Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 398

For people with sarcopenia, the primary intervention should include resistance exercise interventions. The increase in muscle protein mass is attributable to an acute and chronic increase in muscle protein turnover, resulting in the rate of muscle protein synthesis exceeding that of muscle proteolysis. Coincident with the increase in the amount of muscle protein are increases in maximum voluntary muscle strength and muscle fibre hypertrophy.⁸⁰ Progressive resistance training two or three times per week improves physical function and reduces physical disability and muscle weakness in older adults. Functional limitations such as balance, gait speed, timed walk, timed get up and go, chair rise, and climbing stairs also improve.⁸¹ The improvement in muscle mass and strength with resistance exercise extends even to the very old. However, little is known about the duration of these effects once training has stopped.

Figure 14.2 Mini‐Nutritional Assessment (MNA).

.Source: Nestle Nutrition Institute, Mini Nutritional Assessment. © 2020, Nestle Nutrition Institute. © Société des Produits Nestlé SA 1994, Revision 2009. MNA® website for further information: www.mna‐elderly.com.

Table 14.3 Comprehensive gerontological assessment (CGA) to address weight loss management.

Domain	Subdomain	Proposed screening tools	Action if impaired	Link to other subdomains and nutrition
Mental health
	Cognition	MMSE, MOCA	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