Home | Volume 37 | Article number 229


Geriatric syndromes in an urban elderly population in Cameroon: a focus on disability, sarcopenia and cognitive impairment

Geriatric syndromes in an urban elderly population in Cameroon: a focus on disability, sarcopenia and cognitive impairment

Marie Josiane Ntsama Essomba1,2,&, Daniel Atsa3, Dimitri Zogo Noah2, Marylin Zingui-Ottou1, Ginette Paula1, Jan René Nkeck2, Jean Jacques Noubiap4, Gloria Ashuntantang2


1Geriatric Unit, Yaoundé Central Hospital, Yaoundé, Cameroon, 2Department of Internal Medicine and Specialties, University of Yaoundé I, Yaoundé, Cameroon, 3Yaoundé Emergencies Center, Yaoundé, Cameroon, 4Center for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia



&Corresponding author
Marie Josiane Ntsama Essomba, Geriatric Unit, Yaoundé Central Hospital, Yaoundé, Cameroon




Introduction: geriatric syndromes are multifactorial conditions that are associated with substantial disability, poor quality of life and mortality in the elderly. The patterns of these conditions are poorly described in sub-Saharan Africa. This study aimed to determine the prevalence and correlates of common geriatric syndromes in Cameroon.


Methods: we conducted a cross-sectional study in the geriatrics unit of a university hospital in Cameroon. All people aged ≥55 who attended a health promotion and screening campaign in September 2019 were included. Geriatric syndromes including functional decline, cognitive impairment and sarcopenia were assessed. We also examined sociodemographic characteristics and comorbidities.


Results: overall, 104 participants were enrolled with median age of 65 (IQR: 62.2 - 70.8). About 67% of participants presented at least one geriatric syndrome. Disability in activities of daily living and instrumental activities of daily living were present in 10% and 38% of participants respectively and associated factors were male gender (OR 4.7, p=0.005), age 75 and above (OR 5.7, p=0.027), osteoarthritis (OR 3.3, p=0.055) and polypharmacy (OR 7.7, p=0.012). Sarcopenia occurs in 26% with female gender (OR 3.1, p=0.029) and SARC-F ≥4 (OR 4.9, p=0.002) as associated factors. Cognitive impairment was present in 20% of participants and associated with illiteracy (p=0.008).


Conclusion: our study shows a high prevalence of geriatric syndromes in older adults in an urban area. Geriatric principles and frailty awareness should be considered in clinical care of older adults in our setting.



Introduction    Down

Geriatric syndromes (GS) are clinical conditions that are highly prevalent in the aging population. They are not necessarily attributed to a specific isolated underlying disease but rather multifactorial, ultimately leading to substantial vulnerability and reduced quality of life [1,2]. GS include cognitive impairment, delirium, functional decline, falls, urinary incontinence [2-4]. These conditions are associated with recurrent hospitalizations and mortality, as well as significant healthcare expenditure [1,2].


Diseases in the elderly are a major public health problem globally, especially in the high-income countries where the life expectancy is highest. Although they have long been neglected in low-income countries especially in sub-Saharan Africa, geriatric conditions are gaining more attention as the elderly population grows in these countries [5,6]. Indeed, the burden of geriatric diseases is rising in sub-Saharan Africa, with more elderly requiring medical attention, frequent hospitalizations with longer stay and unfortunately high mortality rates [6-8]. Therefore, healthcare systems in low-income countries need some policy shifts to cope with this growing burden of disease in the elderly population. Disability is usually defined as a difficulty in performing activities necessary for independent living [9]. According to a worldwide report, approximately 1 billion people are living with one or more disabling conditions [10,11]. Difficulty in performing basic activities of daily living is present in more than 45% of older adults and influenced by many factors such as older age, cognitive disorders, chronic diseases, limb dysfunction, pain, polypharmacy and high or low body mass index (BMI) [9-13]. Cognitive impairment and dementia are increasing in developing world [14,15]. Cognitive impairment is defined by a progressive decline in some cognitive functions without satisfying diagnosis criteria of dementia. Few studies to determine its prevalence have been conducted in sub-Saharan Africa. The prevalence ranged from 6 to 25% and major risk factors include older age, female gender, cardiovascular diseases and illiteracy [16-18]. Sarcopenia is a muscle disease, with low muscle strength being the principal determinant. Muscle strength is actually the most reliable measure of muscle function. Low grip strength is a predictor of outcomes such as increased functional limitations, poor quality of life as well as longer hospital stay and death [19-21].


