Association between sarcopenia risk, activities of daily living, and quality of life in acute exacerbation of COPD

Authors

Abstract

AimThe aim of this study was to investigate the relationship between sarcopenia risk and both basic and instrumental activities of daily living (ADLs), as well as health status, in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD).
MethodsTwenty-seven patients (7 females and 20 males) aged 50 years and older who were hospitalized due to COPD exacerbation were included in the study. Sarcopenia risk was assessed using the Strength, Assistance with walking, Rise from a chair, Climb stairs (SARC-F) questionnaire. Dyspnea was evaluated using the modified Medical Research Council (mMRC) dyspnea scale. Basic and instrumental ADLs were assessed using the Barthel Index (BI) and the Lawton Instrumental Activities of Daily Living Scale (Lawton-IADLs), respectively. Health status was evaluated using the COPD Assessment Test (CAT).
ResultsBased on the SARC-F score, 24 patients with COPD exacerbation (88.9%) were identified as being at risk of sarcopenia. The mean forced expiratory volume in the first second (FEV₁) (% predicted) was 40.46 ± 13.81. The mean CAT score was 25.30 ± 6.46, indicating a substantial symptom burden. Higher SARC-F scores were moderately associated with greater dependency in basic ADLs (BI: r = −0.572, p = 0.002) and poorer performance in instrumental ADLs (Lawton-IADLs: r = −0.468, p = 0.014).
ConclusionSarcopenia risk is highly prevalent in patients hospitalized for COPD exacerbation and is strongly associated with functional dependency. Routine screening with the SARC-F and ADLs may enable early identification of high-risk patients and support timely, function-oriented pulmonary rehabilitation.

Keywords

Introduction

Sarcopenia is a highly prevalent, treatable trait in patients with chronic obstructive pulmonary disease (COPD), with reported rates ranging from 14% to 67%.¹ The development of sarcopenia in COPD has been attributed to the complex interplay of chronic systemic inflammation, oxidative stress, mitochondrial dysfunction, physical inactivity, hypoxia, malnutrition, endocrine disturbances, and corticosteroid-induced muscle catabolism.^1,2 Persistent hypoxia and hypercapnia, particularly during acute exacerbations of the disease, impair mitochondrial function and satellite cell regeneration, suppress protein synthesis, and, together with exacerbation-related reductions in circulating insulin-like growth factor-1, contribute to progressive skeletal muscle dysfunction and loss.^1,2,3 Evidence from prospective cohort studies demonstrates that the presence of sarcopenia in stable COPD is also associated with a 2–6-fold increase in rehospitalization risk and poorer long-term survival.⁴
The sarcopenia prevalence was shown to be 16.3% during an acute exacerbation of COPD. Malnutrition and increased disease severity were closely related to the presence of sarcopenia.⁵ Although the prevalence of sarcopenia and malnutrition decreased from 48% and 52% during hospitalization to 30% at 6 months, both conditions persisted in a substantial proportion of patients with COPD.³ Sarcopenia was reported to be independently associated with worse basic activities of daily living (ADLs) and greater dyspnea-related functional limitation, particularly driven by low skeletal muscle mass and reduced gait speed in stable patients with interstitial lung disease.⁶ Moriyama et al. showed that probable respiratory sarcopenia is independently associated with reduced ADLs in older hospitalized patients with respiratory diseases.⁷
Early identification of sarcopenia facilitates timely and effective targeted multidisciplinary interventions, thereby improving clinical outcomes in COPD.¹ Although there is limited data on the relationship between respiratory sarcopenia and ADLs, current data are based on patients with chronic respiratory disorders,⁷ and there is scarce evidence on the association between sarcopenia risk and ADLs during acute exacerbations of COPD. Therefore, the aim of the study was to investigate the relationship between the risk of sarcopenia and ADLs and quality of life in patients with COPD exacerbation.

