and/or physical performance (1). Epidemiological surveys show that globally, the prevalence of sarcopenia among elderly in community is approximately 10%, while 23% and 38-41% in hospitalized and institutionalized older adults, respectively (2, 3).

Sarcopenia had an important impact on patient health outcomes, personal and social economic outcomes. Studies have found sarcopenia was associated with increased risk of falls, fractures, functional impairments, frailty, increased mortality and longer hospital stays (4-8). Such negative consequences entail excessive healthcare burden associated with outpatient clinic visits and hospitalization (7, 9). Ethgen, et.al. predicted that the number of sarcopenia patients would dramatically increase over the next 30 years (10). Results of a large community-based study indicated that the direct healthcare costs were more than 2 times higher for elderly with sarcopenia than for those without (9). Goates, et.al suggested in 2014, hospitalization costs for US adults with sarcopenia added up to USD $40.4 billion annually, accounting for about 4.1 percent of the National Health Expenditures (NHE) on hospital care (11).In addition, sarcopenia is silent and asymptomatic in initial stage (12). Therefore, early assessment and subsequent interventions are important. For this, awareness among healthcare professionals is a prerequisite, and this also requires adequate knowledge regarding the concept of sarcopenia, diagnostic strategies and optimal interventions for sarcopenia (13).
Sarcopenia was recognized as an independent clinical condition in 2016 (14), which means a significant step similar to recognition of osteoporosis as a disease. Theoretically, this should help advocate more awareness and interest about sarcopenia among healthcare professionals and an increase in awareness and knowledge of sarcopenia may be expected. However, the limited surveys indicated that knowledge regarding sarcopenia was incomplete and limited amongst professionals, some even didn’t hear of sarcopenia, let alone its diagnosis or management (15). Considering the important role of professionals in the diagnosis and management of sarcopenia, several studies examining the professionals’ awareness and knowledge regarding sarcopenia had been conducted. However, the evidence remained inconclusive as the surveys focus on either one type of study design, such as qualitative method, or only involving dietitians and excluding physicians, nurses or physical therapists and other professionals in different disciplines, who are also essential to the diagnosis and management of patients with sarcopenia. To prevent, diagnose and manage sarcopenia early, awareness and adequate knowledge among healthcare professionals is essential and highly required (13).
Therefore, the objective of the review is to summarize available publications to identify the healthcare professionals’ awareness and current state knowledge about sarcopenia. This will provide a clear and comprehensive evidence and help to guide further researches.

 

Methods

To address the objectives proposed in this study, the scoping review will be performed based on the Scoping Review guidelines published by The Joanna Briggs Institute (JBI) in Australia in December 2019 (16).

Inclusion and exclusion criteria

The inclusion and exclusion criteria for studies were developed based upon the “PCC” (Population, Concept and Context) elements. The population of the review were healthcare professionals, such as physicians, nurses, dietitians and physical therapists and professionals from other disciplines. The overarching concept of interest for the review is healthcare professionals’ awareness and knowledge about sarcopenia. Reviews, conference abstracts and articles that were not available in full text, reviews or conference abstracts were excluded.

Search strategy

The following six databases, PubMed, Embase, CINAHL, Web of Science, Cochrane Library and CNKI were searched systematically. The search strategy was based on the various combinations of the following Mesh terms and keywords: sarcopenia, sarcopenic, muscle wasting, muscular atrophy, myopenia syndrome, muscle loss syndrome, less muscle disease, knowledge, awareness, understanding, health care personnel, health care providers, healthcare providers, healthcare provider, healthcare workers, health care professionals, healthcare professionals, doctors, physicians, nurses, physical therapists, physiotherapists, dietitians, dieticians, and nutritionists. The Boolean operators, AND or OR, were used to connect the words. No geographical or methodological restrictions were imposed on search strategy. The time limit for research was until March 20,2021.

Study selection

After importing all retrieved studies into Endnote and removing duplicates, two researchers performed two stages of screening independently. The first stage was to screen the titles and abstracts of the articles based on the pre-specified criteria for inclusion and exclusion. Selected studies as potentially relevant to the review from the first stage were screened full text at the second stage according to the same criteria. Any disagreements between the two researchers were resolved through discussion between two researchers or the third researcher adjudication.
After the list of the included articles was determined, the main researcher would examine the references of the included articles to check for additional studies that might meet the inclusion criteria. All studies that fit the inclusion criteria will be included in this review.

Data extraction

The key information from the included studies was recorded and collated in a data extraction table, including: authors, year of publication, objectives of the study, study design, sampling method, participant characteristics, country where the research was conducted, outcome measures and main findings.

