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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 61:707-712 (2006)
© 2006 The Gerontological Society of America

Handgrip Strength Among Nonagenarians and Centenarians in Three European Regions

Bernard Jeune, Axel Skytthe, Amandine Cournil, Valentina Greco, Jutta Gampe, Maurizio Berardelli, Karen Andersen-Ranberg, Giuseppe Passarino, Giovanna DeBenedictis and Jean-Marie Robine

1 Aging Research Centre and Epidemiology, Institute of Public Health, University of Southern Denmark.
2 INSERM, Health and Demography, University of Montpellier, France.
3 Dipartimento di Biologia Cellulare, Università degli Studi della Calabria, Rende, Italy.
4 Max-Planck-Institut für demografische Forschung, Rostock, Germany.

Address correspondence to Bernard Jeune, MD, Aging Research Center, and Epidemiology, Institute of Public Health, University of Southern Denmark, J. B. Winsløws Vej 9B, 5000 Odense C, Denmark. E-mail: bjeune{at}health.sdu.dk


   Abstract
Top
 Abstract
Materials and Methods
 Results
 Discussion
 References
 
Background.Handgrip strength is an important predictor of disability and mortality among old people. The aim was to compare the grip strength among very old people in three regions of Europe.

Methods.In this substudy of the European Challenge for Healthy Aging project, only the long-lived probands were included. The maximum value of three measurements of handgrip strength was selected for the analysis. Adjustment for factors known to be correlated with grip strength was made by linear regression.

Results.Among 598 very old people (median age = 98 years) a clear North–South gradient was observed: For men, handgrip strength dropped from 24.2 kg in Southern Denmark to 20.8 kg in Languedoc-Roussillon, France and 14.2 kg in Calabria, Italy (p <.0001), whereas for women the drop was smaller (from 12.2 to 9.2 kg; p =.0021). The difference remains significant after adjustment for age, gender, housing, knee height, Activities of Daily Living (ADL) scale score, score on the Six-Item Mini-Mental State Examination, chair stand, and number of age-related diseases, although these factors explain two thirds of the variation in handgrip strength.

Conclusions.Among nonagenarians and centenarians in three different European regions, we found a significant North–South gradient in handgrip strength with substantially lower values in Calabria. This finding may be due both to population background differences (e.g., genetic variations, birth weight, childhood growth) and to sociocultural differences (e.g., lifestyle, health care).

HANDGRIP strength has been found to be a good indicator of overall muscle strength (1–3). It peaks between the ages of 20 and 40, and declines beyond the age of 40 (4–6). At every age beyond adolescence, handgrip strength among men is almost twice the strength of women (2,3,7). It is also a useful single marker of frailty (8), and is significantly associated with important inflammatory markers such as C-reactive protein and interleukin-6 (9). It has been shown to be an important predictor of disability and mortality (7,10–15).

Age-related changes such as decreasing physical activity, loss of muscle mass, alterations in muscle fibers, decreasing hormone levels, chronic diseases, and malnutrition may all have an impact on the decline of handgrip strength (5,8,13,15). Earlier life conditions such as early life nutrition and exercise habits may affect midlife muscle strength (16). Genetic effects seem to have a moderate to relatively high impact on handgrip strength (17–19).

Comparisons of handgrip strength across different populations have been hampered due to different measurement tools and methods (1–3,7–12,18). Furthermore, the amount of available data on persons 90 years old or older is limited. Comparison of handgrip strength across regions may provide some insight as to historical regional differences in genetic factors, nutritional deficiencies, and/or sociocultural environment. The aim of the present study was to compare the handgrip strength of nonagenarians and centenarians in three different European regions extending from the North to the South of Europe.


   MATERIALS AND METHODS
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 Abstract
 Materials and Methods
Results
 Discussion
 References
 
The present study is a substudy of the European Challenge for Healthy Aging (ECHA) project. The ECHA project used a family-based design, including a long-lived proband and a child and a nephew or niece of this proband. A condition for a long-lived person to be included was to have at least one living child.

