Pathy's Principles and Practice of Geriatric Medicine - Группа авторов

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Memory clinic Full CGA Supportive care Comorbidities function Anorexia Dependence for feeding Social support needs Depression GDS (geriatric depression scale) Non‐drug and drug treatment Anorexia Self‐care impairment Delirium CAM (confusion assessment method) Search for causes Nursing Anorexia Function Risk of falls Clinical exam Timed ‘get up and go’ test Unipodal stance SPPB (risk for disability) Nutritional exam Search for causes Physiotherapy Incentive for physical activities Nutritional support Malnutrition may be a causal factor ADL (basic daily living activities) IADL (instrumental activities, including housekeeping, budget and drugs management, phone, and transportation) Sensorial loss Katz scale Barthel Index Lawton and Brody scale Rehabilitation Human help Technical aids Budget control (family, lawyer) Specialist treatment Environmental adaptation Impaired access to food Impaired choice of food Pathologies Morbidities Search for history Clinical exam Cancer screening Creatinine clearance Blood cell count, serum albumin, CRP dosage Specialized advice Grading inflammation Integrative management Causes of malnutrition Inadequate diet Treatment Treatment conciliation Search for adverse effects and interactions Benefit/risk ratio Treatment optimization Education Human help for treatment handling Causes of malnutrition (adverse event) Nutrition BMI MNA Weight history Swallowing test Constipation and faecal impaction screening Oral exam Nutrition counselling Meal texture adaptation Housekeeper for shopping and meal preparation Meals on wheel Regulation of intestinal transit Dental treatment and oral health hygiene (asialia, candidiosis, dental plaque, loss of occluding pairs) Social Family and other caregivers Environment Needs and abilities of caregivers Support of caregivers Education Plan of care and follow‐up Difficulties in providing nutritional support Socioeconomic Social and financial possibilities Help to obtain financial resources Difficulties in providing adequate food Financial management ability Help from close relations, or asking for legal protection Difficulties in providing adequate food

      MMSE, Mini‐Mental State Examination; MOCA, Montreal Cognitive Assessment; SPPB, Short Physical Performance Battery.

      Bed rest reduces muscle protein synthesis and induces a loss of lean body mass, a model that simulates sarcopenia due to inactivity. Essential amino acid supplementation has been shown to stimulate muscle protein synthesis in healthy volunteers to a greater extent than meals, intact proteins, or similar energy intake. Continued stimulation of muscle anabolism positively affects the preservation of lean body mass and the amelioration of functional decrement throughout inactivity. However, in the setting of critical illness, the loss of lean body mass is exacerbated by persistent hypercortisolaemia. Although essential amino acids promote muscle anabolism during hypercortisolaemia, it is unlikely that a nutritional intervention alone would be effective in maintaining lean body mass during severe stress or prolonged hypercortisolaemia.82

      During hospitalization, comprehensive management of nutritional risk, including nutritional support and early exercising, does not produce a significant body weight increase but prevents loss of functional independence,83 particularly in those with bed rest.84

      Several studies suggest a potential benefit of creatine, especially when combined with exercise, to increase phosphocreatine stores in the muscle and replenish phosphocreatine and adenosine triphosphate, but more studies are needed to confirm these findings. In patients with chronic obstructive pulmonary disease (COPD), combined daily supplementation with creatine 340 mg and 320 mg coenzyme Q‐Ter resulted in increased lean body mass and exercise tolerance as compared to placebo.85

      Various orexigenic stimulants to improve body weight have been studied. Corticosteroids have improved appetite but have not demonstrated a gain in body weight in clinical trials. Cyproheptadine has been shown to increase appetite in cancer patients without weight gain. Cannabinoids (dronabinol, marinol, and nabilone) have shown promise in improving mood and appetite in cancer patients and AIDS cachexia. Thalidomide, a tumour necrosis factor inhibitor, has produced body weight gain in a small number of patients with HIV‐associated wasting syndrome.

      Of the pharmacological agents demonstrated to produce weight gain in patients with anorexia and cachexia, megestrol acetate has been the most widely studied agent. In a meta‐analysis of 26 trials, megestrol acetate was found to increase appetite, produce weight gain, and improve health‐related quality of life in oncology patients, compared with placebo. In AIDS patients, increased weight was demonstrated. Only oedema was significant as an adverse event.86

      Steroids and hormonal agents such as megestrol acetate are currently widely used in the treatment of cachexia and anorexia. They act through multiple pathways, such as increasing neuropeptide‐Y levels to increase appetite and downregulating proinflammatory cytokines. Pharmacological treatment of anorexia with agents that modulate cytokine production may produce weight gain in cachexia states. The action of thalidomide has been linked to inhibition and degradation of TNF‐α.87 The results of these pharmacological trials raise the interesting hypothesis that the improvement in appetite and weight gain may be related to their effect on cytokines.

      Involuntary weight loss has an intensified effect on mortality and disability risk and is usually associated with clinical illness. Some data suggest that even voluntary weight loss in older people may carry a higher mortality risk. Body weight is an easily obtained clinical measurement, and weight loss is a profound marker for adverse outcomes.

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