徐小艷,張?jiān)伱?/p>
·科研綜述·
結(jié)直腸癌病人衰弱管理研究進(jìn)展
徐小艷,張?jiān)伱?
遵義醫(yī)科大學(xué),貴州 563099
從衰弱對(duì)結(jié)直腸癌病人不良結(jié)局的影響、結(jié)直腸癌病人的衰弱評(píng)估及衰弱管理現(xiàn)狀進(jìn)行綜述,提出醫(yī)護(hù)人員應(yīng)盡早識(shí)別結(jié)直腸癌病人的衰弱狀態(tài),結(jié)合衰弱病人最優(yōu)需求,從醫(yī)患雙方衰弱視角下探索適合我國(guó)結(jié)直腸癌病人的最佳衰弱管理策略。
結(jié)直腸癌;衰弱;不良結(jié)局;衰弱管理;綜述
結(jié)直腸癌是全球第三常見(jiàn)癌癥,也是癌癥死亡的第二原因[1],大約60%的結(jié)直腸癌病人年齡大于65歲[2],受人口老齡化、飲食習(xí)慣及微生物暴露等多種因素影響,其發(fā)病率呈逐年上升趨勢(shì)[3?4],預(yù)計(jì)2030年全球結(jié)直腸癌新增病人將達(dá)到220萬(wàn)例[5]。衰弱是一種由于多個(gè)器官系統(tǒng)的生理功能和儲(chǔ)備下降,機(jī)體應(yīng)激與維持內(nèi)環(huán)境穩(wěn)定能力失衡的老年綜合征,其主要特征是經(jīng)歷外界較小刺激即可導(dǎo)致一系列臨床不良結(jié)局[6?7]。結(jié)直腸癌病人由于機(jī)體消化吸收功能下降、能量代謝紊亂、慢性炎癥增多及免疫功能抑制等極易發(fā)生衰弱[8]。據(jù)報(bào)道,衰弱在結(jié)直腸癌病人中發(fā)生率高達(dá)60.5%[9],常導(dǎo)致病人術(shù)后并發(fā)癥、死亡率及再入院率等風(fēng)險(xiǎn)增加,嚴(yán)重影響結(jié)直腸癌病人的生存質(zhì)量[2,9],及時(shí)的衰弱干預(yù)及管理能有效改善病人的預(yù)后[10?11]。因此,本研究從衰弱對(duì)結(jié)直腸癌病人不良結(jié)局的影響、結(jié)直腸癌病人的衰弱評(píng)估及衰弱管理現(xiàn)狀進(jìn)行綜述,以期為我國(guó)醫(yī)務(wù)人員開(kāi)展衰弱管理工作提供參考。
1.1術(shù)后并發(fā)癥增加衰弱與結(jié)直腸癌病人術(shù)后并發(fā)癥密切相關(guān)。衰弱病人在應(yīng)對(duì)手術(shù)刺激時(shí)更易激活下丘腦?垂體?腎上腺軸及交感?腎上腺髓質(zhì)軸,導(dǎo)致體內(nèi)糖皮質(zhì)激素分泌增多,蛋白質(zhì)的含量和合成速率降低,并且衰弱病人體內(nèi)的高炎癥水平會(huì)破壞血管內(nèi)皮屏障完整性,使白蛋白從毛細(xì)血管滲出,低蛋白血癥發(fā)生率增高,結(jié)直腸癌病人術(shù)后相關(guān)并發(fā)癥也隨之增加[12?13]。研究顯示,結(jié)直腸癌衰弱病人發(fā)生并發(fā)癥的風(fēng)險(xiǎn)是非衰弱者的2~4倍[14?16],以術(shù)中低血壓、術(shù)后吻合口瘺、譫妄及腸道功能恢復(fù)延遲等多見(jiàn)[17?18]。此外,Ommundsen[19]研究發(fā)現(xiàn),19%的結(jié)直腸癌衰弱病人住院期間未發(fā)生并發(fā)癥,但出院后相繼發(fā)生了尿路感染和淺表手術(shù)部位感染等并發(fā)癥。