Definiert das Alter den geriatrischen Patienten?

Zusammenfassung

Ältere Menschen stellen einen wachsenden Anteil unserer täglich medizinisch und chirurgisch zu versorgenden Patienten dar. Allerdings definiert das kalendarische Alter alleine den älteren Patienten nur unzureichend. Vielmehr scheint das biologische Alter oder das Maß an Gebrechlichkeit entscheidend für die Charakterisierung zu sein. Auch der Prozentsatz der Menschen, die gebrechlich sind, ist in den letzten Jahrzehnten stetig gestiegen. Gebrechlichkeit oder Frailty ist ein geriatrisches Syndrom, welches durch verringerte physische und psychische Reserven zur Kompensation gekennzeichnet ist. Die beiden am häufigsten genutzten Ansätze zur Definition von Gebrechlichkeit sind der phänotypische Ansatz und der Ansatz der Defizitakkumulation. Für ältere Patienten haben sich in diesem Zusammenhang 2 Interventionspunkte in der klinischen Praxis herauskristallisiert: 1. die präinterventionelle/operative Identifizierung von Hochrisikopatienten, um sowohl die Patientenerwartungen als auch die chirurgische Entscheidungsfindung zu steuern, und 2. periinterventionelle/operative Optimierungsstrategien für gebrechliche Patienten. Noch fehlt ein mit vertretbarem Zeitaufwand in der klinischen Praxis umsetzbarer, objektiver Goldstandard zur Analyse der Frailty.

Abstract

Whereas the proportion of elderly patients is increasing, age by itself is not a good parameter to characterize this population. Instead, the biological age or frailty seems to be more relevant. The percentage of frail people is increasing in our society as well. Frailty as a geriatric syndrome is characterized by a reduced physical and psychical coping reserve. It can be defined phenotypically or by the accumulation of deficits. In the clinical practice, frailty seems to be important within two intervention points: 1. the preinterventional/-operative identification of high-risk patients to clarify the patientʼs expectations and the interventional decisions and 2. to optimize the intervention itself. Unfortunately, a gold standard of frailty assessment in the clinical practice does not exist.

Was ist wichtig?

Mit der steigenden Lebenserwartung steigt auch das Alter der zu versorgenden Patienten. Insbesondere bei über 70-Jährigen scheint weniger das kalendarische Alter, sondern die Gebrechlichkeit den Patienten zu definieren, obwohl ein einheitlicher Goldstandard zur Bestimmung der Gebrechlichkeit noch fehlt.

Schlüsselwörter

biologisches Alter - Gebrechlichkeit - kalendarisches Alter - präinterventionelle Analytik

