脆弱的管理:认错树

IF 3.3 Q2 GERIATRICS & GERONTOLOGY
Matteo Cesari, M. Canevelli, R. Calvani, I. Aprahamian, M. Inzitari, E. Marzetti
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In this context, it is noteworthy that randomized controlled trials testing lifestyle modifications in older persons with frailty (e.g., LIFE (19), FINGER (20)) tend to report a higher number of adverse events in the intervention group. Of course, we are not putting into question the clear benefits that physical activity and adequate nutrition have on an older person’s health status. We are also aware that methodological justifications may explain these findings (e.g., reporting bias). However, the excess vulnerability that characterizes frail persons poses them at a higher risk of homeostatic disruption and complications when a stressor (perhaps, also one that is theoretically beneficial) is applied. After all, it cannot be excluded that the lack of statistical significance might be due to low statistical power. 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The detection of frailty paradoxically nests the inclusive idea of “doing more” (sometimes even invasively) for persons who would otherwise be inadequately/insufficiently considered. Furthermore, it is not easy for many to see frailty outside the monodimensional paradigm of a “disease”. Frailty is not a disease and, as such, does not fit with the approach used for traditional nosological conditions: one biological abnormality resulting in a monodimensional clinical expression that needs a “one-fits-all” treatment. Another controversial point, frequently stemming from the erroneous framing of frailty as a disease, is related to the interventions to implement. It is not infrequent to see recommendations indicating lifestyle modifications (particularly, physical activity and healthy diet) as definitive solutions for the problem. 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引用次数: 3