Materials and Methods

ParticipantsThis cross-sectional study was carried out between October 2025 and January 2026 among patients hospitalized at Bursa City Hospital’s Chest Diseases Clinic with a diagnosis of acute exacerbation of COPD. The inclusion criteria were hospitalization due to an exacerbation, age ≥ 50 years, being cooperative, able to mobilize, and willing to participate in the study. Patients with additional chronic respiratory, neuromuscular, musculoskeletal, cardiac, rheumatological, neurological, psychiatric, or orthopedic conditions, or other chronic diseases that could affect balance and gait, were excluded.
Assessments
The pulmonary function test (PFT) recordings from the patients' most recent visit were retrieved from their files, and the following parameters of PFT were recorded: forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, peak expiratory flow rate (PEF), and 25-75% of forced expiratory flow (FEF25-75%). The severity of airway obstruction was classified based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1-4.⁸
The Strength, Assistance with walking, Rise from a chair, Climb stairs (SARC-F) questionnaire was used to assess the risk of sarcopenia. The use of the SARC-F questionnaire is recommended by the European Working Group on Sarcopenia in Older People 2 (EWGSOP-2) for easy identification of characteristic signs of sarcopenia. This questionnaire is a five-item questionnaire that includes patient-reported information on muscle strength, falls, assistance with walking, rising from a chair, and climbing stairs. A score of 4 or higher on the questionnaire indicates a risk of sarcopenia.¹
The Modified Medical Research Council (mMRC) dyspnea scale was used to determine the level of dyspnea in daily life. The mMRC scale is a category scale that evaluates shortness of breath on a scale of 0-4 points. A higher score indicates higher dyspnea perception.⁹
The level of comorbidity was assessed using the Charlson Comorbidity Index (CCI). The Charlson Comorbidity Index is a widely used and valid index for predicting mortality. The severity of comorbid diseases and mortality risk is classified as mild (CCI scores 1–2), moderate (CCI scores 3–4), and severe (CCI scores ≥ 5).¹⁰
Handgrip strength (HGS) was measured in a seated position with the arm close to the body, the elbow flexed at 90°, and the forearm in a neutral position (Grip D dynamometer, Takei, Tokyo, Japan). The measurements were repeated three times for the left and right sides, and values were recorded in kilograms of force (kgF). The best values were used for statistical analysis. HGS% values were calculated based on reference values according to age and sex.¹¹
The nutritional status of patients was assessed and recorded using the Mini Nutritional Assessment Short Form (MNA-SF) for screening purposes. MNA-SF includes questions about the patients’ body mass index (BMI); whether there has been weight loss in the last 3 months; whether they have experienced psychosocial stress or an acute illness in the last 3 months; their mobility status; whether they have had neuropsychological problems such as dementia or depression; and whether they have experienced decreased food intake due to loss of appetite in the last 3 months. Each item is scored on a scale of 0–3, yielding a total score. A score of 11 or above indicates normal nutrition, 7–11 indicates a risk of malnutrition, and a score below 7 indicates malnutrition.¹²
The basic and instrumental ADLs were assessed using the Barthel Index (BI) and the Lawton Instrumental Activities of Daily Living Scale (Lawton-IADLs). The Barthel Index is a 10-item scale widely used in functional disability assessments to measure an individual's performance in ADLs. The total score ranges from 0 to 100 points. The classification is as follows: 0-20 points: total dependency, 21-61 points: severe dependency, 62-90 points: moderate dependency, 91-99 points: slight dependency, 100 points: independent.¹³ The Lawton-IADLs Scale consists of 8 items. The scale is evaluated by assigning scores of 0 and 1 to the relevant items. The total score ranges from 0 to 8 points. A lower score indicates a higher level of dependency.¹⁴
Health-related quality of life was assessed using the COPD Assessment Test (CAT). The CAT evaluates the symptoms such as cough, sputum, dyspnea, and the effect of the disease on daily life. The CAT consists of eight items, each one scored from 0 to 5 (0 = no defect). The total score ranges between 0 and 40 points. The CAT scores of 0-10, 11-20, 21-30, and 31-40 indicate mild, moderate, severe, and very severe clinical status, respectively.¹⁵
Ethical ApprovalThis study was approved by the Ethics Committee of Bursa City Hospital (Date: 2025-11-05, No: 2025–21/16).
Statistical AnalysisThe minimum sample size required to achieve adequate statistical power (80%) was calculated as 22. By assuming a correlation coefficient of 0.80 and a confidence interval width of 0.40 (0.60–1.00) at the 95% confidence level. Taking into account an anticipated dropout rate of 20.0%, the final sample size was planned to be at least 25 participants.¹⁶
Descriptive statistics (mean and standard deviation) were calculated. Shapiro–Wilk tests and histograms were used to assess normality. The correlation between SARC-F score and other variables was examined using Pearson correlation analysis or Spearman correlation analysis, respectively, under parametric or nonparametric test conditions. Correlation coefficients were interpreted as negligible (<0.10), weak (0.10–0.39), moderate (0.40–0.69), strong (0.70–0.89), and very strong (≥0.90).¹⁷ The level of statistical significance was set at p<0.05.
Reporting GuidelinesThis study is reported in accordance with the STROBE guidelines.

