Malnutrition, Sarkopenie und Kachexie im Alter - Von der Pathophysiologie zur Therapie

Zusammenfassung

Malnutrition, Sarkopenie und Kachexie sind drei Syndrome, die für Funktionalität, Morbidität und Mortalität älterer Menschen große Bedeutung besitzen. Der Begriff der Malnutrition beschreibt eine defizitäre Versorgung mit Makro- und Mikronährstoffen. Bei der Sarkopenie handelt es sich um einen altersassoziierten Verlust von Muskelkraft und Muskelmasse. Die Kachexie ist durch einen Gewichtsverlust mit übermäßigem Abbau von Muskelmasse bei akuter oder chronischer Inflammation charakterisiert. Für alle drei Entitäten ist das Zusammenwirken eines weiten Spektrums möglicher Kausalfaktoren typisch. Hierbei sind für Sarkopenie und Kachexie neben inflammatorischen Prozessen auch Veränderungen der hormonellen Regulation von wesentlicher Bedeutung. Die Diagnose von Malnutrition, Sarkopenie und Kachexie erfordert neben einer diesbezüglichen Sensibilität des Arztes die Kenntnis der unterschiedlichen pathophysiologischen Grundlagen sowie den Einsatz spezieller diagnostischer Methoden. Aufgrund der demographischen Entwicklung ist durch den steigenden Betreuungsaufwand der betroffenen Patienten eine zunehmende Belastung des öffentlichen Gesundheitswesens zu erwarten. Daher sind weitere Studien erforderlich, die insbesondere für Sarkopenie und Kachexie die Entwicklung neuer Therapieoptionen auf der Basis der pathophysiologischen Kenntnisse ermöglichen.

Summary

Malnutrition, sarcopenia and cachexia are three syndromes that are highly relevant for capacity, morbidity and mortality of the elderly. The term malnutrition denotes a deficit of macro- und micronutrients, while sarcopenia describes an age-associated loss of muscle mass and strength. In cachexia weight loss und changes in body composition are closely related to acute and chronic inflammatory co-morbidities. A wide array of possible causal factors is typical for all three entities. Inflammatory processes and changes in hormonal regulation are of prominent importance for sarcopenia and cachexia.

The diagnosis of malnutrition, sarcopenia and cachexia requires, in addition to a special interest of the treating physician, a thorough knowledge of pathophysiology as well as the use of specific diagnostic methods. A better understanding of the causes of malnutrition, sarcopenia and cachexia will make it possible to use specific modes of treatment.

Because of the demographic shift an increasing financial burden has to be faced by the public health system resulting from the growing expenditure needed for the care of affected patients. Additional studies are, therefore, necessary to develop new therapeutic options based on the pathophysiology of these three entities. This is especially important with regard to sarcopenia and cachexia.