The ECHA project included three sampling areas in Europe with very different populations—Southern Denmark, Languedoc-Roussillon in Southern France, and Calabria in Southern Italy. Each area has between 1.6 and 2.3 million inhabitants. A higher male/female ratio among centenarians (20) is found in Calabria than in the two other regions. To obtain approximately equal numbers of women and men, different age criteria for long-lived probands were used: ≥98 years for women and ≥95 years for men.

Due to the different population registration methods in the three areas, it was necessary to apply different sampling procedures. In Denmark, the national central population register was used to identify eligible long-lived persons. Because the population register does not hold any information about family relations for cohorts born before 1953, the participants were asked during the initial contact whether they had living children. In Calabria, no central population register covering the whole population exists. Instead, population registration takes place at the municipal level through the Anagraphe system. A letter was sent to all municipalities asking for lists of long-lived persons. If a municipality reported long-lived persons, the Anagraphe was searched for information about the long-livers' family. Birth, marriage, and death registration in Languedoc-Roussillon takes place at the local level, but unlike in Calabria, no available register of residents exists. Instead, all general practitioners and nursing homes were contacted by telephone about possible long-livers. After being identified, the long-lived proband was asked whether they had living children.

By the end of the 2-year sampling and examination period (mid-2002 to mid-2004), the following numbers of persons had been interviewed and examined in the three regions: in Southern Denmark, 269 probands and 308 children and nephews/nieces; in Calabria, 182 probands and 243 children and nephews/nieces; and in Languedoc-Roussillon, 147 probands and 200 children and nephews/nieces. Only the long-lived probands are included in this substudy—in all, 598 nonagenarians and centenarians. The participation rate of the probands was similar in Southern Denmark and Calabria (76.4% vs 78.2%). Due to the special identification procedure in France, a comparable participation rate could not be calculated. The different numbers of probands in the three regions was mainly due to the different difficulties in the procedures of identification.

The interview included information on sociodemographic factors, self-reported age-related diseases (diabetes, hypertension, angina pectoris, heart failure, irregular heart rhythm, asthma, chronic bronchitis, arthrosis, depression, osteoporosis, cancer), functional status, as well as measurements of cognitive function and physical performance. The number of self-reported diseases was used as an index of comorbidity. Functional status was assessed according to the Katz Index of Activities of Daily Living (ADL) and was grouped into two groups. Index A–C signify the lowest level of disability (the participant is able to perform at least four of the following tasks: feeding, dressing, transfer from bed, bathing, going to toilet, and control of urination and bowel movements), and Index D–G, the highest level of disability (fewer than four tasks could be performed) (21). Cognitive function was assessed using the Mini-Mental State Examination (MMSE). Due to a relatively high proportion of illiterate participants in Calabria, the Six-Item MMSE (which year, which month, which day of week, delayed recall of three words) (22) was used in this substudy, with a score >3 indicating nonimpairment.

Knee-to-floor height was measured in Southern Denmark and Calabria. In Languedoc-Roussillon, self-reported height was noted. The participants from Calabria had a smaller knee height than did the Danish participants. For a subset of the participants, both self-reported height and knee height were ascertained, but estimated height from knee height according to (23) did not yield comparable results with self-reported height in both regions.

The assessment of physical performance included measurement of handgrip strength, chair stand, and walking speed. Participants not able to understand or carry out the instruction (e.g., some of the bedridden or demented participants) were excluded. In addition, assessment of walking speed was carried out only when the interviewer was confident that the test could be done safely. Consequently, a small number of participants (<60%) took the walking test. We therefore only consider handgrip and chair stand as physical performance tests in this study. Handgrip strength was measured with a handgrip dynamometer (Smedley, model 281128; Scandidact, Kvistgaard, Denmark) under standard conditions. The maximum value in kilograms of three measurements on the hand of choice was selected for the analysis.