Results

A total of 35 patients with COPD exacerbation were assessed for eligibility during the hospitalization period. The study flow diagram is presented in Figure 1. Twenty-seven patients hospitalized due to COPD exacerbation (7 females and 20 males) were evaluated in this cross-sectional study. According to the total SARC-F score, 88.9% (n = 24) of patients with COPD were at risk of sarcopenia. The physical and clinical characteristics of participants were given in Supplementary Table 1. The mean FEV1 (%) of participants was 40.46 ± 13.81%. According to the GOLD COPD 2026 report, the degree of airflow obstruction was as follows: moderate (26.9%), severe (38.5%), and very severe (38.6%). The distribution of comorbidities was as follows: Diabetes mellitus (18.5%), systemic hypertension (59.3%), coronary artery disease (33.3%), hyperlipidemia (22.2%), and prostate cancer (7.4%). Based on the CCI score, all participants were classified as having a mild mortality risk.
The SARC-F score was positively correlated with smoking exposure (pack-years) (r = 0.406, p=0.036) and negatively correlated with the Lawton–IADL score (r = −0.468, p=0.014) and the Barthel Index (BI) score (r = −0.572, p=0.002) (Table 1, Figure 2).
Post hoc power analysis indicated that the study achieved a statistical power of 94% (1 − β = 0.94) based on correlation analysis between SARC-F and BI scores in our sample at an alpha level of 0.05.

Discussion

This study investigated the potential relationships between the risk of sarcopenia, limitations in ADLs, and quality of life in patients with COPD exacerbation. The main findings of this study were that increased sarcopenia risk is associated with greater limitations in both basic and instrumental ADLs during COPD exacerbation. This study showed that ADL limitation can be an indicator of sarcopenia risk during COPD exacerbations. Therefore, ADL status can be used as a predictor of sarcopenia during exacerbation periods, to support the application of protective pulmonary rehabilitation approaches, and subsequently for early identification of sarcopenia as a treatable trait in COPD.
Bendixen et al. reported in a study of 80 hospitalized patients with COPD exacerbations that patients frequently report markedly reduced efficiency and increased fatigue during ADLs across multiple domains, with a substantial proportion requiring assistance for household tasks independent of age, gender, and clinical features of the disease.¹⁸ Evidence from pedometer-based monitoring demonstrates that COPD exacerbations lead to a rapid decline in daily physical activity, while frequent exacerbations contribute to an accelerated decline in activity over time.¹⁸ There is a vicious cycle between physical inactivity, limitations in ADLs, and sarcopenia. Whereas physical inactivity leads to muscle disuse atrophy and adverse changes in muscle structure, sarcopenic patients with COPD exhibit slower gait speed, poorer performance in activities of daily living, and greater physical limitations.^1,19 The reason for the relatively low percentage (14%) of patients who are severely dependent on basic ADLs could be related to the fact that most patients have moderate comorbidity severity based on the CCI score and retain more than 50% of their muscle strength.
Previous studies have demonstrated a high prevalence of malnutrition among patients hospitalized with acute exacerbations of COPD, characterized by low body weight, reduced BMI values, and diminished anthropometric indices. Nutritional impairment was shown to be closely associated with pulmonary function, with body weight correlating positively with FEV₁/FVC.²⁰ Patients with COPD are at increased risk of malnutrition and sarcopenia. Nutritional status was reported to influence antioxidant and anti-inflammatory capacity and is inversely associated with the risk of developing sarcopenia.²¹ Poberezhets et al. identified low BMI, increased visceral adiposity and body fat percentage, reduced physical activity, and severe airflow limitation as key factors associated with sarcopenia in patients with COPD.²² As expected, most of our hospitalized patients with COPD exacerbation and severe disease status (mean FEV1 = 40.46 ± 13.81%) had malnutrition risk (37.0%), and 29.6% of them were malnourished in accordance with previous findings. In our study, spirometric assessment based on GOLD 2026 criteria revealed that 26.9% of patients had moderate, 38.5% had severe, and 38.6% had very severe airway obstruction. The high prevalence of severe and very severe disease points to an advanced COPD population. The GOLD guidelines support the clinical significance of our findings by emphasizing that advanced airway restriction is associated with worse clinical outcomes.
Sarcopenia emerges as a major determinant of impaired health-related quality of life in patients with COPD, amplifying perceived physical limitations and leading to markedly reduced functional capacity compared with non-sarcopenic patients.¹ Sarcopenic patients were shown to be more symptomatic and have impaired health-related quality of life based on CAT scores despite similar mmMRC dyspnea scores with the non-sarcopenic group.²² Patients with COPD and sarcopenia exhibited significantly higher total and activity-related St George Respiratory Questionnaire scores, indicating poorer health-related quality of life, particularly due to greater physical activity limitations in another study.²³ Based on our findings, health status and symptom perception were severely/very severely affected in 85.2% of patients with COPD exacerbation. This was an expected finding that incorporates a study sample with severe COPD, and most of them were at risk of sarcopenia and activity limitation. The lack of an association between ADL limitations and health-related quality of life may be attributable to the predominance of male patients in our sample and the use of patient-reported outcome measures to assess ADLs. As these instruments primarily reflect functional capacity under stable conditions, assessment during an exacerbation period may have led to an underestimation of patients’ baseline functional abilities. Acute symptoms such as dyspnea, fatigue, and hospitalization-related restrictions may have influenced patients’ responses, potentially limiting the generalizability of the findings to stable COPD populations. However, the assessments provide valuable information on functional impairment during acute exacerbation, which is clinically relevant for discharge planning and pulmonary rehabilitation needs.