摘要

虚弱是当今科学界和临床医生的热门话题。老年医生不再是唯一讨论这种与年龄有关的疾病的专家。许多医学学科(例如,肿瘤学家(1)、心脏病学家(2)、神经学家(3)、肾病学家(4)、传染病专家(5)、肺病学家(6)、麻醉师(7))终于开始关注老年人的这一关键方面,尤其是对预后和治疗方式的影响(例如,(8,9))。在关于这种“新颖”条件的辩论中,有时可能会出现“脆弱”一词使用不当的情况,这表明对兴趣条件的理解仍然不完整。有些概念似乎很难理解,尤其是在那些不习惯老年医学的整体方法和多学科性的领域。例如,对于1)虚弱的理论概念(10)、2)捕捉这种情况的模型(例如,身体表型模型(11)、健康缺陷累积模型(12)、生物-心理-社会模型(13))和3)将模型转化为临床使用的评分的工具之间的差异,存在相当大的混淆。毫不奇怪,不同的模型经常互换使用,这会产生混乱和误解(14)。关于虚弱的模糊性与它在过去几年中一直假设的年龄歧视内涵有关(15)。如今,虚弱通常被翻译为“不要”,并将人们排除在干预之外。事实上,这似乎是一种比按年龄来区分更优雅的方式。不同的是,虚弱被认为是实施干预措施的目标条件,目的是1)增加个人的储备(16)和2)为他/她提供最合适和有效的解决方案(17)。矛盾的是,对脆弱性的检测嵌套了一个包容性的想法,即为那些原本没有得到充分/充分考虑的人“做得更多”(有时甚至是侵略性的)。此外,对于许多人来说,在“疾病”的一维范式之外看到脆弱并不容易。虚弱不是一种疾病,因此不符合用于传统疾病学条件的方法:一种生物学异常导致一维临床表现,需要“一刀切”的治疗。另一个有争议的观点,通常源于将虚弱视为一种疾病的错误定义,与实施的干预措施有关。建议改变生活方式(特别是体育活动和健康饮食)作为解决问题的最终方案并不罕见。对于熟悉体弱老年人生物学、临床和社会复杂性的临床医生来说,这些说法是如何将现实过于简单化的,这是显而易见的。首先,几乎任何临床状况都受益于体育活动和最佳营养摄入。健康的生活方式对每个人的幸福至关重要,无论他/她的年龄如何。因此,将体育活动和健康饮食纳入初级预防让位于“基态预防”(18)。同样值得注意的是,一些强化的生活方式改变计划在最脆弱的人群中显示出了最具临床意义的益处(19)。因此,虚弱可能会影响建议的意义/相关性(从普遍促进健康衰老的常识到增加疲惫生物体储备的基本策略)。其次,不能从全面的老年评估(CGA)中预先确定老年体弱者的生活方式干预处方,以衡量其储备、需求和优先事项。例如,对虚弱状态与未确诊的癌症有关的人开出体育活动处方可能毫无意义(甚至有害)。此外,如果社会经济因素阻碍了人们获得高质量食物,那么对富含蛋白质饮食的坚持可能会很低。很明显,针对疾病表型表达的干预措施并不一定能根除其根本原因。在这种情况下,值得注意的是,测试老年体弱者生活方式改变的随机对照试验(如LIFE(19)、FINGER(20))往往在干预组中报告更高数量的不良事件。当然,我们并没有质疑体育活动和充足营养对老年人健康状况的明显益处。我们也意识到,方法论的正当性可以解释这些发现(例如,报告偏见)。然而,当施加压力源(也许也是理论上有益的压力源)时,体弱者的过度脆弱性使他们面临更高的稳态破坏和并发症风险。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The Management of Frailty: Barking Up the Wrong Tree
Frailty is today a hot topic in the scientific community and among clinicians. Geriatricians are no longer the only specialists discussing this age-related condition. Many medical disciplines (e.g., oncologists (1), cardiologists (2), neurologists (3), nephrologists (4), infectious disease specialists (5), pneumologists (6), anesthesiologists (7)) have finally started looking at this critical aspect in older persons, particularly impactful on prognosis and treatment modalities (e.g., (8, 9)). In the debate about this “novel” condition, it may sometimes happen that the word “frailty” is inappropriately used, suggesting a still incomplete understanding of the condition of interest. Some concepts seem difficult to get through, especially in those fields that are not used to the holistic approach and multidisciplinarity typical of geriatrics. For example, there is considerable confusion about the difference between 1) the theoretical concept of frailty (10), 2) the models to capture this condition (e.g., the physical phenotype model (11), the accumulation of health deficit model (12), the bio-psycho-social model (13)), and 3) the instruments to translate the model into a score for clinical use. Not surprisingly, the different models are often interchangeably used, which generates confusion and misunderstandings (14). An ambiguity around frailty is related to the ageistic connotation it has been assuming over the past years (15). Today, frailty is often translated with “do not” and excludes persons from interventions. Indeed, it seems a more elegant way than chronological age to discriminate. Differently, frailty was conceived as a target condition to implement interventions with the aim of 1) increasing the individual’s reserves (16) and 2) offering him/her the most suitable and effective solution (17). The detection of frailty paradoxically nests the inclusive idea of “doing more” (sometimes even invasively) for persons who would otherwise be inadequately/insufficiently considered. Furthermore, it is not easy for many to see frailty outside the monodimensional paradigm of a “disease”. Frailty is not a disease and, as such, does not fit with the approach used for traditional nosological conditions: one biological abnormality resulting in a monodimensional clinical expression that needs a “one-fits-all” treatment. Another controversial point, frequently stemming from the erroneous framing of frailty as a disease, is related to the interventions to implement. It is not infrequent to see recommendations indicating lifestyle modifications (particularly, physical activity and healthy diet) as definitive solutions for the problem. It is evident to clinicians familiar with the biological, clinical, and social complexity of an older person with frailty how these statements oversimplify the reality. First, virtually any clinical condition benefits from physical activity and optimal nutrient intake. A healthy lifestyle is critical for the well-being of every individual, regardless of his/ her age. For this reason, the inclusion of physical activity and healthy diet in primary prevention gives way to “ground-state prevention” (18). It is also noteworthy how some intensive programs of lifestyle modifications have shown the most clinically meaningful benefits among the frailest individuals (19). Frailty may thus influence the meaning/relevance of the recommendations (from common sense in the general promotion of healthy aging to an essential strategy to boost the reserves of an exhausted organism). Second, the prescription of lifestyle interventions to an older person with frailty cannot be prescinded from a comprehensive geriatric assessment (CGA) to measure his/her reserves, needs, and priorities. For example, the prescription of physical activity to a person whose frailty status is related to undiagnosed cancer may be pointless (or even harmful). Further, adherence to a protein-rich diet may be expected to be low if socioeconomic factors preclude access to high-quality foods. It is evident that interventions directed towards the phenotypic expression of a condition do not necessarily eradicate its underlying causes. In this context, it is noteworthy that randomized controlled trials testing lifestyle modifications in older persons with frailty (e.g., LIFE (19), FINGER (20)) tend to report a higher number of adverse events in the intervention group. Of course, we are not putting into question the clear benefits that physical activity and adequate nutrition have on an older person’s health status. We are also aware that methodological justifications may explain these findings (e.g., reporting bias). However, the excess vulnerability that characterizes frail persons poses them at a higher risk of homeostatic disruption and complications when a stressor (perhaps, also one that is theoretically beneficial) is applied. After all, it cannot be excluded that the lack of statistical significance might be due to low statistical power. The management of frailty is critically based on the © Serdi and Springer Nature Switzerland AG 2022
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来源期刊
Journal of Frailty & Aging
Journal of Frailty & Aging GERIATRICS & GERONTOLOGY-
CiteScore
5.90
自引率
7.70%
发文量
54
期刊介绍: The Journal of Frailty & Aging is a peer-reviewed international journal aimed at presenting articles that are related to research in the area of aging and age-related (sub)clinical conditions. In particular, the journal publishes high-quality papers describing and discussing social, biological, and clinical features underlying the onset and development of frailty in older persons.          The Journal of Frailty & Aging is composed by five different sections: - Biology of frailty and aging In this section, the journal presents reports from preclinical studies and experiences focused at identifying, describing, and understanding the subclinical pathophysiological mechanisms at the basis of frailty and aging. - Physical frailty and age-related body composition modifications Studies exploring the physical and functional components of frailty are contained in this section. Moreover, since body composition plays a major role in determining physical frailty and, at the same time, represents the most evident feature of the aging process, special attention is given to studies focused on sarcopenia and obesity at older age. - Neurosciences of frailty and aging The section presents results from studies exploring the cognitive and neurological aspects of frailty and age-related conditions. In particular, papers on neurodegenerative conditions of advanced age are welcomed. - Frailty and aging in clinical practice and public health This journal’s section is devoted at presenting studies on clinical issues of frailty and age-related conditions. This multidisciplinary section particularly welcomes reports from clinicians coming from different backgrounds and specialties dealing with the heterogeneous clinical manifestations of advanced age. Moreover, this part of the journal also contains reports on frailty- and age-related social and public health issues. - Clinical trials and therapeutics This final section contains all the manuscripts presenting data on (pharmacological and non-pharmacological) interventions aimed at preventing, delaying, or treating frailty and age-related conditions.The Journal of Frailty & Aging is a quarterly publication of original papers, review articles, case reports, controversies, letters to the Editor, and book reviews. Manuscripts will be evaluated by the editorial staff and, if suitable, by expert reviewers assigned by the editors. The journal particularly welcomes papers by researchers from different backgrounds and specialities who may want to share their views and experiences on the common themes of frailty and aging.The abstracting and indexing of the Journal of Frailty & Aging is covered by MEDLINE (approval by the National Library of Medicine in February 2016).
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