Cameroon, a country in Central Africa region reported an increase in life expectancy by 10 years between 1950 and 2015. The healthcare demand in this aging population is increasing, but health system is ill-prepared to meet their needs. The older population was estimated at 1.2 millions individuals in 2018 [22]. As we are writing this paper, there is only one geriatrics-dedicated unit and less than three geriatricians in the whole country [6]. Furthermore, there is a dearth of data on the patterns and determinants of GS in this population. Hence, this study aimed to determine the prevalence of disability, cognitive impairment, sarcopenia and their correlates in an urban population in Cameroon. Such data would inform policies to improve geriatric care in Cameroon.



Methods Up    Down

Study setting, design and participants: this cross-sectional study was carried out in September 2019, in the Geriatric Unit of the Yaoundé Central Hospital, a 650 bedded hospital located in the capital of Cameroon. This hospital has the lone functional geriatrics-dedicated unit of the country with about 200 hospitalizations per year. Participants were recruited during a health promotion and screening campaign. We included people aged 55 years and above, who provided an informed written consent. This cut-off age to define elderly population and which is lower than that of high-income countries, is a reflection of the country´s life expectancy. We did not include participants who were seriously ill or unable to communicate.


Data collection: a pre-designed questionnaire was developed by our team to collect data. The demographic data included age, gender, marital status, current professional activity and educational level (illiterate, primary, secondary, university). Clinical data included past medical history, falls history, number of drugs and comorbidities such as hypertension, diabetes mellitus, cerebrovascular diseases, dementia, cancer, heart disease, osteoarthritis, human immunodeficiency virus (HIV), hepatitis B and C infections. For the purpose of this study, polypharmacy was defined as taking more than four different drugs for chronic diseases. Fall was defined as an unexpected event in which a person come to rest on the floor, the ground or lower level. Falls were assessed by self-report to the question «have you fallen in the past 12 months?»


Measurements: geriatric syndromes explored were: disability, sarcopenia and cognitive impairment. Disability was assessed using the Katz Index of independence in Activities of Daily Living (ADLs) [23] and Instrumental Activities of Daily Living (IADLs) adopted from the Lawton scale [24]. The Katz Index of independence in ADL is widely used to assess the older patient ability to perform basic activities of daily living by measuring six functions: bathing, dressing, toileting, transferring, continence and feeding. The Katz Index is sensitive to decline in functional status in various care setting. The Lawton IADL scale is appropriate to assess skills that are more complex than the basic activities of daily living. There are eight functions measured with the scale: ability to use phone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility for own medications and ability to handle finances. The Lawton IADL scale has an inter-rater reliability of 0.85 and its correlation with other scales was significant [24]. For the purpose of our study and to limit gender bias, food preparation has been excluded for men. Participants who had difficulty in performing any one of the basic or instrumental activities were classified as living with disability.


Sarcopenia was assessed with the SARC-F questionnaire and the measurement of the muscle strength. SARC-F is an acronym for strength, assistance with walking, rise from a chair, climb stairs and falls. The SARC-F is a screening tool that was evaluated in three large populations, with a high specificity for identifying people at risk of sarcopenia. It consists in a 5 items questionnaire to evaluate patient´s limitations in strength, walking ability, rising from a chair, stair climbing and experiences with falls. Risk of sarcopenia is present if SARC-F ≥4 [25,26]. The measure of the muscle strength was performed by measuring the handgrip strength of the dominant hand with a Jamar dynamometer, sitting upright in a chair. Only one measure was recorded for each participant. According to the European Working Group on Sarcopenia in Older People (EWSGOP), muscle strength is the primary parameter of sarcopenia. Grip strength correlates with strength in other body compartments. The Jamar dynamometer is validated for measuring grip strength [19]. Sarcopenia was present if muscle strength was <30kg for men and <20kg for women.


