clinical management of sarcopenia: from medical to ... medical to orthopedic dr.dai.pdf ·...
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Clinical Management of
Sarcopenia: from Medical to
Orthopedic Problems
Dr David Dai
Geriatrician
14/4/2016
www.no-fa
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Frailty and Fragility
Sarco-osteopenia
Nutrition, Vitamins and Exercise
Pharmacological treatment
Frailty, Falls and Fracture
Ageing Bone
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Osteoporosis P5www.no-fa
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Figure 1. Incidence of vertebral fractures in women and men, (Reprinted withPermission from [5]
The American Journal of Medicine Vol 98 (suppl 2A):76S-87S J of Gerontology Medical Sciences Vol 11(4):M107-M111www.no-fa
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NIH Consensus Development on Osteoporosis 2001
• Bone quality( micro-architectural deterioration)
• Systemic skeletal disease• Insufficient bone strength: bone
density• ↑Fracture risk
質與量www.no-fa
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The importance of bone microarchitecture.
Brandi M L Rheumatology 2009;48:iv3-iv8Bone 39 (2006) 1173-1181www.no
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Frailty (Fried 2001)
•Sarcopenia • Neuroendocrine dysfunction • Immune dysfunction • Weight loss• Low grip strength • Low energy (exhaustion) • Slow gait speed • Low physical activity
失肌症www.no-fa
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Muscle Quality:Type IIB fibers positively correlate with BMD
( CMJ 2010; 123(21): 3009-3014)
23 yr old 83 yr old
IIA
IIB
I
N=16 Male, 24 Female, Age 53±20 years (22-82)www.no-fa
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• Type IIB positive relationship with hip BMD irrespective of age
• Type II fibers critical for postural control and maintain bone quality
• Impact loading increases BMD; high impact (running, hockey, tennis, weight lifting)
• Whole body Vibration 30-50Hz may compensate for loss of firing rate due to type II fibers
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Fried Phenotype model( Aus J Age 2015; 34(1): 68-73)
3 or more of:1) Wt loss2) Exhaustion3) Weak grip4) Strength5) Slow walking speed and low physical
activity
體能表現www.no-fa
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Frailty
Function
Hospitalization
Institutionalization
Death
Mobility
Fall Osteopenia
Hip Fracture
Fear of
Falling
Social
Activity
Incontinence
Stroke
Adverse Outcomes
不良後果www.no-fa
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Gavrilov theory
• Progressive accumulation of random damage to a complex system of redundant parts
• Ageing organism losses redundancy• System loses resilience and vulnerable to
external and internal stressors
儲備透支www.no-fa
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Fall
摔跌www.no-fa
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Hip Fracture: Frailty
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Frailty, Falls and Fracture( J Morley JAMDA 2013; 149-151)
FatigueResistance (can you walk up one
flight ?)Aerobic ( can you walk more than a
block?)Illness ( > 5)Loss of weight (> 5% in 6 months)www.no
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FRAILTY
• Physical• Cognitive• Psychosocial
體能
認知 社倫
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Old AgeFrailty (Reserve) and VulnerabilityOsteopeniaSarcopeniaFallsPre-mobid multiple co-morbiditiesPerioperative medical instability Hospitalization syndrome (Delirium, infection, polypharmacy)Functional declinePsychosocial issuesPost-discharge support
Fragility FractureSyndrome
Post discharge period“I year”www.no-fa
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Declining Physiological Reserves( Crit Care Med 2004; 32(suppl): S92-S101)
• Cardiac• Respiratory• Renal• GI• Hepatobiliary• Body composition and energy use
• CNS (Delirium)
• Pain • Immune function• Haemopoietic
Hip Fracture and Hospitalization as Stress Agent
儲備透支
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The Stressor: Hospitalization
Dementia
Hospitalization Complications:
RestraintsMedicationsFunctional
decline
BPSDBladderInfections
Acute illness
Gait/Falls
