Korean Journal of Family Medicine (가정의학회지)

The Korean Academy of Family Medicine (대한가정의학회)
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Integrative Approach to Elderly Frailty

노인 허약에 대한 통합의학적 접근

  • Park, Byoung-Jin (Department of Family Medicine, Yonsei University College of Medicine) ;
  • Lee, Yong-Jae (Department of Family Medicine, Yonsei University College of Medicine)
  • 박병진 (연세대학교 의과대학 가정의학교실) ;
  • 이용제 (연세대학교 의과대학 가정의학교실)
  • Received : 2010.07.28
  • Accepted : 2010.10.15
  • Published : 2010.10.20
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Abstract

Elderly frailty has been recognized as a distinct clinical syndrome with a physiologic basis. It reflects a decreased functional reserve and consequent reduction in resilience to any stressors. It is important to understand that frailty process could be a transitional state with dynamic properties: normal aging${\rightarrow}$pre-frail${\rightarrow}$frailty${\rightarrow}$complication status. Hence, frailty could be preventable and its progression may be delayed. Furthermore, there is the potential reversibility of many of its features. The earlier stages of frailty might not be clinically apparent, but later stages manifest as significant deficits accumulate. The major phenotype of frailty includes weight loss, sarcopenia, relative inactivity, decreased balance and mobility, decreased cognitive function, and impaired nutritional status. Therefore, frail patients could be implicated by decreased performance status and have a significantly increased risk of cardiovascular diseases, cancer, falls and mortality. Regular exercise, essential amino acid and vitamin D are recommendable to prevent and treat elderly frailty, but hormone replacement therapy does not have consistent evidence yet. In upcoming (super) aging society, the importance of elderly frailty would be more noticed and multidisplinary approach should be actively performed.

'노인 허약'은 생리학적 기전에 근거한 정상 노화와 구별 된 뚜렷한 '임상 증후군'이다. 또한, '노인 허약'은 '정상 노화'${\rightarrow}$'전허약'${\rightarrow}$'노인 허약'${\rightarrow}$'노인병'으로 이어지는 역동성의 관점에 서 이해해야 한다. '노인 허약'은 자신의 능동적 노력에 따라 충분히 가역적인 특징이 있다. 초기에는 증상이 뚜렷하지 않으나 점차 진행할수록 호소하는 증상이 증가한다. 체중 감소, 근육 감소(sarcopenia), 활동량 감소, 균형감각 및 보행 속도의 저 하, 인지기능 저하와 영양 부족 소견들이 관찰된다. 따라서, '노인 허약'이 있을 경우 이동 능력 등 일상생활 수행 기능이 저하되기 쉽고, 심혈관 질환, 암, 낙상의 발생 위험이 증가할 뿐 아니라 사망률이 증가한다. '노인 허약'의 예방과 치료를 위해서는 저항 운동이 포함된 운동요법, 비타민, 미네랄, 필수아미노산, 비타민 D 등의 영양요법의 권고 근거가 높으며, 호르몬 보충요법은 아직 근거가 미약하다. 향후 '노인 허약'에 대한 정확한 이해를 바탕으로 '노인 허약'의 예방 및 치료적 중재 가이드라인을 제시할 다 학제간 연구가 활발히 이루어질 것으로 기대한다.