 

Results

Literature research results

1316 titles and abstracts were retrieved from the databases, including: PubMed (n = 30), Embase (n = 160), CINAHL(n=235), the Cochrane library(n=143), Web of Science (n = 736), and CNKI (n = 12). Additional 3 records were yielded in the reference lists, making the total record of 1319. A total of 1037 titles and abstracts were screened after removing the duplications (n =282). After two stages of screening, two researchers identified six and eight related articles related to the research question, respectively. Two of the articles on which agreement could not be reached were adjudicated by corresponding author. After careful evaluation by the corresponding author, one of the two articles was included in the review, and the other one were not, because it was mainly concerned with the diagnosis and management of sarcopenia in clinical practice, rather than the awareness and knowledge of the healthcare professionals. In the end, a total of six studies were included in this review. Fig. 1 shows a flowchart of the search process.

Figure 1. Search process flowchart

 

General aspects of the included studies

A total of 6 studies were identified, including 5 quantitative studies and 1 qualitative study. All of quantitative studies used self-developed questionnaires, either online or manually delivered for the collection of data. The qualitative study was in the form of semi-structured, individual face-to-face interview. Table 1 describes the general aspects of the included studies.

Table 1 General aspects of the included studies (n=6)

 

Specific aspects of the included studies

As can be seen from the Table 2, three of the researches were from Australia, two from Europe and one from South America, and none from Asia. Of the six included studies, two assessed the current knowledge of healthcare professionals about sarcopenia, including its definition, causes, health consequences, diagnostic strategy and treatment (13, 17). In the remaining 4 included studies, two specifically aimed at dietitians (18, 19), one exclusively aimed at nurses working in primary care services (15), and last one exclusively examined the awareness and knowledge regarding cancer –related sarcopenia among oncology clinicians (20). Table 2 describes the specific aspects of the included studies.

Table 2. Specific aspects of included studies (n=6)

 

Awareness and general knowledge of sarcopenia

Awareness and knowledge were at times used interchangeably in the included studies. Five studies examined the awareness and general knowledge of sarcopenia among healthcare professionals (13, 15, 17, 19, 20). A study conducted in healthcare professionals in Australia and New Zealand found that only 14.7% of professionals knew sarcopenia was a disease, 73% knew sarcopenia could be prevented and that being overweight or obese could not reduce the risk of sarcopenia. When asked about the age at which muscle mass and muscle strength began to decline, the median age answered by professionals was 50 years, which is much higher than correct answer of 30 years (17). This is contrast to a study conducted in Netherland healthcare professionals, in which 69.7% knew the definition of sarcopenia (13). Participants in both above studies attended a professional development event called “The Sarcopenia Roadshow”. The Sarcopenia Roadshow was a 2-hour lecture series delivered by a senior geriatrician and a dietitian with the aim to raise the healthcare professionals’ awareness of sarcopenia and transfer knowledge about the concept of sarcopenia, diagnostic strategy and management of sarcopenia. The lecture was based on the current literature, and encompassed the presentation of the following topics: the European Working Group on Sarcopenia in Older People (EWGSOP) 2010 definition, pathophysiology of sarcopenia, diagnostic strategy and non-pharmacological interventions, both from exercise and nutritional perspective (13, 17). Immediately after the event, healthcare professionals’ awareness and knowledge of sarcopenia improved dramatically, but after 6 months, an online questionnaire assessed whether the knowledge was retained indicated that knowledge was not retained after a single educational event (17). However, in general, professionals who received previous sarcopenia-related education had significantly better knowledge about sarcopenia before attendance of the Sarcopenia Roadshow (17).
Sarcopenia had been listed as a key component of malnutrition by the European Society for Clinical Nutrition and Metabolism (ESPEN), and muscle mass, fat mass as well as muscle strength were important indicators of nutritional status (21, 22). Therefore, dietitians are expected to be more familiar with sarcopenia. However, a 2016 study of dietitians sowed that only 13% -30% of dietitians had “sufficient knowledge” to distinguish correctly sarcopenia, cachexia and starvation, which overlap in clinical symptoms. The study also indicated that dietitians working in institutional environments (such as hospitals and nursing homes) had more knowledge than their colleagues working in other workplaces, but no association was found between working experience and the level of knowledge (19).
Cancer-related sarcopenia is an important component of cancer-related malnutrition, which has been the focus of oncology health professionals (23). A survey conducted in cancer clinicians revealed high awareness and understanding of cancer-related sarcopenia, with 88% of clinicians able to identify accepted definition of sarcopenia as well as its importance and value in the context of cancer care. However, half of the participants lacked confidence in identifying sarcopenia (20). Another qualitative study specifically for nurses in primary care services indicated that nurses either were conceptually unaware of sarcopenia or knew about sarcopenia in an incipient way. There were some recorded statements to demonstrate: when asked how they understand by sarcopenia, most of nurses replied that “we don’t know about”, “we have not seen it at graduation”, “sarcopenia means a weakness in the muscles of the elderly and many times we don’t notice”, or “Sarcopenia is only the loss of muscle strength in the elderly”. Majority of them also said they have never participated in any training in the area of gerontology in work (15).