Cognitive impairment was assessed with the Mini Mental State Examination (MMSE) [27]. The test was administered by a geriatrician or a neurologist. The MMSE is the most widely used cognitive impairment and dementia screening test, including low-literacy settings [28,29]. Its performance in a recent review showed a sensitivity of 0.83 and a specificity of 0.82 in low and middle-income countries [30]. The cut-off values used for the purposes of our study was: 22 for illiterate or primary level, 24 for secondary level and 26 for university level. Numerous studies used different cut-off points for participants with and without formal education to improve the sensitivity and specificity of the test [31-33]. Cognitive impairment was present if the MMSE score was below the cut-off values for each educational level.


Data analysis: data were coded, entered and analyzed with the Statistical Package for Social Sciences (SPSS 23.0) for Windows (SPSS, Chicago, Illinois, USA). Quantitative variables were described using mean and standard deviation or median with interquartile range (IQR). Categorical variables were presented with frequencies and percentages. Association between categorical variables were explored using Khi-square test and Fisher´s test. To explore factors associated with geriatric syndromes, we performed univariate and multivariate analysis with odds ratios (OR) and 95% confidential intervals (95% CI). To account for potential confounders, we included in the multivariate model all variables with a p-value <0.2 in the univariate analysis. A p-value of <0.05 was considered statistically significant.


Ethics approval: this study has been approved by the institutional board of the Yaoundé Central Hospital (Number 02/ACE/DR/CIE/MINSANTE/SG/DHCY). An informed consent was obtained from all participants included in this study.



Results Up    Down

Characteristics of participants: overall, one hundred and four participants were recruited for the study of whom 52.9% (n=55) were female. The median age was 65 (IQR: 62.2 - 70.8) with 47.1% (n=49) of participants aged between 55-64 years. About 60.6% of participants (n=60) presented at least one chronic medical condition, the commonest were hypertension (35.6%, n=37), osteoarthritis (24%, n=25) and diabetes mellitus (8.7%, n=9). Table 1 shows characteristics of all participants.


Geriatric syndromes and associated factors: the prevalence of geriatric syndromes (GS) in the overall population was 67.3% (n=70). Younger age (under 64) seems to protect against the occurrence of GS in univariate analysis (OR 0.3, p=0.012). GS occur significantly in male participants (OR 1.7, p=0.036), in those with BMI <20kg/m2 (p=0.029) and in presence of comorbidities (OR 2.3, p=0.049), especially osteoarthritis (OR 4.7, p=0.011). On multivariate analysis, male gender (OR 2.7, p=0.035) and osteoarthritis OR 4.3, p=0.034) were associated with the presence of any GS (Table 2).


Our results showed that 9.6% (n=10) of participants had at least one difficulty with ADLs. Concerning IADLs, difficulty was reported by 37.5% (n=39) of participants with a significant male predominance (p=0.022). In ADLs, the commonest limitations were transferring (80%) and continence (20%). Housekeeping, laundry and shopping caused difficulties in IADLs for the majority of participants. As presented in Table 3, disability in IADLs occurs significantly in male participants (OR 1.6, p=0.022), in those aged 75 and above (OR 7.1, p=0.004), in presence of osteoarthritis (OR 3.4, p=0.008) and polypharmacy (OR 6.8, p=0.001). Those factors remain associated with occurrence of IADL disability in multivariate analysis as shown in Table 3.


