Panita Limpawattana Geriatric Medicine, Internal Medicine Department, Faculty of Medicine, KKU

Transcription

1 Frailty and Sarcopenia: One of the Geriatric Syndrome Panita Limpawattana Geriatric Medicine, Internal Medicine Department, Faculty of Medicine, KKU

2 Scopes What is Frailty & Sarcopenia? Consequences Prevalence and pathophysiologic changes Diagnosis Management

3 What is Frailty? Frailty? A biological syndrome of decreased reserve & resistance to stressors Result from: cumulative declines across multiple physiologic systems Causing: vulnerability to adverse outcomes Involve: psychological, cognitive, emotional, social & spiritual factors physical & non-physical frailty Cruz-Jentoft AJ, et al. European Geriatric Medicine 2013

4 What is Sarcopenia? Proposed by Irwin Rosenber in 1988 Age-associated loss of skeletal m. mass & function Association: sarcopenia vs. functional decline is more significant in men > women Sometimes known as physical frailty Wang C, Bai L. Geriatr Gerontol Int 2012, Kim TN, Choi MK. J Bone Metab 2013, Cruz-Jentoft AJ, et al. European Geriatric Medicine 2013,Chen LK, et al. JAMDA 2014

5 X-sectional area of male thigh Age 25 Age 65

6 Consequences of frailty & sarcopenia Disease Ageing Intrinsic causes Dec.body reserve Extrinsic causes Physical inactivity Failure to thrive Sarcopenia Increased metabolic demands Frailty Fall Poor performance Poor metabolic eff Disability (loss of ADLs) Poor QOL Inc. care cost Mortality Modified from Morley JE. Family Practice 2012, Roubenoff R. European Journal of Nutrition 2000

7 Prevalence of frailty & sarcopenia Various prevalence: different definition & ethnicity Frailty: 5-15% in community Sarcopenia in Asia: Low muscle mass: 5-57% (men) and 4-34% (women) Thailand: 32.5% (men), 34.75% (women) Based on EWGSOP/AWGS definition: Thailand: ongoing research Chen LK, et al. JAMDA 2014, Meng P, et al. Geriatr Gerontol Int. 2014, Yamada M, et al. JAMDA 2013, Wu CH, et al. Geriatr Gerontol Int. 2014

8 Genetic factors Epigenetic mechanisms Environmental factors Cumulative molecular and cellular damage Reduced physiological reserve -Brain, endocrine, immune, skeletal muscle, cardiovascular, respiratory, renal Nutritional factors Physical activity Frailty Stressor event Falls, delirium, flutuating disability Increased care needs Admission to hospital Admission to long-term care Pathophysiology of frailty

9 Frailty screening High risk group 1. Age > 70 years 2. Unintentional weight loss > 5% of BW 3. Chronic illness 4. Low physical activity 5. Impaired ADLs 6. Older adults with musculoskeletal conditions Milte R, Crotty M. Best Pract Res Clin Rheumatol 2014

10 Diagnosis of frailty Frailty phenotype 5-Item questionnaire with mixture of selfreport & performance measures Focusing on: wt. loss, exhaustion, low activity levels, slowness in mobility & GS weakness Interpretation: >3 = frailty 1-2 = pre-frail 0 = normal Fried LP, et al. J Gerontol A Biol Sci Med Sci 2001.

11 Frailty phenotype ใน 1 ป ท ผ านมา น าหน กท านลดลงมากกว า 4.5 ก โลกร ม ท านร ส กเหน อยตลอดเวลา ท านไม สามารถเด นได โดยล าพ ง ต องม คนมาพย ง ให ผ ส งอาย เด นเป นเส นตรงระยะทาง 4.5 เมตร จ บเวลาเม อ เร มเด นพบว าใช เวลา 7 ว นาท ข นไป หร อไม สามารถเด นได 5. ผ ส งอาย ม ความอ อนแรงของก าล งม อ แขน ขา ช ดเจน

12 Sarcopenia leads to physical frailty Chronic diseases Multi-morbidity

13 Sarcopenia

14 Sarcopenia Age-related (Primary) Sex hormones, apoptosis, mitochondrial dysfunction Disuse Immobility, physical inactivity, zero gravity Endocrine Corticosteroids, GH, IGF-1, abnormal thyroid function, insulin resistance Neuro-degenerative diseases Motor neuron loss Inadequate nutrition/ Malabsorption Cachexia Mechanisms of sarcopenia

15 Diagnosis of sarcopenia 1. Low muscle mass 2. Low muscle strength 3. Low physical performance Stage Presarcopenia Sarcopenia Severe sarcopenia Muscle mass Dec Dec Dec = (1) + (2) or (3) Performance Muscle strength Dec Dec OR AND Dec Dec Cruz-Jentoft AJ, et al.age Ageing 2010, Chen LK, et al. JAMDA 2014

16 Sarcopenia Screening in Asia Community settings Specific clinical conditions in all healthcare settings Chen LK, et al. JAMDA 2014

17 Recommended diagnostic algorithm of AWGS People > 60 or 65 yrs (based on elderly definition in each country) Handgrip strength (HS) & gait speed (GS) No low HS & No low GS Low HS and/or low GS Muscle mass measurement No sarcopenia Normal Low No sarcopenia Sarcopenia Chen LK, et al. JAMDA 2014