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(24% discharged to OAH)older age ( ↑1.6 risk for 10 yrs increase age)dementialow mobility scoreslow basic and instrumental ADL
( Asian J Gerontol Geriatr 2007; 2: 69-77)
Predictors for old age home placement in HK:
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Declining Physiological Reserves( Crit Care Med 2004; 32(suppl): S92-S101)
• Cardiac• Respiratory• Renal• GI• Hepatobiliary• Body composition and energy use• CNS
• Pain • Immune function• Haemopoietic
Hip Fracture and Hospitalization as Stress Agentwww.no-fa
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Ortho-geriatric Co-managementat PWHwww.no
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Geriatric Clinical Assessment1) Greet patient (mental state, cognition,mood)2) Raise your arms ( stroke, parkinsonism, local
injury)3) Neurovascular examination ( CVS and fluid
status, AF, carotid bruit, reflexes )4) Respiration ( SaO2, chest, CXR)5) Abdomen ( bladder, bladder scan, bowel,
Foley’s)
6) Legs (edema, ? DVT) www.no-fa
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Independent Nurse Assessmentwww.no-fa
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Ortho-geriatric Roundwww.no-fa
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Expected benefits of acute orthogeriatric care(Curr Anae & Critical Care 2005, 16:2-10)
Superior medical careOptimal scheduling of fracture surgeryBetter communication with patients and
their relativesBetter communication within the
multidisciplinary teamInitiation of research, education and auditReduction in adverse eventsEarlier initiation of rehabilitation and more
effective use of discharge resourceswww.no-fa
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Probability of patient survival after hip fracture
according to geriatric and medical intervention
Time, days
0 50 100 150 200 250
Cu
mu
lativ
e s
urviv
al fr
ee o
f p
atie
nt
aft
er h
ip f
ractu
re
0.0
0.2
0.4
0.6
0.8
1.0
Geriatric Intervention
Conventional Care without Medical Consultation
Conventional Care with Medical Consultation
Log-rank: P < 0.0001
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Ambulatory Status – at 3 months
P value <0.01 www.no-fa
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Ambulatory Status – at 12 months
P value <0.01 www.no-fa
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Osteoporosis Case Manager( Arch Intern Med 2009; 169(1): 25-31)
• Rates of appropriate osteoporosis treatment are less than 10-20% in the year after hip fracture
• A hospital-based osteoporosis case manager could lead to 51% rate of bisphosphonate treatment within 6 months of fracture ( vs 22% for controls)
護理統籌www.no-fa
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J of Clin Densitometry: Assessment of Skeletal HealthVol (12); 4:413-416, 2009www.no-fa
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Sarcopenia in Hip Fracture( Archives of Geron & Geriatrics 2011; 52:71-74)
• 313 women within 3 weeks of hip fracture
• DXA• 58% sarcopenic• 74% osteoporotic
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Gerontology 2014;60:294-305www.no-fa
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Translational Neuroscience 2015;6:103-110www.no-fa
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Muscle Wasting Disease( J Cach Sarc Mus 2014; 5: 83-87)
• Muscle Wasting Disease: myopenia, sarcopenia, cachexia
Sarcopenia: primarily neurodegenerationCachexia: inflammatory muscle disorder
• Gold standard: Exercise
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Sarcopenia: Measurement
• Muscle mass• Muscle strength• Gait speed
量質功能
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Int J Evid Based Healthc 2014;12:227-243www.no
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Int J Evid Based Healthc 2014;12:227-243www.no
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J Musculoskelet Neuronal Interact 2014;14(4):425-431www.no-fa
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Treatment
• Exercise• Nutritional supplementation: the evidence
grows ( JAMDA 2015; 16: 717-719)
• Pharmacological
運動, 營養, 藥物
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2 Birds with 1 Stone( Curr Osteo Rep 2014, March 16)