Key words

calendar age - biological age - frailty - preinterventional analytics

Publication History

Article published online:
22 October 2020

• Literatur

• 1 Strandell H, Wolf P. Chapter 1: Population Developments. In: Wolf HSP. ed. Ageing Europe: looking at the Lives of older People in the EU/2019 edition. Luxembourg: Publications Office of the European Union; 2019: 15-32
• 2 Oeppen J, Vaupel JW. Demography. Broken limits to life expectancy. Science 2002; 296: 1029-1031 doi:10.1126/science.1069675
• 3 Friede T, Zapf A, Roeder N. Morbidität und Mortalität der Herzkrankheiten, Strukturentwicklung. In: Klawki R, Schmidt K, Heinemann M. Hrsg. Herzbericht 2018. Frankfurt am Main: Deutsche Herzstiftung e.V.; 2019: 29-49
• 4 Miall WE, Lovell HG. Relation between change of blood pressure and age. Br Med J 1967; 2: 660-664 doi:10.1136/bmj.2.5553.660
• 5 OʼRourke MF, Nichols WW. Aortic diameter, aortic stiffness, and wave reflection increase with age and isolated systolic hypertension. Hypertension 2005; 45: 652-658 doi:10.1161/01.HYP.0000153793.84859.b8
• 6 Burkle A, Moreno-Villanueva M, Bernhard J. et al. MARK-AGE biomarkers of ageing. Mech Ageing Dev 2015; 151: 2-12 doi:10.1016/j.mad.2015.03.006
• 7 Meisinger C, Heier M, Volzke H. et al. Regional disparities of hypertension prevalence and management within Germany. J Hypertens 2006; 24: 293-299 doi:10.1097/01.hjh.0000200508.10324.8e
• 8 Lakatta EG, Levy D. Arterial and cardiac aging: major shareholders in cardiovascular disease enterprises: Part I: aging arteries: a “set up” for vascular disease. Circulation 2003; 107: 139-146 doi:10.1161/01.cir.0000048892.83521.58
• 9 Nashef SAM, Rogues F, Michel P. et al. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16: 9-13 doi:10.1016/S1010-7940(99)00134-7
• 10 Shahian DM, OʼBrien SM, Filardo G. et al. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1–coronary artery bypass grafting surgery. Ann Thorac Surg 2009; 88: S2-S22 doi:10.1016/j.athoracsur.2009.05.053
• 11 Di Dedda U, Pelissero G, Agnelli B. et al. Accuracy, calibration and clinical performance of the new EuroSCORE II risk stratification system. Eur J Cardiothorac Surg 2013; 43: 27-32 doi:10.1093/ejcts/ezs196
• 12 Shahian DM, Jacobs JP, Badhwar V. et al. The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development. Ann Thorac Surg 2018; 105: 1411-1418 doi:10.1016/j.athoracsur.2018.03.002
• 13 Luc JGY, Graham MM, Norris CM. et al. Predicting operative mortality in octogenarians for isolated coronary artery bypass grafting surgery: a retrospective study. BMC Cardiovasc Disord 2017; 17: 275 doi:10.1186/s12872-017-0706-z
• 14 Stortecky S, Schoenenberger AW, Moser A. et al. Evaluation of multidimensional geriatric assessment as a predictor of mortality and cardiovascular events after transcatheter aortic valve implantation. JACC Cardiovasc Interv 2012; 5: 489-496 doi:10.1016/j.jcin.2012.02.012
• 15 Kirkwood TB. A systematic look at an old problem. Nature 2008; 451: 644-647 doi:10.1038/451644a
• 16 De Francesco D, Wit FW, Burkle A. et al. Do people living with HIV experience greater age advancement than their HIV-negative counterparts?. AIDS 2019; 33: 259-268 doi:10.1097/QAD.0000000000002063
• 17 Simm A. Protein glycation during aging and in cardiovascular disease. J Proteomics 2013; 92: 248-259 doi:10.1016/j.jprot.2013.05.012
• 18 Horvath S. DNA methylation age of human tissues and cell types. Genome Biol 2013; 14: R115 doi:10.1186/gb-2013-14-10-r115
• 19 Hoffmann U, Sieber CC. [Is Age a Comorbidity?]. Dtsch Med Wochenschr 2017; 142: 1030-1036 doi:10.1055/s-0042-109861
• 20 Sieber CC. Frailty – From concept to clinical practice. Exp Gerontol 2017; 87: 160-167 doi:10.1016/j.exger.2016.05.004
• 21 Fried LP, Tangen CM, Walston J. et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146-M156 doi:10.1093/gerona/56.3.m146
• 22 Rockwood K, Stolee P, McDowell I. Factors associated with institutionalization of older people in Canada: testing a multifactorial definition of frailty. J Am Geriatr Soc 1996; 44: 578-582 doi:10.1111/j.1532-5415.1996.tb01446.x
• 23 Rockwood K, Song X, MacKnight C. et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173: 489-495 doi:10.1503/cmaj.050051
• 24 Vetrano DL, Palmer K, Marengoni A. et al. Frailty and Multimorbidity: A Systematic Review and Meta-analysis. J Gerontol A Biol Sci Med Sci 2019; 74: 659-666 doi:10.1093/gerona/gly110