About 23.1% (n=21) of participants were at risk of sarcopenia. Sarcopenia was present in 26.2% (n=27) of participants and the median muscle strength was 27 kg (IQR 21.1 - 34.4). Table 4 shows factors associated with sarcopenia. Female gender (OR 3.5, p=0.009), falls history (OR 8.4, p=0.005), SARC-F ≥4 (OR 3.3, p=0.000) and BMI<20kg/m2 (OR 4.1, p=0.036) were significantly associated in a univariate model. On multivariate analysis, only female gender (OR 3.1, p=0.036) and SARC-F ≥4 (OR 4.9, p=0.027) were independently associated with the presence of sarcopenia. Cognitive impairment was present in 20.2% (n=21) of participants. The median score was 26 (IQR 24-28). Only educational level was significantly associated with cognitive impairment (p=0.043).



Discussion Up    Down

We found a high prevalence of disability in our study. Our results are similar to those found in Europe, where the disability rate among older people varies between 11 and 44% for ADLs and between 8 and 40% for IADLs [34,35]. In our study, the prevalence was higher in population aged 75 and above, reaching 77% for those reporting limitations in IADLs. In Poland, the odds of having difficulties increased by 8% and 10% with increasing age for ADLs and IADLs respectively [35,36]. The risk of functional disability was four-fold increased in the 80 and above age group in an Irish study [13]. Functional impairment in older people is becoming a major issue in our setting probably because the awareness is still very low among healthcare givers and family members. Factors independently associated with disability in our study were male gender, age ≥75, osteoarthritis and polypharmacy. Similar findings were seen in other studies [37,38]. Housekeeping, laundry and shopping are rarely done by men in our setting, especially when they are in relationship. This can be a confounder in male participants IADLs assessment. Osteoarthritis can impair mobility of older people and causes limitations to perform basic and complex activities. Moreover, limitations due to osteoarthritis can be associated with pain. Some authors demonstrate that the occurrence of disability increases with the number of chronic medical conditions [36,39,40]. Association between disability and polypharmacy is not well described but we can assume polypharmacy is usually associated to multimorbidity.


Sarcopenia was highly prevalent in our study population. This finding is in concordance with previous studies [41,42]. But our prevalence is higher than in other studies conducted in Nigeria and Brazil [43,44]. Because of the variability of the instruments used to screen sarcopenia, the cut-off values, age of the study population and comorbidities, the prevalence of sarcopenia varies widely [19,45,46]. According to the European Working Group on Sarcopenia in Older People (EWGSOP), handgrip strength of the dominant hand is the best evidence at date, to assess general muscle strength in a clinical setting or in community health care [19]. Older Africans have been found to have higher muscle mass than their Caucasians counterparts. However, new research showed that muscle strength could be addressed independently of muscle mass [47,48]. In our study, women were at a higher risk of having sarcopenia. Women undergo an accelerated loss of muscle mass at an earlier age than men beginning at the time of menopause. Our results are in line with other studies [43,49,50]. We reported a higher risk of sarcopenia among individuals with history of falls. The consequences of falls can be disastrous since they are associated with physical disability, functional impairment and increased morbidity and mortality [51-53].


Cognitive impairment was present in 20.2% of participants in this study and was associated with illiteracy. This prevalence is lower than the 33.3% obtained in rural Cameroon [54]. However, the prevalence of cognitive impairment varies widely in Cameroon and in other African countries [16,55,56]. Discrepancies found between different studies can be explained by the multiplicity of tools and cut-off values. Indeed to improve the sensitivity of the MMSE in our population, it was important to adjust the cut-offs to educational level [31-33]. However, we were not able to determine related factors with statistical significance, this could be explained by our small sample size.


The burden of geriatric conditions is increasing in sub-Saharan Africa and needs to be identified to plan preventive and therapeutic approach. According to World Health Organization, 2020-2030 is the decade of healthy aging. It is therefore important to raise awareness of healthcare givers about health issues of the older adults. Further studies are highly needed in this rare area to provide concrete actions for a healthy aging in our setting.