• Muscle and Bone development:coordinated unitcommon mesenchymal progenitor
• Mechanostat Theory:mechanical force drives periosteal growth, bone density andgeometryGH/IGF-1 axis
• Paracrine or endocrine cross talk:skeletal muscle “ second periosteum”
trophic factors, morphogens, cells bidirectional
一石二鳥, 骨肉同根生www.no-fa
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Exercise
• Enhance protein metabolism• Improve motor unit function• Stimulate non-satellite stem cells and• Release growth factors resulting in• Satellite cell proliferation and
differentiation
運動www.no-fa
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Sarcopenia in Older People( Int J Evid Based Healthc 2014; 12: 227-243)
• Physical activity• Aerobic/ endurance: lower intensity for frail
older persons; 30 mins, 2 times/week, incremental over 9 weeks
• Progressive resistance: 2 non-consecutive days/ wek; 8-10 exercises , 10-15 repetitions, 2 min rest in between
• Flexibility• Balancewww.no
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Nutrition
• Protein supplementation increase muscle synthesis in conjunction with exercise
• PROTAGE: 1-1.5kg of high quality protein ( leucine-enriched, balanced aas)
• INTERCOM: copd, heart failure, hospitalisation
• Cochrane: weight gain and reduce mortality
營養www.no-fa
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Feeding strategies( Int J Evid Based Healthc 2014; 12:227-243)
• Protein provided with a meal: anabolic • Spread evenly across the day/ pulse
feeding• Immediately after resistance training• Whey protein, fast protein• EAAs: leucine• Β-HMB
進食策略www.no-fa
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Kobe 2013(International Cachexic Conference)
1)Orexigenics ( ghrelin-like agents): enchance food intake, GH secretion, capromelin, MK-0677, anamorelin, OHR118
2) Megestrol plus thalidomide3) Cannabinoid-like drugs4) Testosterone5) Androgen receptor molecules (SARMS)www.no
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6) Activin receptor antibody:myostatin inhibitor; bimagrumab
7) Cardiological: perindopril, espindolol8) Fast skeletal muscle troponin activitor:
amplify response to motor neuron input; tirasemtiv, CK-2127101)
9) Mitrochondrial enhancer: bendavia
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Vitamin D
• Biologically active 1,25(OH)2D binds to VDR
• Muscle and bone osteoblasts and osteoclasts express VDR
• Severe Vit D deficiency causes type II atrophy
• Reduction of VDR in aging muscle• IOM and US Endo Soc: target 25OHD 50-
75 nmol/Lwww.no-fa
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Vitamin D and Myogenesis( Biomed Res Int 2014)
• VDR in muscle fibres, myoblastic proliferation and differentiation
• 1α, 25(OH)2D3 induce c-Src tyrosine kinase
• Vitamin D increase cell proliferation and inhibit apoptosis; satellite cells
• Vitamin D beneficial effects among patients with glucose intolerance and insulin resistancewww.no
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Amer J Med 2006;119:1019-1026www.no-fa
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Vibration Therapy( Curr Opin Endo Diab Obes 2014; 21(6):447-453)
• Skeletal disuse leads to consequences in musculoskeletal system
• Anabolic mechanical signals to mimic exercise in bone
• Mesenchymal stem cells, progenitors for bone and muscle growth
高頻率, 低幅度www.no-fa
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Fig 1. Cellular targets of vibration. The physiological effects of vibration are mediated by individual cellular actions. Low-magnitude mechanical signals target many cell types including mesenchymal stem cells, osteoblasts, osteocytes, adipocytes, osteoclasts, myocytes, and neurons. Curr Opin Endocrinol Diabetes Obes 2014; 21(6):447-453www.no
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Fig 2. Physiological responses of whole-body vibration. Delivery of low-magnitude mechanical signals mimic aspects of loading exercise, providing direct benefits to the skeleton, but also indirectly improves musculoskeletal outcomes including balance, posture, and muscle strength. These additional benefits feed back to further enhance skeletal strength.
Curr Opin Endocrinol Diabetes Obes 2014; 21(6):447-453www.no-fa
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