By Annette Immel-Very / very elderly people often seem fragile. Although wasting and weight loss corresponds to the typical picture of advanced age, this condition is not necessarily and certainly not desirable. Targeted measures can counteract the weight loss and improve the prognosis. The sooner you start, the better.
The group of old people is very heterogeneous. Firstly, the physical and mental health of people over 75 years is very different. This requires the degree of their independence and mobility or their auxiliaries and care. Secondly, the circumstances, including the financial situation is very different: living alone, with a partner, in a larger family, retirement or nursing home. All these factors affect the nutritional status, physical activity and thus health and quality of life.
Figure 1: Effects of malnutrition, sarcopenia and cachexia on body weight and body composition
Gradual changes
Many old people lose weight, and their body composition changes. This is often barely noticeable, because the processes are slow and not initially notice. In a study of living at home care Older people in Germany showed that 59 percent had been taken care of. This seems all the more astonishing than their life was mostly stayed in familiar paths. With more than 70 percent of the elderly members were preparing meals, about two-thirds ate predominantly in society (1).
Depending on how to change body composition and body weight, geriatricians define three syndromes: sarcopenia, malnutrition and cachexia (Figure 1). The underlying pathophysiology of this syndrome differs, will result in different therapeutic strategies. However, a definition of the syndrome is often only theory, because they often overlap. The pharmacy team should be noisy when old people or their relatives complain of weight loss or increasing weakness in any case.
Exercise and strength training are worthwhile at any age.
Sarcopenia: muscle wane
The loss of muscle mass is a natural phenomenon of aging. Starting the 50th Age of the average man loses about 1 to 2 percent of their muscle mass per year. Also, the muscle strength decreases: first, by about 1.5 percent, according to the 60th Age by as much as 3 percent per year (2). But not everyone ages the same, and the individual differences in the degradation of muscle mass are significant. The reasons for this lie not only in the genes, but also in physical activity.
The excessive, progressive age-related loss of skeletal muscle and muscle strength is called sarcopenia. This may, but need not necessarily be accompanied by a weight loss. The fat mass is unchanged. Thus, obese people may be affected by sarcopenia, although this is not apparent at first glance.
The sarcopenia moves only in recent years more and more into focus, since it has recognized the risks involved. 2009 formulated the European Working Group on Sarcopenia in Older People (EWGSOP), the representatives of various medical societies belong, a definition for the clinical practice. Then there is a sarcopenia ago, when functional muscle loss can be detected in addition to a reduced muscle mass, that is, decrease muscle strength and physical performance.
As a diagnostic measure of muscle strength, the grip strength has been proven, for the physical functioning, the transition speed. For a measurable reduction of manual force or at a walking speed of 0.8 m / sec is suspected sarcopenia. Then the muscle strength should be measured (3) According to EWGSOP. A first simple measurement in suspected sarcopenia is the determination of the lower leg circumference. If this is less than 31 cm could be the syndrome (4).
The decreasing muscle strength makes it difficult to cope with everyday life more and more. Movements are laborious, and much faster than earlier raises an exhaustion. Over time, the mobility is limited, and there is increasing to falls and fractures. As a sarcopenia may eventually lead to the need for care and take the picture at a home required. Moreover, sarcopenia increases the risk of mortality, independent of age and other diseases (5).
The figures on the prevalence of sarcopenia vary greatly due to the previously inconsistent definition. 5 to 13 percent of 60 - to 70-year-old people are concerned, for the over-80-year-olds are the details 11-50 percent (2).
Frailty
In the German medical literature is found more often the term "Frailty". He can best be translated as "frailty". But the German expression appears too narrow for the very complex phenomenon, which is at issue. Hence the name became common. Frailty is a total for the loss of functional capacity of the elderly. The aged body is less resilient and no longer has sufficient functional reserve to respond to endogenous and exogenous disturbances. The sarcopenia is only one aspect of frailty. The psychological and social dimensions of increasing frailty belong to the frailty syndrome.
Multiple causes
The causes of excessive muscle breakdown are very complex and not yet understood in detail. It is clear that muscle and associated neurons are lost. The muscle fiber loss is due to an activation of proteolytic pathways. Both oxidative stress and mitochondrial dysfunction play a role. It also leads to apoptosis of muscle cells and a decrease in its sensitivity to anabolic stimuli (6, 7).
