- 期刊
周全性老年評估個案報告：心臟衰竭合併多重慢性病患之體重減輕
Comprehensive Geriatric Assessment of a Patient with Congestive Heart Failure, Comorbidities and Unintentional Weight Loss: A Case Report
摘要
老人的非刻意體重下降定義半年到一年內，體重下降超過原有的5%或10%以上，是預後不良的指標，影響住院率與死亡率、增加入住機構的風險、增加骨折的風險。體重下降成因多樣化，常非單一因子造成，除了營養不良（malnutrition）等之外，也可能由惡病質（cachexia）所致。本個案報告藉由一位罹患心臟衰竭、冠心症、高血壓、高血脂等多重共病之八十五歲男性，因半年到一年的體重減輕而反覆至多專科求診未果，經過周全性老年評估確立其體重減輕和心因性惡病質的關聯性，接著探討心因性惡病質的成因以及多專科團隊共同規劃診治方向。心臟衰竭惡病質造成之體重減輕是死亡的獨立預測危險因子，預後較差且病人功能受限、生活品質受損。心因性惡病質的病生理機轉涉及全身系統，腸胃消化系統吸收不佳造成營養不良，心肌細胞作功超載，細胞功能因巨量和微量營養素缺乏而運作失調，並產生全身慢性發炎，不僅消耗許多能量，能量無法有效利用，也讓老年人容易流失的瘦肉組織（lean muscle mass）萎縮減少。心臟衰竭治療已有指引建立，但末期心臟衰竭病人常無法靠藥物逆轉心臟功能退化，如何限制殘障和維持功能是老年醫學的著力點，必須多方向介入控制心臟衰竭惡病質，藥物、營養、活動、身心各方面加強缺一不可，憑藉跨領域的醫療團隊共同協助病人建立長期治療及追蹤的計畫。
並列摘要
Unintentional weight loss, an indicator of poor prognosis and risk factor for hospitalization, institutionalization, fracture, and mortality, is defined as more than 5% loss of body weight in 6-12 months. Unintentional weight loss often involves multifactorial and interrelated causes, such as malnutrition and cachexia. In this case report, an 85-year-old man with multiple comorbidities including congestive heart failure, coronary artery disease, hypertension, and hyperlipidemia was aware of his weight loss and visited different specialists with no significant improvement for months. We conducted a comprehensive geriatric assessment and diagnosed his weight loss as cardiac cachexia-related. We identified the causes of cardiac cachexia and developed an integrated plan through interdisciplinary team assessment. Cardiac cachexia related weight loss is an independent risk factor predicting mortality in heart failure patients, and it also results in functional decline and impairs quality of life. The pathophysiology of cardiac cachexia involves the whole body system, ranging from malnutrition due to gastrointestinal malabsorption, cardiac muscle cells overloading, to cell dysfunction due to deficiencies of macro- and micro-nutrients. Systemic chronic inflammation induces energy consumption and less efficient energy use. It causes lean muscle mass wasting in the elderly. The guidelines for treatment of congestive heart failure focus on pharmacological treatment and sometimes could not reverse or stop the worsening of heart function. Geriatricians, with comprehensive geriatric assessment, should focus on how to limit disability and maintain function through interdisciplinary management of cardiac cachexia to provide patients with plans for long-term treatment and follow-up integrating pharmacological, nutritional, physical, and psychological therapies.