Differences between two groups were tested by t test, whereas one-way analysis of variance was used for testing differences between several groups. Linear regression was used to estimate the influence of age, gender, region, housing condition, chair stand, ADL score, Six-Item MMSE score, and self-reported diseases on handgrip strength, and knee-height (for Southern Denmark and Calabria). All analyses were done using Stata 8 (StataCorp LP, College Station, TX).


   RESULTS
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 Materials and Methods
 Results
Discussion
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The basic characteristics of the participants are shown in Table 1. The proportion of participants who lived in nursing homes is about the same for Southern Denmark and Languedoc-Roussillon, but extremely low in Calabria (where about one half lived in the homes of their family). In Southern Denmark, almost no participants were bedridden, whereas in Calabria a substantial proportion of women were bedridden. Nevertheless, the proportion of those participants with the lowest level of disability (Index of ADL: A–C) was approximately the same in the three regions. A lower proportion of the participants in Calabria had a Six-Item MMSE score >3 than in Southern Denmark and Languedoc-Roussillon.


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  		Table 1. Basic Characteristics of the Study Sample.

 
Handgrip was measured in 476 (80%) of the 598 participants, with a slightly higher proportion in Southern Denmark and Languedoc-Rousillon than in Calabria: 225 (83.6%) and 118 (80.3%) versus 133 (73.1%). It was possible to measure handgrip strength in about half of the bedridden probands (in 3 of 4 in Southern Denmark, in 5 of 10 in Languedoc-Rousillon, and in 19 of 38 in Calabria). The lower proportion in Calabria was therefore due in part to the high number of bedridden participants in that region.

Measured handgrip strength (Table 2) is significantly higher for men than for women in each of the three regions (p <.0001). A clear North–South gradient is observed for men: The mean handgrip strength is reduced from 24.2 kg in Southern Denmark to 14.2 kg in Calabria, with Languedoc-Roussillon in between (p <.0001). Although the North–South gradient among women was smaller, it was significant (from 12.2 kg to 9.2; p =.0021). The North–South gradient is also evident for the measurements of handgrip strength at every level of disability, cognitive function, chair stand, and comorbidity.


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  		Table 2. Unadjusted Handgrip Measurements for the Study Sample, and Distributed on Housing Condition, Index of ADL, Six-Item MMSE, Chair Stand, and Reported Diseases.

 
The unadjusted handgrip strength among those participants who lived in their own home was higher than for those living in a nursing or proxy home in Southern Denmark and Languedoc-Roussillon (p <.005), but not in Calabria (p =.66). However, the mean grip strength among participants with the lowest level of disability was much higher than that among participants with the highest level of disability in all three regions, i.e., including Calabria (p <.0001). In all regions, participants with a Six-Item MMSE score >3 had a higher handgrip strength compared to those with a low score, and those who were able to rise from a chair had higher handgrip strength than those who were not. However, handgrip strength among participants with no self-reported diseases was approximately the same as that in participants with one or more diseases.

In Calabria, handgrip strength was significantly lower for bedridden women than for those who were not bedridden (5.6 kg vs 10.2 kg; p =.0003). Among the few bedridden men, the difference was not significant (11.4 kg vs 14.4 kg; p =.23).

Adjusted for age and gender but without other explanatory variables, handgrip was 2.4 kg lower (p <.0005) in Languedoc-Roussillon and 6.4 kg lower (p <.0005) in Calabria than in Southern Denmark. In Table 3, the regression coefficients for both the full model (including all explanatory factors) and the reduced model (with only significant factors) are shown. The coefficients indicate that handgrip strength is 2.2 kg lower among the French participants and 5.6 kg lower among Calabrian participants than among the Danish participants; both differences are strongly significant. Disability level, cognitive function, and chair stand were also significantly related to handgrip strength, with poorer performance associated with lower handgrip strength. However, housing condition, being bedridden, or number of self-reported diseases was not significantly associated with handgrip strength in this analysis. Adding knee height to the model (only for Southern Denmark and Calabria) reduced the difference between Southern Denmark and Calabria by 0.6 kg, but knee height was not significantly related to handgrip strength in this analysis. Otherwise, the association of handgrip with ADL, Six-Item MMSE, and chair stand was of a size comparable to that in the analyses without knee-height. The factors included explained about two thirds of the variation in handgrip strength in both models (R2 = 0.68 and R2 = 0.64, respectively).