Hormones and neurotransmitters are involved in the development of sarcopenia. So clearly, the age-associated decrease in testosterone, growth hormone and IGF-1 levels and a slight increase of proinflammatory mediators (C-reactive protein, interleukin (IL) -2 and -6 and TNF-alpha) is important. These physiological processes occur in sarcopenia from reinforced. In addition, a change in the renin-angiotensin-aldosterone system is discussed. Because circulating angiotensin II apparently the muscle and the decrease in IGF-1 levels play a role (8).
Two other factors play a significant role in the development of sarcopenia: physical activity and nutrition. Both a sedentary lifestyle as well as the insufficient intake of energy, protein and micronutrients such as vitamin D can diminish muscle mass and muscle strength.
Intervene early
In an early stage sarcopenia is largely reversible. Later, you can often just try to curb further loss of muscle mass and strength. There are three therapeutic strategies: strength training, nutrition and drug optimization.
The greatest success achieved to strength training. It is proven to increase both muscle mass and strength and balance of older people (6). An improvement in muscle strength can be achieved even with a once-weekly training for twelve weeks. This is even with over-90-year-olds demonstrated (8).
But anyone who has driven all his life, not exercise, is struggling with a relatively intense workout. For people who have little joy of movement or who can not train intensively due to health problems, there is less strenuous alternatives. Using a whole-body vibration and whole-body electromyostimulation (WB-EMS) can be strengthened to a relevant measure of the effect of a light body workout.
A vibration training can be, especially in older people with a low level, muscle strength significantly and to a similar extent as classic strength training increase (9). The patient stands with both feet on a plate out of the high-frequency oscillations. This will stimulate the tendon reflexes and activate the muscles. Only three weekly units of 15 minutes, improved muscle strength in a study significantly (10).
For a full-body EMS training the muscle cells are innervated by electrical stimuli. Surface electrodes, which are inserted on a vest and on arm and leg cuffs, give low-power pulses at low current levels. In a study by the University of Erlangen-Nuremberg with athletic inactive women over 70 showed that whole-body EMS training sarcopenia influenced significantly better than a lightweight functional training (11).
Drinking high-calorie foods can significantly improve the energy and protein intake of the elderly.
Photo: DAK health
Proteins for building muscle
To prevent further weight loss and muscle wasting that energy and nutrient intake must be demand. Even if an existing sarcopenia can improve not only through protein intake, the diet is very important. Muscle protein synthesis is stimulated by dietary proteins. Particularly the essential amino acids for the anabolic effect, and especially the branched chain such as leucine, of importance.
Older people need to formation of muscle proteins, a higher protein intake than young adults. Therefore, it is discussed to adapt the recommendations for protein intake. The German Nutrition Society currently recommends for adults regardless of age per day, 0.8 g protein / kg body weight. For old people could 1.2 g / kg / day be useful (12). A recommended intake of 1.0 to 1.5 g / kg / day is discussed (7) for people with sarcopenia. The intake of protein should be distributed evenly among the three main meals. Maximum of about 30 g of protein per meal, the body can efficiently utilize for muscle protein synthesis (12), although the elderly are unlikely to reach this amount three times a day. To illustrate: One egg contains about 8 g protein, 4 g of a cup of yogurt, a slice of Gouda approximately 9 g, and a pork chop about 33 g of protein.
The energy and protein intake can be targeted to improve by drinking high-calorie foods. Meanwhile, there are products available in many flavors. A nutrient density of 1 kcal / ml is due to the lower osmolarity usually better tolerated than 2 kcal / ml. Patients with evidence of sarcopenia should start early with such food additive and, for example, make a late meal with it. Latest from a body mass index (BMI) below 20 kg/m2 is an energy-and protein-rich liquid food urgently indicated (13).
Vitamin D is very important for muscle strength. Low serum concentrations of 25-hydroxy-vitamin D (<50 nmol / l) correlate in older people with less muscle strength and frailty (12). Old people are often under-served, so supplements can be useful. To counteract oxidative stress and the inflammatory processes that occur in sarcopenia, one of antioxidants (carotenoids, vitamin E, vitamin C) and omega-3 fatty acid-rich diet is both for prevention as well as sarcopenia been incurred recommended.