Knowledge of screening and diagnosis

The six studies included in the review evaluated the knowledge about screening and diagnosis of sarcopenia among healthcare professionals (13, 15, 17-20). A survey conducted in healthcare professionals in Australia and New Zealand found that although 90% of the healthcare professionals knew muscle mass, muscle strength and physical performance as diagnostic indicators of sarcopenia, the percentage of professionals who could correctly state the cut-off values for these indicators was very low. For example, only 2% could accurately state the sex-specific cut-off points for low handgrip Strength (17). Another study conducted in Netherland healthcare professionals indicated that only 21.4% of professionals knew how to correctly diagnose sarcopenia (13). Two studies conducted among dietitians suggested different results. One study conducted in Australia discovered that, 76% of dietitians considered that muscle wasting was key diagnostic criterion of sarcopenia, 50% was loss of muscle strength, and 16%was weight loss (18). The other one study performed among dietitians in Belgium, Netherlands, Sweden and Norway indicated that 74% of dietitians knew the accepted diagnostic criteria of sarcopenia, better than the previous study (19).
A survey conducted in oncology clinicians suggested that, although 88% of clinicians were able to correctly identify the diagnostic criteria for sarcopenia, half of the participants expressed a lack of confidence in identifying sarcopenia (20).One study conducted in nurses found that the weakness of the nurses’ knowledge about the definition of sarcopenia were also reflected in the lack of knowledge of diagnostic strategy for sarcopenia (15). Given the rise of sarcopenia and the accessibility of specialized instruments, the AWGS and EWGSOP recommended the evaluation of the calf circumference (CC) as a screening method for sarcopenia (1, 24), which have moderate sensitivity and specificity in predicting sarcopenia (25, 26). However, even though calf circumference was listed in the CSPI (Elderly Person Health Booklet in Brazil), nurses often neglected to fill it out. There are several reasons for this: from not knowing how to do it, to prioritizing other chronic problems suffered by the elderly (15).

Knowledge of management and treatment

Three studies assessed the knowledge about management and treatment of sarcopenia among healthcare professionals (17-19). As for the management and treatment of sarcopenia, majority of healthcare professionals knew resistance exercise and adequate protein supplementation were appropriate interventions. For example, one study conducted in Australia and New Zealand found that 90% of healthcare professionals correctly identified resistance exercise and adequate protein intake as treatment for sarcopenia, while 21.4% still thought sarcopenia should be treated with pharmacological intervention (17). For dietitians, nutritional supplements were considered as the primary treatment for sarcopenia. A study conducted in 2011 indicated that, 75% of dietitians chose a high-energy high-protein diet to treat sarcopenia, followed by high-energy high-protein snacks (48%), oral nutritional supplements (42%) and enteral feeding (32%) (18). Dietitians in the other study also said the most provided possible therapies for sarcopenia were high energy diet, high protein diet and snacks (19).

 