Limitations: although we expect this study to help increasing public health awareness concerning geriatric conditions, it should be interpreted considering some limitations. Our data might not reflect the entire elderly population in our setting as we conducted a hospital-based study in one center. Another limitation was the fact that factors associated with cognitive impairment such as mood disorders were not taken into account.



Conclusion Up    Down

This study shows evidence for high prevalence of GS in Cameroonian older people in an urban setting. The burden of GS needs to be identified early to minimize the related complications. Further research among community-dwelling and hospitalized older individuals are needed to motivate the government to put in place policies and implement appropriate preventive measures.

What is known about this topic

  • Geriatric syndromes are associated with substantial disability, poor quality of life and mortality in the elderly;
  • Assessment of functional status, cognition and frailty is important to prevent adverse events in older patients.

What this study adds

  • To our knowledge, this study is the first in sub-Saharan Africa to assess geriatric conditions in outpatients including disability and sarcopenia;
  • This study shows evidence of high prevalence of geriatric syndromes in outpatients and can help to initiate a community-dwelling screening of those conditions in older adults in our setting.



Competing interests Up    Down

The authors declare no competing interests.



Authors' contributions Up    Down

MJNE and DA conceived the study; MJNE, DA, MZO, GP and DZ performed data collection; MJNE and GA supervised data collection; MJNE, JJN and JRN analyzed data; MJNE and DA drafted the manuscript; GA and JJN critically revised the manuscript. All the authors have read and agreed to the final manuscript.



Acknowledgments Up    Down

The authors thank the patients and their advisers for accepting to participate in the study and the health professionals of the Yaoundé Central Hospital for assisting in the data collection.



Tables Up    Down

Table 1: characteristics of participants

Table 2: factors associated with the presence of any geriatric syndromes using univariate then multivariate analysis

Table 3: factors associated with disability in IADL using univariate then multivariate analysis

Table 4: factors associated with sarcopenia using univariate then multivariate analysis



References Up    Down

  1. Olde Rikkert MGM, Rigaud AS, van Hoeyweghen RJ, de Graaf J. Geriatric syndromes: medical misnomer or progress in geriatrics. Neth J Med. 2003 Mar;61(3):83-7. PubMed | Google Scholar

  2. Tinetti ME, Inouye SK, Gill TM, Doucette JT. Shared risk factors for falls, incontinence and functional dependence: unifying the approach to geriatric syndromes. JAMA. 1995 May 3;273(17):1348-53. PubMed | Google Scholar

  3. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-156. PubMed | Google Scholar

  4. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007 May;55(5):780-91. PubMed | Google Scholar

  5. Smith SM, Mensah GA. Population aging and implications for epidemic cardiovascular disease in sub-Saharan Africa. Ethn Dis. 2003;13(2 Suppl 2):S77-80. PubMed | Google Scholar

  6. Louise DC, Rufus OA, William KG, Richard WW. Geriatric medicine: services and training in Africa. Age Ageing. 2013;42(1):124-8. PubMed | Google Scholar

  7. Ntsama MJE, Kowo M, Ndikum V, Nzana V, Simeni R, Timnou A et al. Iatrogenic illness in elderly inpatients from a department of internal medicine in Cameroon: a Prospective Study. HEALTH SCIENCES AND DISEASE. 2018 Oct 13. Google Scholar

  8. Kalache A, Aboderin I, Hoskins I. Compression of morbidity and active ageing: key priorities for public health policy in the 21st century. Bull World Health Organ. 2002;80(3):243-4. PubMed | Google Scholar

  9. Tas U, Verhagen AP, Bierma-Zeinstra SMA, Odding E, Koes BW. Prognostic factors of disability in older people: a systematic review. Br J Gen Pract. 2007 Apr;57(537):319-23. PubMed | Google Scholar