Table: causes and trigger factors of malnutrition in old age (modified after 4)
Changes problems Examples
Physiological changes decreased appetite early age, long-lasting satiety response rigidity of appetite regulation declining or impaired sense of smell and taste
Serious diseases or acute diseases chronic depressive disorders dementia syndromes adverse drug reactions
Problems with disabilities while shopping cooking and preparing meals chewing and swallowing
Social factors Loneliness Loss of a partner move to a retirement or nursing home low socioeconomic status
Old friends
Drugs for the targeted treatment of sarcopenia are not available. However, there are positive experiences with the administration of testosterone, estrogen, growth hormone and vitamin D.
Also a well-known drug group doing here talking point: ACE inhibitors. They are apparently able to stop the loss of muscle strength. Although further studies are needed, but today this treatment approach appears very promising. Different effects of ACE inhibitors may be useful when used against sarcopenia: the improvement of endothelial function, blood flow to the muscles and uptake of glucose into the muscle cell and a modulation of hormonal control loops, for example, insulin growth factor-1 (IGF-1). Finally, ACE inhibitors may also have a direct trophic action on skeletal muscle, as has been known from the cardiac muscle (2, 8).
In public, the problem of sarcopenia is practically ignored. Unlike, say, in osteoporosis, there is little effort to prevention. Each individual, could gain a lot of quality of life when a sarcopenia would be stopped. However, exercise programs for the elderly are often ridiculed - even by the elderly themselves where the pharmacy team can do a lot of educational work. However, it is unfortunately missing in many places still on special training programs for the elderly to build up muscle strength.
Malnutrition in Germany
In addition to the sarcopenia, there is another reason why the body composition of the elderly may change unfavorably and lose unwanted weight. It is the malnutrition. This term stands for the inadequate intake of macro-and micronutrients. Malnutrition leads to weight loss, especially the loss of fat reserves.
Who has much pleasure in eating, is less likely to suffer malnutrition.
Photo: Shutterstock / auremar
In Germany, the land of prosperity malnutrition of the elderly is little attention. Numerous studies have shown that an increased weight loss increased morbidity and mortality. Malnourished older people have a higher risk of complications and longer recovery times (14) for example, a hospital stay.
When removal is questionable? A weight loss of 5 percent or more in the last three months and 10 percent in half a year is considered to be relevant and requires an intervention (4). However, a slower decrease may be important in old age. It was shown that a weight loss of 5 percent over three years is associated with a significant increase in mortality (15).
65 years of the desirable BMI is in the range 22-29 kg/m2 (12). A BMI below 20 kg/m2 is for old people than being underweight (14). The BMI alone is not sufficient as a diagnostic criterion because it can be misinterpreted. So it may come from a failure to fluid retention, so the BMI is in the normal range, although the patient is malnourished.
No more pleasure in eating
The causes of malnutrition are very diverse. In addition to age-related changes in body diseases and the current situation in life, the pleasure of eating and drinking diminish (Table). Aged the hunger feeling is weaker than before. In about half of the elderly have to taste and smell. The secretory salivary glands decreases, which can lead to dry mouth and difficulty swallowing. Tooth wear, and education on dental apparatus makes it difficult to chew. Not infrequently ill-fitting dentures are the cause of eating disorders.
Figure 2: Typical weight profile of a elderly with increasing malnutrition
Weight loss can not compensate for the body in old age. When an old man, for example, in a period of mourning or when an infection has no appetite and decreases, it can - in contrast to the young people - hereinafter hardly or no longer be compensated. Thus, the body weight decreases continuously (Figure 2).
Also, side effects of drugs such as dry mouth, diarrhea or chronic nausea can spoil the appetite. Therefore, pharmacists should in people who complain of problems with appetite or altered taste, check the medication list to such side effects and discuss the medication with the doctor if necessary.
The most common cause of malnutrition in elderly is depression (13). About 10 per cent of over-65s who live at home, have major depression in people living in nursing homes, there are up to 40 percent (16).
Together it tastes better.