Limitations

This study has several limitations. Firstly, the relatively small sample size (n = 27) and the predominance of male participants may limit the generalizability of the findings to the broader COPD population. Secondly, the cross-sectional design precludes the establishment of causal relationships between sarcopenia risk and functional or clinical parameters. Sarcopenia, defined by the fat-free mass index, was significantly associated with sarcopenia risk as assessed by the SARC-F questionnaire in a cohort of patients with COPD aged ≥50 years, supporting the clinical utility of SARC-F as a practical screening tool for the early identification of sarcopenia in patients with COPD.²⁴ The strength of our study was that close relations of SARC-F score with both basic and instrumental ADLs confirmed that evaluating ADL performance could be used to identify or predict sarcopenia risk in COPD exacerbation.

Conclusion

In conclusion, patients hospitalized with COPD exacerbation exhibit a very high risk of sarcopenia, which is closely associated with functional dependency. The significant relationship between SARC-F scores and daily living activities underscores the clinical relevance of sarcopenia screening during acute exacerbations. These findings support the routine use of SARC-F and monitoring limitations in ADLs during the exacerbation phase, which may enable early identification of high-risk patients and support timely, function-tailored pulmonary rehabilitation strategies.

Declarations

Abbreviations

ADLs: Activities of daily living
BI: Barthel Index
CAT: COPD Assessment Test
CCI: Charlson Comorbidity Index
COPD: Chronic obstructive pulmonary disease
EWGSOP-2: European Working Group on Sarcopenia in Older People 2
FEF25-75%: Forced expiratory flow at 25–75% of pulmonary volume
FEV₁: Forced expiratory volume in 1 second
FVC: Forced vital capacity
GOLD: Global Initiative for Chronic Obstructive Lung Disease
HGS: Handgrip strength
Lawton-IADLs: Lawton Instrumental Activities of Daily Living scale
mMRC: Modified Medical Research Council dyspnea scale
MNA-SF: Mini Nutritional Assessment Short Form
PEF: Peak expiratory flow
PFT: Pulmonary function test
SARC-F: Strength, Assistance with walking, Rise from a chair, Climb stairs
STROBE: Strengthening the Reporting of Observational Studies in Epidemiology

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About This Article

Received:

January 28, 2026

Accepted:

April 18, 2026

Published Online:

April 20, 2026