Keywords

References

  1. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care. J Gerontol A Biol Sci Med Sci 2004;59:255-63. https://doi.org/10.1093/gerona/59.3.M255
  2. Fulop T, Larbi A, Witkowski JM, JcElhaney J, Loeb M, Mitnitski A, et al. Aging, frailty and age-related diseases. Biogerontology 2010;11:547-63. https://doi.org/10.1007/s10522-010-9287-2
  3. Ahmed N, Mandel R, Fain MJ. Frailty: an emerging geriatric syndrome. Am J Med 2007;120:748-53. https://doi.org/10.1016/j.amjmed.2006.10.018
  4. Lang PO, Michel JP, Zekry D. Frailty syndrome: a transitional state in a dynamic process. Gerontology 2009;55:539-49. https://doi.org/10.1159/000211949
  5. 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;56:M146-56. https://doi.org/10.1093/gerona/56.3.M146
  6. Wilson JF. Frailty-and its dangerous effects-might be preventable. Ann Intern Med 2004;141:489-92. https://doi.org/10.7326/0003-4819-141-6-200409210-00035
  7. Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med 2002;162:2333-42. https://doi.org/10.1001/archinte.162.20.2333
  8. Lenze EJ, Schulz R, Martire LM, Zdaniuk B, Glass T, Kop WJ, et al. The course of functional decline in older people with persistently elevated depressive symptoms: longitudinal findings from the Cardiovascular Health Study. J Am Geriatr Soc 2005;53:569-75. https://doi.org/10.1111/j.1532-5415.2005.53202.x
  9. Chin A Paw MJ, de Groot LC, van Gend SV, Schoterman MH, Schouten EG, Schroll M, et al. Inactivity and weight loss: effective criteria to identify frailty. J Nutr Health Aging 2003;7:55-60.
  10. Binder EF, Storandt M, Birge SJ. The relation between psychometric test performance and physical performance in older adults. J Gerontl A Biol Sci Med Sci 1999;54:M428-32. https://doi.org/10.1093/gerona/54.8.M428
  11. Abellan van Kan G, Rolland Y, Bergman H, Morley JE, Kritchevsky SB, Vellas B. The I.A.N.A task force on frailty assessment of older people in clinical practice. J Nutr Health Aging 2008;12:29-37. https://doi.org/10.1007/BF02982161
  12. Rockwood K, Song X, Macknight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489-95. https://doi.org/10.1503/cmaj.050051
  13. Iones DM, Song X, Rockwood K. Operationalizing a frailty index from a standardized comprehensive geriatric assessment. J Am Geriatr Soc 2004;52:1929-33. https://doi.org/10.1111/j.1532-5415.2004.52521.x
  14. Romero-Ortuno R, Walsh CD, Lawlor BA, Kenny RA. A Frailty Instrument for primary care: findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). BMC Geriatr 2010;10:57. https://doi.org/10.1186/1471-2318-10-57
  15. Klein BE, Klein R, Knudtson MD, Lee KE. Frailty, morbidity, and survival. Arch Gerontol Geriatr 2005;41:141-9. https://doi.org/10.1016/j.archger.2005.01.002
  16. Graham JE, Snih SA, Berges IM, Ray LA, Markides KS, Ottenbacher KJ. Frailty and 10-year motality in community-living Mexican American older adults. Gerontology 2009;55:644-51. https://doi.org/10.1159/000235653
  17. Rookwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol Biol Sci Med Sci 2007;62:722-7. https://doi.org/10.1093/gerona/62.7.722
  18. Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med 2002;162:2333-41. https://doi.org/10.1001/archinte.162.20.2333
  19. Villareal DT, Banks M, Siener C, Sinacore DR, Klein S. Physical frailty and body composition in obese elderly men and women. Obes Res 2004;12:913-20. https://doi.org/10.1038/oby.2004.111
  20. Abbatecola AM, Paolisso G. Is there a relationship between insulin resistance and frailty syndrome? Curr Pharm Des 2008;14:405-10. https://doi.org/10.2174/138161208783497750
  21. Evans WJ, Paolisso G, Abbatecola AM, Corsonello A, Bustaccini S, Strollo F, et al. Frailty and muscle metabolism dysregulation in the elderly. Biogerontology 2010;11:527-36. https://doi.org/10.1007/s10522-010-9297-0
  22. Rolland Y, Czerwinski S, Abellan Van Kan G, Morley JE, Cesari M, Onder G, et al. Sarcopenia: its assessment, etiology, pathogenesis, consequences and future perspectives. J Nutr Health Aging 2008;12:433-50. https://doi.org/10.1007/BF02982704
  23. Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace RB. Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability. N Engl J Med 1995;332:556-61. https://doi.org/10.1056/NEJM199503023320902
  24. Cesari M, Penninx BW, Newman AB, Kritchevsky SB, Nicklas BJ, Sutton-Tyrrell K, et al. Inflammatory markers and onset of cardiovascular events: results from the Health ABC study. Circulation 2003;108:2317-22. https://doi.org/10.1161/01.CIR.0000097109.90783.FC