Also often leads to loneliness that older people are malnourished. In a French study of people living alone over 70 years showed that 43 percent of seniors not eating enough and did not cover their energy needs. A progressive weight loss is programmed. One in every five participants was already a manifest malnutrition (17).
About diagnosis doctors with a standardized questionnaire in five minutes to perform an initial screening (Mini Nutritional Assessment; www.mna-elderly.com). There is evidence of malnutrition, a detailed survey should follow to find out possible causes. Not every problem can be solved, but also many small practical measures can bring along that old people get back appetite for food and drink and improves energy and nutrient intake. Early intervention is recommended in any case.
Too confused to eat
A separate problem area related to malnutrition are dementia diseases. People with dementia lose progression of the disease almost always in body weight, fat mass in the first place there. Demented women often take off earlier than men. This is explained by the fact that most women are responsible for planning and preparing meals. If they do not cope with this, it does not taste as good or the food did not succeed. In contrast, men are often "cooked". If cognitive deficits occur in them, but is still worried for tasty meals (18).
At the beginning of dementia disease are disorders of short-term memory, inefficiency and light difficulties in coping with everyday tasks. Complex actions such as planning of purchasing and preparing a meal can cause problems. Often the disease is at this time but not yet diagnosed. In advanced stages it comes to local and situational disorientation, psychomotor agitation with a high need for movement and problems in the course of standard situations. The patient may hunger and thirst, food and eating situations no longer interpret and use. In the late stage of the complex process of swallowing often no longer works.
Cachexia: consumed by disease
Cachexia (wasting) is usually the result of a serious underlying condition such as cancer, chronic cardiac and / or renal failure, chronic obstructive pulmonary disease, rheumatoid arthritis and AIDS. Patients with neoplastic disease, COPD or chronic heart failure who develop cachexia, have a significantly higher mortality than patients without cachexia (4).
At first glance, the cachexia of sarcopenia is similar with the difference that it is more severe. It is characterized by excessive breakdown of muscle mass, which leads to a progressive loss of weight. In addition, a decrease in body fat mass. Loss of appetite and severe tiredness (fatigue) are more characteristic of cachexia.
When cachexia is the moderate inflammatory activity, which is present in the sarcopenia, aggravated by other diseases. There is a significant excess of proinflammtorischen cytokines such as IL-1beta, IL-6, TNF-alpha and interferon gamma. These substances stimulate muscle proteolysis and slow the synthesis of muscle proteins. They also affect the central regulation of appetite and accept appetite. They may also reduce gastrointestinal motility and gastric acid secretion. There is a lack of testosterone and IGF1, both of which stimulate protein synthesis. In addition, an increased concentration of glucocorticoids and myostatin that inhibit muscle growth observed (4).
The chronic inflammation can be detected is diagnostically, for example, by an increased level of C-reactive protein. Also a decreased albumin value (<35 g / L) speaks for cachexia. Unintentional weight loss (≥ 5 percent) and low body weight (BMI <22 for over-65s) are also considered diagnostic criteria (4).
In the treatment of cachexia, the effective treatment of the underlying disease is paramount. A more caloric requirement can be offset with high-calorie liquid food (in addition to meals). Physical exercise and strength training are desirable, but because of serious underlying disease often not or only partly possible.
Medication cachexia is difficult to treat. In oncology, progestins such as megestrol are often used because they stimulate the appetite, among other things, and thereby influence the nutritional status positively. Furthermore, prokinetics, glucocorticoids and cannabinoids are used. Cannabinoids in cancer patients in one study were less effective than progestins. In patients with AIDS, Alzheimer's disease and COPD cannabinoids are effective. However resulted side effects such as dizziness, fatigue and dizziness in some patients discontinue therapy (19-21).
Scientists are currently pursuing several strategies in the search for a drug to treat cachexia. As selective androgen receptor modulators and ghrelin agonists are tested in phase III trials. They are also trying to curb the cachexia with myostatin antagonists and Melanokortin4 receptor antagonists (22, 23).
Summary
Sarcopenia, malnutrition and cachexia impact the quality of life and significantly worsen the prognosis of elderly people. Therefore, they should be taken very seriously. Will counteract the earlier, the better the chances of success. Pharmacists and PTA should be attentive and ask if a customer complains about declining forces and loss of appetite. /
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