  10. United Nations. Ageing and disability: United Nations enable. 2015.

  11. World Health Organization. World report on disability 2011. Geneva: World Health Organization. 2011. PubMed | Google Scholar

  12. Stuck AE, Walthert JM, Nikolaus T, Büla CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-living elderly people: a systematic literature review. Soc Sci Med. 1999 Feb;48(4):445-69. PubMed | Google Scholar

  13. Connolly D, Garvey J, McKee G. Factors associated with ADL/IADL disability in community dwelling older adults in the Irish longitudinal study on ageing (TILDA). Disabil Rehabil. 2017;39(8):809-16. PubMed | Google Scholar

  14. Mavrodaris A, Powell J, Thorogood M. Prevalences of dementia and cognitive impairment among older people in sub-Saharan Africa: a systematic review. Bull World Health Organ. 2013 Oct 1;91(10):773-83. PubMed | Google Scholar

  15. Ineichen B. The epidemiology of dementia in Africa: a review. Soc Sci Med. 2000 Jun;50(11):1673-7. PubMed | Google Scholar

  16. Guerchet M, M'belesso P, Mouanga AM, Bandzouzi B, Tabo A, Houinato DS et al. Prevalence of dementia in elderly living in two cities of Central Africa: the EDAC survey. Dement Geriatr Cogn Disord. 2010;30(3):261-8. PubMed | Google Scholar

  17. Baiyewu O, Unverzagt FW, Ogunniyi A, Hall KS, Gureje O, Gao S et al. Cognitive impairment in community-dwelling older Nigerians: clinical correlates and stability of diagnosis. Eur J Neurol. 2002 Nov;9(6):573-80. PubMed | Google Scholar

  18. Olayinka OO, Mbuyi NN. Epidemiology of dementia among the elderly in sub-Saharan Africa. Int J Alzheimers Dis. 2014;2014:195750. PubMed | Google Scholar

  19. Cruz-Jentoft AJ, Landi F, Schneider SM, Zñiga C, Arai H, Boirie Y et al. Prevalence of and interventions for sarcopenia in ageing adults: a systematic review: report of the International Sarcopenia Initiative (EWGSOP and IWGS). Age Ageing. 2014 Nov;43(6):748-59. PubMed | Google Scholar

  20. Leong DP, Teo KK, Rangarajan S, Lopez-Jaramillo P, Avezum A, Orlandini A et al. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet. 2015 Jul 18;386(9990):266-73. PubMed | Google Scholar

  21. Ibrahim K, May C, Patel HP, Baxter M, Sayer AA, Roberts H. A feasibility study of implementing grip strength measurement into routine hospital practice (GRImP): study protocol. Pilot Feasibility Stud. 2016;2:27. PubMed | Google Scholar

  22. World Data Atlas. Cameroon Population aged 60+ years, 1950-2019. 2019.

  23. Katz S, Downs TD, Cash HR, Grotz RC. Progress in development of the index of ADL. Gerontologist. 1970;10(1):20-30. PubMed | Google Scholar

  24. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969 Oct 1;9(3):179-86. PubMed | Google Scholar

  25. Bahat G, Yilmaz O, Kiliç C, Oren MM, Karan MA. Performance of SARC-F in regard to sarcopenia definitions, muscle mass and functional measures. J Nutr Health Aging. 2018 Oct 1;22(8):898-903. PubMed | Google Scholar

  26. Malmstrom TK, Miller DK, Simonsick EM, Ferrucci L, Morley JE. SARC-F: a symptom score to predict persons with sarcopenia at risk for poor functional outcomes. J Cachexia Sarcopenia Muscle. 2016;7(1):28-36. PubMed | Google Scholar

  27. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189-98. PubMed | Google Scholar

  28. Ortega L de FV, Aprahamian I, Borges MK, Caço J de C, Yassuda MS. Screening for Alzheimer's disease in low-educated or illiterate older adults in Brazil: a systematic review. Arq Neuropsiquiatr. 2019 Apr;77(4):279-88. PubMed | Google Scholar