  25. Leng SX, Chaves P, Koenig K, Walston J. Serum interleukin-6 and hemoglobin as physiological correlates in the geriatric syndrome of frailty: a pilot study. J Am Geriatr Soc 2002;50:1268-71. https://doi.org/10.1046/j.1532-5415.2002.50315.x
  26. Barzilay JI, Blaum C, Moore T, Xue QL, Hirsch CH, Walston JD, et al. Insulin resistance and inflammation as precursors of frailty: the Cardiovascular Health Study. Arch Intern Med 2007;167:635-41. https://doi.org/10.1001/archinte.167.7.635
  27. Morley J, Kim MJ, Haren MT. Frailty and hormones. Rev Endocr Metab Disord 2005;6:101-8. https://doi.org/10.1007/s11154-005-6722-9
  28. Hamrick MW, Herberg S, Arounleut P, He HZ, Shiver A, Qi RQ, et al. The adipokine leptin increases skeletal muscle mass and significantly alters skeletal muscle miRNA expression profile in aged mice. Biochem Biophys Res Commun 2010;400:379-83. https://doi.org/10.1016/j.bbrc.2010.08.079
  29. Leng S, Cappola AR, Anderson RE, Blackman MR, Koenig K, Blair M, et al. Serum levels of IGF-1 and DHEA-S and their relationship with IL-6 in the geriatric syndrome of frailty. Aging Clin Exp Res 2004;16:153-7. https://doi.org/10.1007/BF03324545
  30. Baumgartner RN, Waters DL, Gallagher D, Morley JE, Garry PJ. Predictors of skeletal muscle mass in elderly men and women. Mechanisms of ageing & Development 1999;107:123-36. https://doi.org/10.1016/S0047-6374(98)00130-4
  31. Matsumoto AM. Andropause: clinical implication of the decline in serum testosterone levels with aging in men. J Gerontol Med Sci 2002;57: M76-99. https://doi.org/10.1093/gerona/57.2.M76
  32. Wu IC, Lin XZ, Liu PF, Tsai WL, Shiesh SC. Low serum testosterone and frailty in older men and women. Maturitas. In press 2010.
  33. Hyde Z, Flicker L, Almeida OP, Hankey GJ, McCaul KA, Chubb SA, et al. Low free testosterone predicts frailty in older men: The Health in Men Study. J Clin Endocrinol Metab 2010;95:3165-72. https://doi.org/10.1210/jc.2009-2754
  34. Puts MT, Visser M, Twisk JW, Deeg DJ, Lips P. Endocrine and inflammatory markers as predictors of frailty. Clin Endocrinol 2005;63:403-11. https://doi.org/10.1111/j.1365-2265.2005.02355.x
  35. Schalk BW, Visser M, Deeg DJ, Bouter LM. Lower levels of serum albumin and total cholesterol and future decline in functional performance in older persons: the Longitudinal Aging Study Amsterdam. Age Ageing 2004;33:M962-5.
  36. Landi F, Russo A, Pahor M, Capoluongo E, Liperoti R, Cesari M, et al. Serum high-density lipoprotein cholesterol levels and mortality in frail, community-living elderly. Gerontology 2008;54:71-8. https://doi.org/10.1159/000111381
  37. Chaves PH, Semba RA, Leng SX, Woodman RC, Ferrucci L, Guralnik JM, et al. Impact of anemia and cardiovascular disease on frailty status of community-dwelling older women: the Women's Health and Aging Studies I and II. J Gerontol A Biol Sci Med Sci 2005;60:729-35. https://doi.org/10.1093/gerona/60.6.729
  38. Lebel P, Leduc N, Kergoat MJ, Latour J, Leclerc C. Un modele dynamique de la fragilite. In:Campbell AJ, editors. L'annee gerontologique. Paris: Serdi Press; 1999. p. 84–94.
  39. Pass RF, Zhang C, Evans A, Simpson T, Andrews W, Huang ML, et al. Vaccine prevention of maternal cytomegalovirus infection. N Engl J Med 2009;360:1191-9. https://doi.org/10.1056/NEJMoa0804749
  40. Larbi A, Pawelec G, Witkowski JM, Schipper HM, Derhovanessian E, Goldeck D, et al. Dramatic shifts in circulating CD4 but not CD8 T cell subsets in mild Alzheimer's disease. J Alzheimer Dis 2009;17:91-103. https://doi.org/10.3233/JAD-2009-1015
  41. Derhovanessian E, Solana R, Larbi A, Pawelec G. Immunity, aging and cancer. Immun Ageing 2008;5:11. https://doi.org/10.1186/1742-4933-5-11
  42. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007;116:1094-105. https://doi.org/10.1161/CIRCULATIONAHA.107.185650
  43. Taaffe DR, Duret C, Wheeler S, Marcus R. Once-weekly resistance exercise improves muscle strength and neuromuscular performance in older adults. J Am Geriatr Soc 1999;47:1208-14. https://doi.org/10.1111/j.1532-5415.1999.tb05201.x
  44. Judge JO, Lindsey C, Underwood M, Winsemius D. Balance improvements in older women: effects of exercise training. Phys Ther 1993;73:254-62.
  45. Xu DQ, Hong Y, Li JX. Tai Chi exercise and muscle strength and endurance in older people. Med Sport Sci 2008;52:20-9. https://doi.org/10.1159/000134281