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  		Table 3. Regression Coefficients for the Influence of Region, Gender, Age, Housing Condition, Index of ADL, Six-Item MMSE, Chair Stand, and Reported Diseases on Handgrip.

 

   DISCUSSION
Top
 Abstract
 Materials and Methods
 Results
 Discussion
References
 
Among nonagenarians and centenarians (median age {approx}98 years) we found a clear North–South gradient of mean handgrip strength in three European populations. The North–South gradient remained significant after adjustment for age, gender, knee height, housing condition, ADL score, Six-item MMSE score, chair stand, and comorbidity, although these factors explained two thirds of the variation in handgrip strength.

The strength of this study is that the same design and the same method for measuring handgrip strength were used in each region. Furthermore, the examiners in the three regions went through a common training course. The weakness of the study is that the three populations were not random samples of nonagenarians and centenarians, as the participants included were only those who had living children. Furthermore, the different recruitment procedure, which had to be applied in Languedoc-Roussillon, may have resulted in a different selection of the participants, although the proportion living in a nursing home corresponds to the proportion of centenarians in a nursing home in France—i.e., one third of the men and one half of the women (24). Finally, the proportion of the participants with measured handgrip strength was a little lower in Calabria than in Southern Denmark and Languedoc-Roussillon, in part due to a higher proportion of bedridden participants.

The differences in housing conditions and care of old people might explain part of the North–South gradient. However, the adjustment for housing conditions and number of bedridden participants did not change the means of handgrip strength in the three regions very much. Furthermore, adjusting for disability, cognitive function, and chair stand removed the association with housing condition and being bedridden.

Because several studies (3,4,7,16,23) have shown that handgrip strength is correlated to height, it could be expected that the higher stature of Danes and lower stature of Calabrians may explain a part of the North–South gradient. Height is not easy to measure in nonagenarians and centenarians, and actual height does not reflect very well the earlier adult height. Knee height better estimates the elderly person's original height (23). As we could confirm that conversion equations are sensitive to the population from which they are derived (25), we adjusted directly for knee height for participants in Southern Denmark and Calabria. It was surprising that adjustment for knee height had little influence on the North–South gradient.

Several studies have found that handgrip is strongly correlated to physical function, cognitive function, and age-related diseases (6–8,10,11,16,26). However, adjustment for these factors, including chair stand, had only a moderate influence on the regional differences (from 2.4 to 2.2 kg between Southern Denmark and Languedoc-Roussillon, and from 6.4 to 5.6 kg between Southern Denmark and Calabria).

Although the factors mentioned above explain only a small proportion of the North–South gradient, they explain the main part of the variation in handgrip strength. That handgrip strength is strongly correlated with functional status (e.g., ADL) and physical performance (e.g., chair stand) is well known (26).

In twin studies, a moderate to relatively high genetic influence explains about one third to one half of the variation in grip strength (17–19). A proportion of the North–South gradient may therefore be explained by genetic differences between the three populations. We have earlier found a difference in the frequency of an important longevity-related gene between Danish and Calabrian centenarians (27).

A British study (28) found that birth weight had independent effects on grip strength in adults 60–69 years old. It is possible that birth weight was lower in Calabria than in Denmark 100 years ago as the social differences at that time were even more marked than today. Poor economic development and bad sanitary conditions entail malnutrition and infections, both increasing infant mortality and limiting the growth of the children. Data from the Human Mortality Database (http://www.mortality.org) indicate a clear North–South gradient in the life expectancy of people born in 1905 in Denmark, France, and Italy: 53.0, 46.6, and 44.2 years for men and 55.8, 50.3, and 43.7 years for women. The same pattern is seen for the infant mortality rate in 1905, which was 0.108, 0.153, and 0.170 for girls, and 0.130, 0.126, and 0.156 for boys.