Schlüsselwörter

Malnutrition - Sarkopenie - Kachexie - Alter - Pathophysiologie

Key words

malnutrition - sarcopenia - cachexia - elderly - pathophysiology

Literatur

• 1 Bauer J M, Volkert D, Wirth R. et al . Diagnostik der Mangelernährung des älteren Menschen.  Dtsch Med Wochenschr. 2006;  131 223-227
• 2 Bauer J M, Wirth R, Troegner J et al. Ghrelin, anthropometry and nutritional assessment in geriatric hospital patients.  Z Gerontol Geriatr. 2007;  40 31-6
• 3 Baumgartner R N, Koehler K, Gallagher D et al. Epidemiology of sarcopenia among the elderly in New Mexico.  Am J Epidemiol. 1998;  147 755-763
• 4 Baumgartner R N, Waters D L. Sarcopenia and sarcopenic-obesity. In: Pathy MSJ, Sinclair AJ, Morley JE Principles and practice of geriatric medicine. 4th edition. John Wiley & Sons Ltd Chichester 2006
• 5 Bruunsgaard H, Andersen-Ranber K, Jeune B. A high plasma concentration of TNF-alpha is associated with dementia in centenarians.  J Gerontol. 1999;  54A M357-64
• 6 Bua E, McKiernan S H, Wanagat J. et al . Mitochondrial abnormalities are more frequent in muscles undergoing sarcopenia.  J Appl Physiol. 2002;  92 2617-2624
• 7 Clarkston W K, Pantano M M, Morley J E. et al . Evidence for the anorexia of aging: gastrointestinal transit and hunger in healthy elderly vs. young adults.  Am J Physiol. 1997;  272 243-8
• 8 Cohen H J, Piper C F, Harris T. The association of plasma IL-6 levels with functional disability in community dwelling elderly.  J Gerontol Med Sci. 1997;  52 M201-208
• 9 De Castro J M. Age-related changes in spontaneous food intake and hunger in humans.  Appetite. 1993;  21 255-72
• 10 Dobbs R J, Charlett A, Purkiss A G. Associations of circulating TNF-alpha and IL-6 with ageing and Parkinsonism.  Acta Neurol Scand. 1999;  100 34-41
• 11 Fearon K C, Voss A C, Hustead D S. et al. Cancer Cachexia Study Group . Definition of cancer cachexia: effect of weight loss, reduced food intake, and systemic inflammation on functional status and prognosis.  Am J Clin Nutr. 2006;  83 1345-50
• 12 Ferry M, Sidobre B, Lambertin A, Barberger-Gateau P. The SOLINUT study: analysis of the interaction between nutrition and loneliness in persons aged over 70 years.  J Nutr Health Aging. 2005;  9 261-8
• 13 Fried L, Tangen C M, Walston J. et al . Frailty in older adults: evidence for a phenotype.  J Gerontol A Biol Sci Med Sci. 2001;  56 M146-M156
• 14 Gariballa S, Forster S. Malnutrition is an independent predictor of 1-year mortality following acute illness.  Br J Nutr. 2007;  98 332-336
• 15 Goodpaster B H, Carlson C L, Visser M. Attenuation of skeletal muscle and strength in the elderly: The Health ABC Study.  J Appl Physiol. 2001;  90 2157-2165
• 16 Goodpaster B, Won P ark S, Harris T B. et al . The loss of skeletal muslce strength, mass, and quality in older adults: The Health, Aging and Body Composition Study.  J Gerontol Biol Sci Med Sci. 2006;  61A 1059-1064
• 17 Iannuzi-Sucich M, Prestwood K M, Kenny A M. Prevalenve of sarcopenia and predictors of skeletal muscle mass in healthy older men and women.  J Gerontol Biol Sci Med Sci. 2002;  57 M772-M777
• 18 Janssen I, Heymsfield S B, Ross R obert. Low relative skeletal muscle mass (sarcopenia) in older persons is associated with functional impairment and physical disability.  J Am Geriatr Soc. 2002;  50 889-896
• 19 Janssen I, Shepard D S, Katzmarzyk P T, Roubenoff R. The healthcare costs of sarcopenia in the United States.  J Am Geriatr Soc. 2004;  52 80-85
• 20 Jeune B, Skytthe A, Cournil A. et al . Handgrip strength among nonagenarians and centenarians in three European regions.  J Gerontol Med Sci. 2006;  61A 707-712
• 21 Kahn R. Weight loss and depression in a community nursing home.  J Am Geriatr Soc. 1995;  43 83
• 22 Kondrup J, Rasmussen H H, Hamberg O. et al . Nutritional Risk Screening (NRS 2002): a new method based on an analysis of controlled clinical trials.  Clin Nutr. 2003;  22 321-336
• 23 MacIntosh C G, Andrews J M, Jones K L. et al . Effects of age on concentrations of plasma cholecystokinin, glucagon-like peptide 1, and peptide YY and their relation to appetite and pyloric motility.  Am J Clin Nutr. 1999;  69 999-1006
• 24 Maggio M, Ceda G P, Lauretani F. et al . Relation of angiotensin-converting enzyme inhibitor treatment to insulin-like growth factor-1 serum levels in subjects > 65 years of age (the InCHIANTI study).  Am J Cardiol. 2006;  97 1525-9
• 25 Melton III L J, Khosla S, Crowson C S. et al . Epidemiology of sarcopenia.  J Am Geriatr Soc. 2000;  48 625-630
• 26 Milne A C, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people.  Ann Intern Med. 2006;  144 (1) 37-48
• 27 Morales A HJ, Carson C C. Andropause: a misnomer for a true clinical entity.  J Urol. 2000;  163 705-712