  46. Cardinale M, Leiper J, Farajian P, Heer M. Whole-body vibration can reduce calciuria induced by high protein intakes and may counteract bone resorption: A prreliminary study. J Sports Sci 2007;25:111-9. https://doi.org/10.1080/02640410600717816
  47. Cardinale M, Rittweger J. Vibration exercise makes your muscles and bones stronger: fact or fiction? J Br Menopause Soc 2006;12:12-8. https://doi.org/10.1258/136218006775997261
  48. Cherniack EP, Florez HJ, Troen BR. Emerging therapies to treat frailty syndrome in the elderly. Altern Med Rev 2007;12:246-58.
  49. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B, et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 2005;293:2257-64. https://doi.org/10.1001/jama.293.18.2257
  50. Heiat A, Vaccarino V, Krumholz HM. An evidence-based assessment of federal guidelines for overweight and obesity as they apply to elderly persons. Arch Intern Med 2001;161:1194-203. https://doi.org/10.1001/archinte.161.9.1194
  51. Morais JA, Chevalier S, Gougeon R. Protein turnover and requirements in the healthy and frail elderly. J Nutr Health Aging 2006;10:272-83.
  52. Timmerman KL, Volpi E. Amino acid metabolism and regulatory effects in aging. Curr Opin Clin Nutr Metab Care 2008;11:45-9. https://doi.org/10.1097/MCO.0b013e3282f2a592
  53. Arnal MA, Mosoni L, Boirie Y, Houlier ML, Morin L, Verdier E, et al. Protein pulse feeding improves protein retention in elderly women. Am J Clin Nutr 1999;69:1202-8.
  54. Candow DG, Chilibeck PD. Effect of creatine supplementation during resistance training on muscle accretion in the elderly. J Nutr Health Aging 2007;11:185-8.
  55. Tarnopolsky MA, Safdar A. The potential benefits of creatine and conjugated linoleic acid as adjuncts to resistance training in older adults. Appl Physiol Nutr Metab 2008;33:213-27. https://doi.org/10.1139/H07-142
  56. Walston J, Xue Q, Semba RD, Ferrucci L, Cappola AR, Ricks M, et al. Serum antioxidants, inflammation, and total mortality in older women. Am J Epidemiol 2006;163:18-26. https://doi.org/10.1093/aje/kwj007
  57. Cooke M, Iosia M, Buford T, Shelmadine B, Hudson G, Kerksick C, et al. Effects of acute and 14-day coenzyme Q10 supplementation on exercise performance in both trained and untrained individuals. J Int Soc Sports Nutr 2008;5:8. https://doi.org/10.1186/1550-2783-5-8
  58. Valenti G, Denti L, Maggio M, Ceda G, Volpato S, Bandinelli S, et al. Effect of DHEAS on skeletal muscle over the life span: the InCHIANTI study. J Gerontol A Biol SCi Med Sci 2004;59:466-72. https://doi.org/10.1093/gerona/59.5.M466
  59. Percheron G, Hogrel JY, Denot-Ledunoid S, Fayet G, Forette F, Baulieu EE, et al. Effect of 1-year oral administration of dehydroepiandrosterone to 60- to 80-year-old individuals on muscle function and cross-sectional area: a double-blind placebo-controlled trial. Arch Intern Med 2003;163:720-7. https://doi.org/10.1001/archinte.163.6.720
  60. Nair KS, Rizza RA, O'Brien P, Dhatariya K, Short KR, Nehra A, et al. DHEA in elderly women and DHEA or testosterone in elderly men. N Engl J Med 2006;355:1647-59. https://doi.org/10.1056/NEJMoa054629
  61. Ottenbacher KJ, Ottenbacher ME, Ottenbacher AJ, Acha AA, Ostir GV. Androgen treatment and muscle strength in elderly men: a meta-analysis. J Am Geriatr Soc 2006;54:1666-73. https://doi.org/10.1111/j.1532-5415.2006.00938.x
  62. Borst SE. Interventions for sarcopenia and muscle weakness in older people. Age Ageing 2004;33:548-55. https://doi.org/10.1093/ageing/afh201
  63. Woo J, Goggins W, Sham A, Ho SC. Social determinants of frailty. Gerontology 2005;51:402-8. https://doi.org/10.1159/000088705
  64. Andrew MK, Rockwood K. Social vulnerability predicts cognitive decline in a prospective cohort of older Canadians. Alzheimers Dement 2010;6:319-25. https://doi.org/10.1016/j.jalz.2009.11.001
  65. Yen IH, Michael YL, Perdue L. Neighborhood environment in studies of health of older adults: a systematic review. Am J Prev Med 2009;37:455-63. https://doi.org/10.1016/j.amepre.2009.06.022
  66. Stuck AE, Egger M, Hammer A, Minder CE, Beck JC. Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression anaylysis. JAMA 2002;287:1022-8. https://doi.org/10.1001/jama.287.8.1022
  67. Lang IA, Hubbard RE, Andrew MK, Llewellyn DJ, Melzer D, Rockwood K. Neighborhood deprivation socioeconomic status, and frailty in older adults. J Am Geriatr Soc 2009;57:1776-80. https://doi.org/10.1111/j.1532-5415.2009.02480.x

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