18 Measurement of sarcopenic variables Cruz-Jentoft AJ, et al. Age Ageing 2010

19 Recommended measure of Muscle mass by AWGS BIA > DXA (community setting) Muscle mass: SMI or Relative ASM (RASM) RASMI = sum of LBM from arms & legs/[ht2] Cut-off points: < 2SD/ lower quintile of ASMI of mean of young subjects (18-39 yrs) DXA: ASMI <7.0 in men, <5.4 kg/m2 in women BIA: ASMI <7.0 in men, <5.7 kg/m2 in women Thai: <7.9 kg/m2 in men, < 6 kg/m2 in women Chen LK, et al. JAMDA 2014

20 Bioelectrical impedance analysis: BIA ข อจ าก ด 1. NPO ก อนตรวจ 4 hrs. 2. ผ ท ไม สามารถย นตรงได เอง 3. ผ ท ม pacemaker 4. ผ ท ใช ยา/สม นไพร/ฮอร โมนท ม ผลต อ m.mass & strength eg. OC, estrogen, testosterone, eltroxin, steroid 5. ด มส ราภายใน 12 hrs 6. ออกก าล งกายหน กใน 12 hrs

21 Recommended measure of Muscle strength by AWGS Handgrip strength (HS) AWGS: <20th percentile of HS = cutoff value for low muscle strength Cutoff points <26 kg for men, <18kg for women Quadriceps strength Thailand Cutoff points of <18 kg in men,<16 kg in women Chen LK, et al. JAMDA 2014, Asssantachai P, et al. Geriatr Gerontol Int. 2014

22 Recommended measure of Physical performance by AWGS Recommend using 6-meter usual gait speed A potential gender difference in cutoff value from 0.6 to 1.2 m/s Cut-off points: < 0.8 m/s for low physical performance based on available data in Asian studies Chen LK, et al. JAMDA 2014

23 Management of sarcopenia? Management Non drug Rx Exercise: esp. resistance exercise Nutritional support: protein, (vitd,antioxidant?) Drug Rx Lifestyle modification: avoid ETOH, smoking Ongoing study

24 Lifestyle factors affecting sarcopenia excess alcohol Dietary factors Dec.m. protein synthesis smoking inc.m. protein low energy & protein intake degradation excess caloric intake Dec.m. Fn&quality sedentary lifestyle Vit D insuff sarcopenia ROM O, et al. RMMJ 2012

25 Physical activity & sedentary life style recumbency 7d: rapid m. loss major risk: chronic dis, frailty, sarcopenia dec. m. protein anabolism & inc.catabolism more prolonged time: 30% reduction esp. lower limbs aerobic & resistance exercise: improve rate of decline with age

26 Aerobic training exercise Inc. CV fitness & endurance Burton LA, et al. Clin Interv Aging 2010, ROM O, et al. RMMJ 2012

27 Resistance exercise (RE (RE)) Inc.protein synthesis Performed 2-5 d/wk (nonconsecutive day) Using a single set of 810 exercises for whole body: 8-12 RE each Peterson MD, et al. Ageing Res Rev. 2010, Burton LA, et al. Clin Interv Aging 2010, ROM O, et al. RMMJ 2012, Forbes SC, et al. Endocrine 2012.

28 Progressive resistance training (PRT) Most commonly used resistance therapy Large increase in muscle strength, physical function & LBM 8-12 repetitions per muscle group in 60-80% of 1 RM 3 sets per day 3 training units per week Peterson MD, et al. j.amjmed 2010, ROM O, et al. RMMJ 2012

29 General recommendation 1. Consider & identify specific activities patient prefers 2. Activity plan: diseases, fall risks, abilities, fitness 3. Prescription in the same manner 4. Progression: individualized 5. Strengthening +balancing may precede aerobic in very frail elderly 6. Supervision 7. Sensory impairment: specific technique 8. Protein 1.5 g/kg/d if no C/I 9. Lifestyle modification

30 Dietary factors in sarcopenia Anorexia of ageing Inadequate protein intake Anabolic resistance: reduced IGF-1 level Vitamin D Weight management ROM O, et al. RMMJ 2012

31 Inadequate protein intake RCT x 12 wks Women (av. 76.7yrs) Placebo HMB/ARG/LYS Results Trend +ve fat free mass (p<0.08) Increased whole body protein 20% Flakoll P, et al. Nutrition 2004

32 Interaction: nutrition & exercise Strength changes in 4 grs of 10-wk intervention RE+calories: increased muscle strength, type II fiber area> RE alone Adequate energy intake during RE is important Singh MA, et al. Am J Physiol Endocrinol Metab 1999

33 Pharmacologic management No drug proven to be as efficious as exercise RE + nutritional intervention (adequate protein + energy) But may reduce functional decline in older people Testosterone DHEA GH Vit D Wang C, Bai L. Geriatr Gerontol Int 2012

34 Take home message! Frailty & Sarcopenia: geriatric syndrome that increases with age & associated with adverse outcomes Prevalence is diverse: different definitions & ethnicities Older adults should be screened Exercise & nutritional support: key components of management

35 Thank you for your attention