• 28 Morley J, Thomas D, Wilson M MG. Cachexia: pathophysiology and clinical relevance.  Am J Clin Nutr. 2006;  83 735-743
• 29 Newman A B, Yanez D, Harris T. et al . Weight Change in Old Age and its Association with Mortalitiy.  J Am Geriatr Soc. 2001;  49 1309-1318
• 30 Newman A B, Kupelian V, Visser M. et al . Strength, but not muscle mass, is associated with mortality in the health, aging and body composition study cohort.  J Gerontol A Biol Sci Med Sci. 2006;  61 72-7
• 31 Onder G, Vedova C D, Pahor M. Effects of ACE inhibitors on skeletal muscle.  Curr Pharm Des. 2006;  12 (16) 2057-64
• 32 Payette H, Roubenoff R, Jacques P F. et al . Insulin-like growth factor-1 and interleukin 6 predict sarcopenia in very old community-living men and women: the Framingham Heart Study.  J Am Geriatr Soc. 2003;  51 1237-1243
• 33 Pirlich M, Schwenk A, Müller M J. Leitlinie Enterale Ernährung - Ernährungsstatus.  Aktuel Ernaehr Med. 2003;  28, Supplement 1 10-25
• 34 Pirlich M, Schutz T, Norman K. et al . The German hospital malnutrition study.  Clin Nutr. 2006;  25 563-72
• 35 Poehlman E T, Dvorak R V. Energy expenditure, energy intake, and weight loss in Alzheimer disease.  Am J Clin Nutr. 2000;  71 650-655
• 36 Rink L, Cakman I, Kirchner H. Altered cytokine production in the elderly.  Mech Ageing Develop. 1998;  102 199-209
• 37 Roberts S B, Fuss P, Heyman M B. et al . Control of food intake in older men.  JAMA. 1994;  272 1601-6
• 38 Rosenberg I H. Summary comments.  Am J Clin Nutr. 1989;  50 1231-1233
• 39 Roubenoff R. Sarcopenia: effects on body composition and function.  J Gerontol Biol Sci Med Sci. 2003;  58 1012-1017
• 40 Roubenoff R. Catabolism of aging: is it an inflammatory process?.  Curr Opin Clin Nutr Metabol Care. 2003;  6 295-299
• 41 QuBaiah O, Morley J E. Pathophysiology of cachexia in the elderly. In: Mantovani G Cachexia. Chapter 7.4. Springer 2006: pp 383-395
• 42 Sayer A, Syddall H E, Gilbody H J, Dennison E M, Cooper C. Does sarcopenia originate in early life? Findings from the Hertfordhire Cohort Study.  J Gerontol Med Sci. 2004;  59A 930-934
• 43 Sipila S, Suominen H. Knee extension strength and walking speed in relation to quadriceps muscle composition and training in elderly women.  Clin Physiol. 1994;  14 333-342
• 44 Sowers M FR, Crutchfield M, Richards K. et al . Sarcopenia is related to physical functioning and leg strength in middle-aged women.  Journal of Gerontology: Medical Sciences. 2005;  60A 486-490
• 45 Springer J, Filippatos G, Akashi Y J, Anker S D. Prognosis and therapy approaches of cardiac cachexia.  Curr Opin Cardiol. 2006;  21 229-33
• 46 Stratton R J, Grenn C J, Elia M. Disease-Related Malnutrition - an evidence based approach to treatment. CABI Publishing 2003
• 47 Thomas D. Distinguishing starvation from cachexia.  Clin Geriatr Med. 2002;  18 883-891
• 48 Thomas D R. Loss of skeletal muscle mass in aging: examining the relationship of starvation, sarcopenia and cachexia.  Clin Nutr. 2007;  26 389-99
• 49 Trappe T, Williams R, Carrithers J. et al . Influence of age and resistance exercise on human skeletal muscle proteolysis: a microdialysis approach.  J Physiol. 2004;  554 803-813
• 50 Volkert D, Frauenrath C, Oster P, Schlierf G. Malnutrition in the aged - effect of physical, mental, psychological and social factors.  Z Gerontol. 1989;  22 6-10
• 51 Volkert D. et al . Ernährungszustand, Energie- und Substratstoffwechsel im Alter.  Aktuel Ernaehr Med. 2004;  29 190-197
• 52 Volkert D. et al . ESPEN Guidelines on Enteral Nutrition: Geriatrics.  Clin Nutr. 2006;  25 330-60
• 53 Volpi E, Sheffield-Moore M, Rasmussen B B, Wolfe R R. Basal muscle amino acid kinetics and protein synthesis in healthy young and older men.  JAMA. 2001;  286 1206-1212
• 54 Wallace J I, Schwartz R S, LaCroix A Z, Uhlmann R F, Pearlman R A. Involuntary weight loss in older outpatients: incidence and clinical significance.  J Am Geriatr Soc. 1995;  43 329-37
• 55 Wilson M M, Thomas D R, Rubenstein L Z. et al . Appetite assessment: simple appetite questionnaire predicts weight loss in community dwelling adults and nursing home residents.  Am J Clin Nutr. 2005;  82 1074-81
• 56 Wirth R, Bauer J, Sieber C C. Cognitive function, body weight and body composition in geriatric patients.  Z Gerontol Geriat. 2007;  40 13-20
• 57 Wolf-Klein G P, Silverstone F A. Weight loss in Alzheimer’s disease: an international review of the literature.  Int Psychogeriatr. 1994;  6 135-42
• 58 Yeh S S, Schuster M W. Treatment of cachexia in the elderly.  In: Mantovani G Cachexia. Chapter 11.1. Springer 2006: 701-717
• 59 Yeh S S, Schuster M W. Geriatric cachexiea: the role of cytokines.  Am J Clin Nutr. 1999;  70 183-197
• 60 Yeh S S, Lovitt S, Schuster M W. Pharmacological treatment of geriatric cachexia: evidence and safety in perspective.  J Am Med Dir Assoc. 2007;  8 363-77