  29. Shulman KI, Herrmann N, Brodaty H, Chiu H, Lawlor B, Ritchie K et al. IPA survey of brief cognitive screening instruments. Int Psychogeriatr. 2006 Jun;18(2):281-94. PubMed | Google Scholar

  30. Paddick S-M, Gray WK, McGuire J, Richardson J, Dotchin C, Walker RW. Cognitive screening tools for identification of dementia in illiterate and low-educated older adults, a systematic review and meta-analysis. Int Psychogeriatr. 2017;29(6):897-929. PubMed | Google Scholar

  31. Gugssa SA, Davey G, Ejigu AA, Metaferia GZ, Medhin G, Kelkile TS. Population norms for the mini-mental state examination in Ethiopia. Ethiop Med J. 2011 Jul;49(3):239-47. PubMed | Google Scholar

  32. Ramlall S, Chipps J, Bhigjee AL, Pillay BJ. Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the mini- mental state examination, six item screener, subjective memory rating scale and deterioration cognitive observee. Afr J Psychiatry (Johannesbg). 2013 Nov 19;16(6). PubMed | Google Scholar

  33. Parker C, Philp I. Screening for cognitive impairment among older people in black and minority ethnic groups. Age Ageing. 2004 Sep;33(5):447-52. PubMed | Google Scholar

  34. Verropoulou G, Tsimbos C. Disability trends among older adults in ten European countries over 2004-2013, using various indicators and Survey of Health, Ageing and Retirement in Europe (SHARE) data. Ageing & Society. 2017 Nov;37(10):2152-82. Google Scholar

  35. Wahrendorf M, Reinhardt JD, Siegrist J. Relationships of disability with age among adults aged 50 to 85: evidence from the United States, England and continental Europe. PLOS One. 2013 Aug 14;8(8):e71893. PubMed | Google Scholar

  36. Cwirlej-Sozanska A, Wisniowska-Szurlej A, Wilmowska-Pietruszynska A, Sozanski B. Determinants of ADL and IADL disability in older adults in southeastern Poland. BMC Geriatrics. 2019 Oct 31;19(1):297. PubMed | Google Scholar

  37. Chalise HN, Saito T, Kai I. Functional disability in activities of daily living and instrumental activities of daily living among Nepalese Newar elderly. Public Health. 2008 Apr;122(4):394-6. PubMed | Google Scholar

  38. Villarreal AE, Grajales S, López L, Oviedo DC, Carreira MB, Gómez LA et al. Limitations in activities of daily living among dementia-free older adults in Panama. Ageing Int. 2018 Jun 1;43(2):237-53. Google Scholar

  39. Rizzuto D, Melis RJF, Angleman S, Qiu C, Marengoni A. Effect of chronic diseases and multimorbidity on survival and functioning in elderly adults. J Am Geriatr Soc. 2017 May;65(5):1056-60. PubMed | Google Scholar

  40. Guido D, Perna S, Peroni G, Guerriero F, Rondanelli M. A comorbidity prognostic effect on post-hospitalization outcome in a geriatric rehabilitation setting: the pivotal role of functionality, assessed by mediation model and association with the Brass index. Aging Clin Exp Res. 2015 Dec;27(6):849-56. PubMed | Google Scholar

  41. Schaap LA, van Schoor NM, Lips P, Visser M. Associations of sarcopenia definitions and their components, with the incidence of recurrent falling and fractures: the longitudinal aging study Amsterdam. J Gerontol A Biol Sci Med Sci. 2018;73(9):1199-204. PubMed | Google Scholar

  42. Landi F, Calvani R, Ortolani E, Salini S, Martone AM, Santoro L et al. The association between sarcopenia and functional outcomes among older patients with hip fracture undergoing in-hospital rehabilitation. Osteoporos Int. 2017;28(5):1569-76. PubMed | Google Scholar