• 25 Marengoni A, Zucchelli A, Vetrano DL. et al. Heart failure, frailty, and pre-frailty: A systematic review and meta-analysis of observational studies. Int J Cardiol 2020;
• 26 Denfeld QE, Winters-Stone K, Mudd JO. et al. The prevalence of frailty in heart failure: A systematic review and meta-analysis. Int J Cardiol 2017; 236: 283-289 doi:10.1016/j.ijcard.2017.01.153
• 27 Veronese N, Cereda E, Stubbs B. et al. Risk of cardiovascular disease morbidity and mortality in frail and pre-frail older adults: Results from a meta-analysis and exploratory meta-regression analysis. Ageing Res Rev 2017; 35: 63-73 doi:10.1016/j.arr.2017.01.003
• 28 Seco M, Edelman JJ, Forrest P. et al. Geriatric cardiac surgery: chronology vs. biology. Heart Lung Circ 2014; 23: 794-801 doi:10.1016/j.hlc.2014.04.008
• 29 Sepehri A, Beggs T, Hassan A. et al. The impact of frailty on outcomes after cardiac surgery: a systematic review. J Thorac Cardiovasc Surg 2014; 148: 3110-3117 doi:10.1016/j.jtcvs.2014.07.087
• 30 Beckmann A, Meyer R, Lewandowski J. et al. German Heart Surgery Report 2019: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2020; 68: 263-276 doi:10.1055/s-0040-1710569
• 31 Bäck C, Hornum M, Olsen PS. et al. 30-day mortality in frail patients undergoing cardiac surgery: the results of the frailty in cardiac surgery (FICS) copenhagen study. Scand Cardiovasc J 2019; 53: 348-354 doi:10.1080/14017431.2019.1644366
• 32 Lee DH, Buth KJ, Martin BJ. et al. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation 2010; 121: 973-978 doi:10.1161/CIRCULATIONAHA.108.841437
• 33 Abdullahi YS, Athanasopoulos LV, Casula RP. et al. Systematic review on the predictive ability of frailty assessment measures in cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24: 619-624 doi:10.1093/icvts/ivw374
• 34 Graham A, Brown CH. Frailty, Aging, and Cardiovascular Surgery. Anesth Analg 2017; 124: 1053-1060 doi:10.1213/ane.0000000000001560
• 35 Birkelbach O, Mörgeli R, Spies C. et al. Routine frailty assessment predicts postoperative complications in elderly patients across surgical disciplines – a retrospective observational study. BMC Anesthesiol 2019; 19: 204 doi:10.1186/s12871-019-0880-x
• 36 Gill TM, Gahbauer EA, Allore HG. et al. Transitions between frailty states among community-living older persons. Arch Intern Med 2006; 166: 418-423 doi:10.1001/archinte.166.4.418
• 37 Afilalo J, Eisenberg MJ, Morin JF. et al. Gait speed as an incremental predictor of mortality and major morbidity in elderly patients undergoing cardiac surgery. J Am Coll Cardiol 2010; 56: 1668-1676 doi:10.1016/j.jacc.2010.06.039
• 38 Afilalo J, Mottillo S, Eisenberg MJ. et al. Addition of frailty and disability to cardiac surgery risk scores identifies elderly patients at high risk of mortality or major morbidity. Circ Cardiovasc Qual Outcomes 2012; 5: 222-228 doi:10.1161/circoutcomes.111.963157
• 39 Robinson TN, Wu DS, Pointer L. et al. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg 2013; 206: 544-550 doi:10.1016/j.amjsurg.2013.03.012
• 40 Chainani V, Shaharyar S, Dave K. et al. Objective measures of the frailty syndrome (hand grip strength and gait speed) and cardiovascular mortality: A systematic review. Int J Cardiol 2016; 215: 487-493 doi:10.1016/j.ijcard.2016.04.068
• 41 Chung CJ, Wu C, Jones M. et al. Reduced handgrip strength as a marker of frailty predicts clinical outcomes in patients with heart failure undergoing ventricular assist device placement. J Card Fail 2014; 20: 310-315 doi:10.1016/j.cardfail.2014.02.008
• 42 Green P, Arnold SV, Cohen DJ. et al. Relation of frailty to outcomes after transcatheter aortic valve replacement (from the PARTNER trial). Am J Cardiol 2015; 116: 264-269 doi:10.1016/j.amjcard.2015.03.061
• 43 Green P, Cohen DJ, Généreux P. et al. Relation between six-minute walk test performance and outcomes after transcatheter aortic valve implantation (from the PARTNER trial). Am J Cardiol 2013; 112: 700-706 doi:10.1016/j.amjcard.2013.04.046
• 44 Green P, Woglom AE, Genereux P. et al. The impact of frailty status on survival after transcatheter aortic valve replacement in older adults with severe aortic stenosis: a single-center experience. JACC Cardiovasc Interv 2012; 5: 974-981 doi:10.1016/j.jcin.2012.06.011
• 45 Green P, Woglom AE, Genereux P. et al. Gait speed and dependence in activities of daily living in older adults with severe aortic stenosis. Clin Cardiol 2012; 35: 307-314 doi:10.1002/clc.21974