Discussion

This scoping review aims to summarize the current state of awareness and knowledge about sarcopenia among healthcare professionals. Although extensive studies have been conducted on the prevalence, etiologies, pathogenesis and adverse outcomes of sarcopenia since the term of “sarcopenia” was proposed (2, 3, 27-29), only a few studies (n=6) examined the professionals’ awareness and knowledge of sarcopenia, and none originated from Asia. This is important because Asia is the most dense and fastest ageing region in the world, and epidemiological surveys have shown that the sarcopenia is also prevalent among elderly in Asian countries (1). Lack of such researches may lead to delays in the diagnosis and management of the group of older adults with sarcopenia (3).
Early prevention, diagnosis and management of sarcopenia requires awareness among healthcare professionals, and awareness may raise with increasing knowledge (30). The studies suggested that the awareness and knowledge of healthcare professionals about sarcopenia varied in different studies, which could be attributed to the difference in sample and different study contexts. With the exception of one study conducted in oncology clinicians, five other studies suggested low awareness and inadequate knowledge of sarcopenia among healthcare professionals, and there remained the need to take measures to improve awareness and knowledge.This is perhaps not surprising when considering sarcopenia was only recently recognized as a disease (14), and has not yet received adequate attention. It is understandable that oncology clinicians had better awareness and knowledge of cancer-related sarcopenia, because cancer-related sarcopenia is a key component of cancer-related malnutrition (31), which is a major concern in the treatment of cancer patients, and a plenty of evidence-based guidelines are available internationally to support the nutritional management of patients with cancer (32, 33). Silva and his colleagues found that nurses who became professionals many years ago were not taught information about sarcopenia screening, also they didn’t have access to information since graduation and had not received training on this topic (15). Yeung et.al also suggested that only 16.9% of healthcare professionals received sarcopenia-related education in practice (17). Thus, the absence of sarcopenia-related education may also contribute to the lack of awareness and knowledge of sarcopenia among healthcare professionals.
Some studies suggested that no significant difference in knowledge and identification ability of sarcopenia was discovered between healthcare professionals with 0 to 5 years of working experience and professionals with 6 or more years of experience (18-20), and the dietitians’ knowledge of malnutrition and sarcopenia was not associated with the number of malnourished and sarcopenia patients treated each week (19). However, whether the workplace influenced professionals’ knowledge about sarcopenia remained inconclusive. Yeung, S S Y found healthcare professionals working in community services had better knowledge about sarcopenia (17), while Ter Beek indicated that dietitians working in hospitals and municipality care had better knowledge compared with dietitians working in other settings (19). The difference may be due to the variations in samples and knowledge assessment methods, thus, further researches conducted in larger samples are needed. Given that sarcopenia is prevalent and costly, as well as associated with a range of adverse health outcomes, early assessment and appropriate interventions are crucial. According to the awareness-agreement-adoption-adherence model, to comply with a new practice, healthcare professionals must first be aware of the new practice, then move to a process of agreement with it, then adopt it, and finally adhering to the practice (34, 35). Therefore, raising the awareness and knowledge of professionals should be the first step in promoting practice. However, a single educational event could not effectively increase professionals’ knowledge of sarcopenia (17). Systematic reviews evaluating the effect of professional development events indicated that, compared to a single exposure, multiple exposures to professional development events were associated with a greater effect on professionals’ knowledge and performance, and it could lead to greater improvement if it was more interactive, used more methods, and focused on outcomes that physicians valued (36, 37). Therefore, educational events should be continuous, using multiple methods, implemented frequently, and combined with regular audits and feedback to maintain knowledge and professional behavior change. Notable, in addition to low awareness and inadequate knowledge, a number of other barriers that influence the diagnosis and treatment of sarcopenia had also been reported, with the most frequent including availability of equipment and time constraints (13, 17, 20). Low level of confidence, lack of treatment protocol or guidelines to support practices and lack of motivation among other healthcare professionals were also identified as main barriers during sarcopenia diagnosis and treatment (13, 20). Therefore, in addition to the emphasis on continuing education, a supportive work environment may also be important for healthcare professionals.

Limitations

The review had some limitations that must be recognized. Firstly, although we searched six major databases in both English and Chinese, only those articles with abstracts and full texts available were included in this review, so some articles relevant to the research objectives may not have been captured. Secondly, the included studies was few, and the subjects of these studies were either healthcare professionals interested in sarcopenia or were from a single organization or association, and were dominated by dietitians, with other professionals in diverse disciplines underrepresented, which may affect the generalizability of the results. Finally, we note that all quantitative studies used self-designed questionnaires to evaluate the professionals’ awareness and knowledge about sarcopenia. These questionnaires were not described in detail and their reliability and validity were not tested. These limitations, together with different healthcare systems across different countries, may limit the generalizability of the results.

 

Conclusion

To date, studies examining the healthcare professionals’ awareness and knowledge regarding sarcopenia were limited, particularly in Asia. The relatively few studies indicated that healthcare professionals had low awareness, and limited knowledge and understanding of sarcopenia, which may influence and hinder the diagnosis and treatment of sarcopenia in practice. The findings and gaps identified in this review can help to inform future interventions to do with sarcopenia. Future research should develop a rigorously tested and valid sarcopenia knowledge assessment tool and researches conducted in larger samples are needed.

 

Funding: No sources of funding support this article.

Conflict of interest: None.

Ethical standards: None ethical approved required.

 

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