An important approach in the treatment of geriatric anorexia-cachexia

Professor Baek Hyun-wook (President of the Korean Women’s Medical Association)

The older you get, the lower your activity level and the less muscle mass you have, which is necessary to reduce the amount of calories consumed, but older people are physiological. It is easy to accompany malnutrition because the amount of food is greatly reduced due to social factors. In addition, with aging the need for certain individual nutrients, such as vitamins and minerals, can increase, which can lead to a nutritional imbalance.

Indeed, weight loss in the elderly is very common and is seen as a form of systemic wasting syndrome, or cachexia. In most cases, generalized wasting syndrome occurs after anorexia and is called “senile anorexia-kakexia” or “senile wasting syndrome-general anorexia”. Geriatric anorexia-cachexia or generalized wasting syndrome increases the morbidity and mortality of infectious diseases such as pneumonia and pressure sores in the elderly.

Senile systemic wasting syndrome is characterized by a decreased ability of the elderly to cope with external stressful situations such as infections, surgery, injuries and depression, which can easily progress to severe symptoms and are difficult to recover from.

Weight loss associated with malnutrition acts as a factor exacerbating cognitive decline and depression, lowering quality of life and causing increased medical costs. Unlike weight loss that accompanies simple starvation, weight loss in the form of cachexia loss is characterized by a very rapid loss of body protein and the majority (70-80%) of weight loss is the loss of lean body mass, primarily muscle mass.

Sarcopenia refers to a decrease in muscle and lean mass and is the result of geriatric general wasting syndrome or cachexia. Muscle strength, power, and endurance are all reduced, resulting in deterioration of the function of various organs. This means loss of physical function or vitality. It goes through “failure to thrive” and eventually leads to frailty.

Treatment and prevention of malnutrition in the elderly

Inhibition of the chronic inflammatory response by increasing intestinal immunity together with balanced nutrient delivery is an important approach for the treatment of geriatric anorexia-cachexia. The generalized wasting syndrome associated with geriatric anorexia does not cause weight gain simply by increasing caloric intake. To resolve malnutrition it is necessary to provide balanced nutrients including micronutrients and, in particular, to resolve sarcopenia, protein intake is sufficient up to 1.5 times that of normal healthy adults. In addition to providing nutrients, it is necessary to suppress the inflammatory response to reduce the body’s wasting response due to increased catabolism and promote appetite. While catabolism is suppressed, anabolic drugs or inflammatory cytokine inhibitors can be tried, and exercise can be combined to reduce age-related weight loss.

Cyproheptadine has issues with dizziness or sedation, but it’s more commonly used as a first line because it can reduce inflammatory cytokines to promote appetite and increase weight.

Megestrol acetate, used as an appetite stimulant for cancer patients, is effective in promoting appetite and preventing weight loss, so it is recommended to use it for a short period of about 2 weeks when needed.

Omega-3 fatty acids are involved in cyclooxygenase and lipooxygenase metabolism and may help promote appetite by inhibiting the production and activity of inflammatory cytokines. Colostrum, which is rich in growth factors, contributes to the strengthening of immunity in the intestinal mucosa and reduces the endotoxemia and bacteremia caused by intestinal bacteria, so it can be safely tried for the elderly. Glutamine is an amino acid that is important for immunity, protein metabolism and maintenance of the intestinal mucosa.

For acute treatment of severe disease-related malnutrition, hospitalization and short-term intensive nutritional treatment centered on intravenous nutrition are effective. However, oral nutritional supplementation (ONS) is a very effective approach to prevent the onset of geriatric systemic wasting syndrome due to malnutrition or for elderly patients who have already developed the condition but do not require hospitalization. As a result of comparing the group that provided ONS once a day for a long period of time in a certain area with the group that did not provide ONS for the elderly who experience daily life without actually being hospitalized, not only the morbidity of the disease, but the number of hospitalizations due to the disease and the number of days of hospitalization also decreased. Oral nutritional supplements are packaged in small quantities with better taste than enteral nutrition preparations Various preparations are being developed for taste, package size, calorie content and for specific diseases. As it is based on an enteral nutritional formulation, it contains the three main nutrients such as proteins, carbohydrates and fats as well as micronutrients such as vitamins and minerals in an appropriate ratio, making it suitable for nutritional supplementation. In principle, the method of intake is to integrate 150 to 200 ml 1 to 3 times a day in the form of snacks avoiding meals, but depending on the individual, the quantity can be adjusted or some meals can be replaced. Most commercial products are classified as foods, but Encover is listed as a drug, so doctors can prescribe it and health insurance applies. It is very useful both in terms of efficacy and economically for the treatment and prevention of malnutrition in cancer patients or patients with systemic senile wasting syndrome.

[Reference]
1) Korean Society of Geriatrics: Geriatrics. 3rd
2) Am J Clin Nutr 2002;75:944-7.
3) Korean Journal of Intravenous Enteral Nutrition, 2013, Vol. 5, No. 2
4) Aging Res Rev 2012 ;11(2):278-96.
5) AGE 2015;37:81
6) Clin Nutr 2019;38(1):10-47
7) Nutrients 2021;13:835
8) J Frailty Aging 2022;11(2):129-134

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