由此可見(jiàn),今后應(yīng)加強(qiáng)術(shù)前衰弱評(píng)估并完善相關(guān)檢查對(duì)病人進(jìn)行風(fēng)險(xiǎn)分層,通過(guò)多學(xué)科合作對(duì)衰弱進(jìn)行積極干預(yù)以改善病人術(shù)前身體狀態(tài),并選擇適當(dāng)?shù)氖中g(shù)及麻醉方式、麻醉藥物等以降低刺激,同時(shí)還需優(yōu)化術(shù)中病人管理并提前采取預(yù)防性措施以改善病人出院后結(jié)局。
1.2死亡率增加及生存率降低衰弱增加了結(jié)直腸癌病人的死亡風(fēng)險(xiǎn),是生存率的獨(dú)立預(yù)測(cè)因子。衰弱病人體內(nèi)單核細(xì)胞、T淋巴細(xì)胞、腫瘤壞死因子、白細(xì)胞介素等指標(biāo)升高,細(xì)胞內(nèi)線粒體數(shù)目減少,生長(zhǎng)激素和胰島素樣生長(zhǎng)因子被抑制,引起機(jī)體免疫系統(tǒng)紊亂,能量代謝異常,肌肉損失加劇,機(jī)體呈惡病質(zhì)狀態(tài),進(jìn)而引起各器官系統(tǒng)功能衰退,增加了病人死亡率的發(fā)生風(fēng)險(xiǎn)[20]。Boakye等[21]通過(guò)系統(tǒng)評(píng)價(jià)結(jié)果發(fā)現(xiàn),結(jié)直腸癌衰弱病人的總死亡率是非衰弱者的2~3倍。Ommundsen等[22]的一項(xiàng)研究顯示,結(jié)直腸癌非衰弱者和衰弱病人的1年生存率分別為92%和80%,5年生存率分別為66%和24%。衰弱降低了病人的生存概率,而提高生存概率是病人接受治療目的之一。可見(jiàn),除加強(qiáng)術(shù)前及術(shù)中衰弱管理外,還應(yīng)注重衰弱管理的延續(xù)性,將衰弱評(píng)估納入隨訪管理工作,對(duì)衰弱病人進(jìn)行動(dòng)態(tài)評(píng)估并給予持續(xù)的營(yíng)養(yǎng)、運(yùn)動(dòng)、心理及社會(huì)等多方面干預(yù),最大限度地提高病人的生存機(jī)會(huì)。
1.3住院時(shí)間延長(zhǎng)及再入院率增加衰弱使結(jié)直腸癌病人住院時(shí)間延長(zhǎng),且再入院率增加。Robinson等[23]研究中行結(jié)直腸癌切除術(shù)的衰弱病人的住院時(shí)間與30 d再入院率均大于非衰弱者。Richards等[24]研究發(fā)現(xiàn),衰弱病人術(shù)后90 d再入院的可能性顯著增加,衰弱病人與非衰弱者至少再入院1次的比例分別為41.7%、14.9%。住院時(shí)間延長(zhǎng)和再入院均是結(jié)直腸癌病人住院費(fèi)用增加的重要因素[25],不僅會(huì)加重病人生理、心理及經(jīng)濟(jì)負(fù)擔(dān),還會(huì)降低醫(yī)療資源利用率。衰弱評(píng)估可及時(shí)發(fā)現(xiàn)病人的身體情況,對(duì)其治療及護(hù)理方案做出動(dòng)態(tài)調(diào)整,而對(duì)于出院病人而言,衰弱評(píng)估可發(fā)現(xiàn)潛在再入院風(fēng)險(xiǎn),可指導(dǎo)病人及時(shí)門診就醫(yī),避免情況惡化致再入院治療。