This is the first study reporting measurements of handgrip strength among nonagenarians and centenarians in different European populations. As declining and low handgrip strength is a good indicator of frailty (8), and a high proportion of centenarians is very frail (29,30), it is not surprising that the mean grip strength of these very old people was very low in all three regions. Compared to the earlier studies on handgrip strength among nonelderly adults (1,4,7–11,13,15,16,18,25,27), it seems that grip strength is about halved among the Danish and French nonagenarians and centenarians in this study. However, grip strength is substantially lower among the Calabrian nonagenarians and centenarians. It seems probable that this substantial European North–South gradient in handgrip strength among the very old is due to both population background (differences in genetic variation, birth weight, and childhood growth) and sociocultural factors (differences in lifestyle and public health care for old people). Longitudinal data are needed to clarify which of these factors are the most important.


   Acknowledgments
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 Materials and Methods
 Results
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This work was supported by grants from the European Union (ECHA, No: QLRT-2001-00128, Call Identifier: QOL-2001-3), the Danish Health Insurance Foundation (Sygekassernes Helsefond, j.nr. 2003B059), and the Foundation Caisse d'Epargne Rhône-Alpes Lyon (CERAL), France.

The scientific-ethical approval of the three regional studies was given from the Scientific-Ethical Committee of the Counties of Funen, Vejle, Ribe, Ringkøbing, and Sønderjylland (Denmark); the Ethical Committee of the University of Calabria, Rende (Italy); and the Ethical Committee of the University Hospital of St. Antoine, Paris, France.


   Footnotes
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Decision Editor: Luigi Ferrucci, MD, PhD

Received June 16, 2005

Accepted December 29, 2005


   References
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 Materials and Methods
 Results
 Discussion
 References
 