  43. Adebusoye LA, Ogunbode AM, Olowookere OO, Ajayi SA, Ladipo MM. Factors associated with sarcopenia among older patients attending a geriatric clinic in Nigeria. Niger J Clin Pract. 2018 Apr;21(4):443-50. PubMed | Google Scholar

  44. Moreira VG, Perez M, Lourenço RA. Prevalence of sarcopenia and its associated factors: the impact of muscle mass, gait speed and handgrip strength reference values on reported frequencies. Clinics (Sao Paulo). 2019;74:e477. PubMed | Google Scholar

  45. Rolland Y, Lauwers-Cances V, Cournot M, Nourhashémi F, Reynish W, Rivière D et al. Sarcopenia, calf circumference and physical function of elderly women: a cross-sectional study. J Am Geriatr Soc. 2003 Aug;51(8):1120-4. PubMed | Google Scholar

  46. Bischoff-Ferrari HA, Orav JE, Kanis JA, Rizzoli R, Schlgl M, Staehelin HB et al. Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporos Int. 2015 Dec;26(12):2793-802. PubMed | Google Scholar

  47. Diz JBM, Queiroz BZ de, Tavares LB, Pereira LSM, Diz JBM, Queiroz BZ de et al. Prevalence of sarcopenia among the elderly: findings from broad cross-sectional studies in a range of countries. Revista Brasileira de Geriatria e Gerontologia. 2015 Sep;18(3):665-78. Google Scholar

  48. Harris-Love MO, Adams B, Hernandez HJ, DiPietro L, Blackman MR. Disparities in the consequences of sarcopenia: implications for African American veterans. Front Physiol. 2014 Jul 7;5:250. PubMed | Google Scholar

  49. Lindle RS, Metter EJ, Lynch NA, Fleg JL, Fozard JL, Tobin J et al. Age and gender comparisons of muscle strength in 654 women and men aged 20-93 yr. J Appl Physiol (1985). 1997 Nov;83(5):1581-7. PubMed | Google Scholar

  50. Song M-Y, Ruts E, Kim J, Janumala I, Heymsfield S, Gallagher D. Sarcopenia and increased adipose tissue infiltration of muscle in elderly African American women. Am J Clin Nutr. 2004 May;79(5):874-80. PubMed | Google Scholar

  51. Landi F, Liperoti R, Russo A, Giovannini S, Tosato M, Capoluongo E et al. Sarcopenia as a risk factor for falls in elderly individuals: results from the ilSIRENTE study. Clin Nutr. 2012 Oct;31(5):652-8. PubMed | Google Scholar

  52. Yeung SSY, Reijnierse EM, Pham VK, Trappenburg MC, Lim WK, Meskers CGM et al. Sarcopenia and its association with falls and fractures in older adults: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle. 2019 Jun;10(3):485-500. PubMed | Google Scholar

  53. Terroso M, Rosa N, Marques AT, Simoes R. Physical consequences of falls in the elderly: a literature review from 1995 to 2010. Eur Rev Aging Phys Act, BioMed Central. 2014 Apr;11(1):51-9. Google Scholar

  54. Tianyi FL, Agbor VN, Njamnshi AK, Atashili J. Factors associated with the prevalence of cognitive impairment in a rural elderly Cameroonian population: a community-based study in sub-Saharan Africa. Dement Geriatr Cogn Disord. 2019;47(1-2):104-13. PubMed | Google Scholar

  55. Callixte K-T, Clet TB, Jacques D, Faustin Y, François DJ, Maturin T-T. The pattern of neurological diseases in elderly people in outpatient consultations in sub-Saharan Africa. BMC Research Notes. 2015 Dec;8:159. PubMed | Google Scholar

  56. Guerchet M, Houinato D, Paraiso MN, Ahsen N von, Nubukpo P, Otto M et al. Cognitive impairment and dementia in elderly people living in rural Benin, West Africa. Dement Geriatr Cogn Disord. 2009;27(1):34-41. PubMed | Google Scholar