  1. Rantanen T, Era P, Kauppinen M, Heikkinen E. Maximal isometric muscle strength and socio-economic status, health and physical activity in 75-year-old persons. J Aging Phys Activity. 1994;2:206-220.
  2. Richards L, Palmiter-Thomas P. Grip strength measurement: a critical review of tools, methods, and clinical utility. Phys Rehabil Med. 1996;8:87-109.
  3. Innes E. Handgrip strength testing: a review of the literature. Austral Occup Ther J. 1999;46:120-140.
  4. Hinson M, Gench BE. The curvilinear relationship of grip strength to age. Occup Ther J Res. 1989;9:53-59.
  5. Kallman DA, Plato CC, Tobin JD. The role of muscle loss in the age-related decline of grip strength: cross-sectional and longitudinal perspectives. J Gerontol Med Sci. 1990;45:M82-M88.
  6. Rantanen T, Masaki K, Foley D, Izmirlian G, White L, Guralnik JM. Grip strength changes over 27 years in Japanese-American men. J Appl Physiol. 1998;85:2047-2053.[Abstract/Free Full Text]
  7. Bassey EJ, Harries UJ. Normal values for handgrip strength in 920 men and women aged over 65 years, and longitudinal changes over 4 years in 620 survivors. Clin Sci. 1993;84:331-337.[Medline]
  8. Syddall H, Cooper C, Martin F, Briggs R, Sayer AA. Is grip strength a useful single marker of frailty? Age Ageing. 2003;32:650-656.[Abstract/Free Full Text]
  9. Cesari M, Penninx BW, Pahor M, et al. Inflammatory markers and physical performance in older persons: the In CHIANTI study. J Gerontol A Biol Sci Med Sci. 2004;59A:242-248.
  10. Nybo H, Petersen HC, Gaist D, et al. Predictors of mortality in 2,249 nonagenarians—the Danish 1905-Cohort Survey. J Am Geriatr Soc. 2003;51:1365-1373.[Medline]
  11. Giampaoli S, Ferrucci L, Cecchi F, et al. Hand-grip strength predicts incident disability in non-disabled older men. Age Ageing. 1999;28:283-288.[Abstract/Free Full Text]
  12. Philips P. Grip strength, mental performance and nutritional status as indicators of mortality risk among female geriatric patients. Age Ageing. 1986;15:53-56.[Abstract/Free Full Text]
  13. Rantanen T, Guralnik JM, Foley D, et al. Midlife hand-grip strength as a predictor of old age disability. JAMA. 1999;281:558-560.[Abstract/Free Full Text]
  14. Rantanen T, Harris T, Leveille SG, et al. Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. J Gerontol Med Sci. 2000;55A:M168-M173.[Abstract/Free Full Text]
  15. Snih SA, Markides KS, Ray L, Ostir GV, Goodwin JS. Handgrip strength and mortality in older Mexican Americans. J Am Geriatr Soc. 2002;50:1250-1256.[Medline]
  16. Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip strength and cause-specific and total mortality in older disabled women: exploring the mechanism. J Am Geriatri Soc. 2003;51:636-641.[Medline]
  17. Carmelli D, Reed T. Stability and change in genetic and environmental influences on hand-grip strength in older male twins. J Appl Physiol. 2000;89:1879-1883.[Abstract/Free Full Text]
  18. Frederiksen H, Gaist D, Petersen HC, et al. Hand-grip strength: a phenotype suitable for identifying genetic variants affecting mid- and late-life physical functioning. Genet Epidemiol. 2002;23:110-112.[Medline]
  19. Tiainen K, Sipilä S, Alen M, Heikkinen E, et al. Heritability of maximal isometric muscle strength in older female twins. J Appl Physiol. 2004;96:173-180.[Abstract/Free Full Text]
  20. Passarino G, Calignano C, Vallone A, et al. Male/female ratio in centenarians: a possible role played by population genetic structure. Exp Gerontol. 2002;37:1283-1289.[Medline]
  21. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW, Cleveland MA. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914-919.[Abstract/Free Full Text]
  22. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40:771-781.[Medline]
  23. Haboubi NY, Hudson PR, Pathy MS. Measurement of height in the elderly. J Am Geriatr Soc. 1990;38:1008-1010.[Medline]
  24. Allard M, Robine JM. Les Centenaires Francais. Paris, France: Serdi Edition; 2000.
  25. Mendoza-Núnez VM, Sanchez-Rodriguez MA, Cervantes-Sandoval A, Correa-Munoz E, Vargas-Guadarrama LA. Equations for predicting height for elderly Mexican Americans are not applicable for elderly Mexicans. Am J Hum Biol. 2002;14:351-355.[Medline]
  26. Hughes S, Gibbs J, Dunlop D, Edelman P, Singer R, Chang RW. Predictors of decline in manual performance in older adults. J Am Geriatr Soc. 1997;45:905-910.[Medline]
  27. Varcasia O, Garasto S, Rizza T, et al. Replication studies in longevity: puzzling findings in Danish centenarians at the 3'APOB-VNTR locus. Ann Hum Genet. 2001;65:371-376.[Medline]
  28. Sayer AA, Sydall HE, Gilbody HJ, Dennison EM, Cooper C. Does sarcopenia originate in early life? Findings from the Hertfordshire Cohort Study. J Gerontol A Biol Sci Med Sci. 2004;59A:930-934.
  29. Andersen-Ranberg K, Schroll M, Jeune B. Healthy centenarians do not exist, but autonomous centenarians do: a population-based study of morbidity among Danish centenarians. J Am Geriatr Soc. 2001;49:900-908.[Medline]
  30. Bruunsgaard H, Andersen-Ranberg K, Hjelmborg JB, Pedersen BK, Jeune B. Elevated levels of tumor necrosis factor alpha and mortality in centenarians. Am J Med. 2003;115:278-283.[Medline]




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