1.4化療不良反應(yīng)增加衰弱增加了結(jié)直腸癌病人的化療毒性,降低了病人接受化療可能性。研究顯示,衰弱指標(biāo)如肌肉減少癥、低蛋白血癥及C?反應(yīng)蛋白與化療毒性獨(dú)立相關(guān)[26?27]。肌肉減少癥會(huì)引起藥物代謝動(dòng)力學(xué)改變,低肌肉質(zhì)量通過(guò)更高的血漿藥物濃度產(chǎn)生更高的毒性[28],低蛋白血癥可干擾藥物在機(jī)體的正常吸收、分布和排泄,炎癥會(huì)降低肝細(xì)胞色素活性和藥物清除率,改變藥物在體內(nèi)作用的時(shí)間與強(qiáng)度[29]。Retornaz等[30]研究發(fā)現(xiàn),基于衰弱指標(biāo)構(gòu)建的預(yù)測(cè)模型能有效預(yù)測(cè)結(jié)腸癌病人的化療毒性,該模型的敏感性為81.6%,特異性為71.4%。另有研究報(bào)道,在接受化療的晚期結(jié)直腸癌病人中,衰弱病人的死亡率是非衰弱者的2.72倍[31]。Meyers等[32]的研究中,埃德蒙頓衰弱量表(EFS)≥7分的結(jié)直腸病人接受化療的可能性降低,Beukers等[33]經(jīng)過(guò)研究也得到了類似的結(jié)論。癌癥病人的身體狀況是選擇適當(dāng)治療方式和強(qiáng)度的重要因素,今后可將衰弱納為結(jié)直腸癌病人制定最佳安全放化療方案的評(píng)估指標(biāo),并協(xié)同傳統(tǒng)評(píng)估指標(biāo),對(duì)病人進(jìn)行全面評(píng)估,將不良結(jié)局降至最低。
1.5其他相關(guān)不良結(jié)局除上述不良結(jié)局外,衰弱還與結(jié)直腸癌病人的獨(dú)立性喪失有關(guān)。研究顯示,在接受急診結(jié)直腸癌切除術(shù)的病人中,31.2%的病人存在衰弱,這些病人術(shù)后再插管、呼吸機(jī)依賴>48 h、再次手術(shù)的風(fēng)險(xiǎn)隨衰弱程度加重而增加,且出院后到護(hù)理或康復(fù)機(jī)構(gòu)的風(fēng)險(xiǎn)增加78%[34?35]??梢?jiàn),即使是在緊急手術(shù)狀態(tài)下,也應(yīng)對(duì)病人進(jìn)行衰弱評(píng)估,但因急診手術(shù)時(shí)間、病人疾病狀態(tài)的限制,應(yīng)選擇快速、準(zhǔn)確地從病人及家屬方面獲得衰弱信息的評(píng)估工具,使醫(yī)務(wù)人員能及時(shí)對(duì)病人進(jìn)行風(fēng)險(xiǎn)分層并制定合適的干預(yù)計(jì)劃,盡可能地改善病人的預(yù)后。
衰弱加重了結(jié)直腸癌病人的不良結(jié)局,但衰弱是動(dòng)態(tài)發(fā)展且可逆轉(zhuǎn)的,盡早識(shí)別衰弱并進(jìn)行有效的干預(yù)能延緩甚至逆轉(zhuǎn)衰弱狀態(tài)。
2.1Fried衰弱表型該量表由Fried等[6]研制,從生理角度對(duì)衰弱進(jìn)行定義,包括步速減慢、握力受損、活動(dòng)水平下降、非自主的體重減輕和自覺(jué)疲憊5項(xiàng)指標(biāo),每項(xiàng)指標(biāo)計(jì)0分或1分,總分0分為健壯,1~2分為衰弱前期,3分及以上為衰弱期,該量表可獨(dú)立預(yù)測(cè)老年人跌倒、入院和死亡等不良事件,是目前使用最廣泛的評(píng)估工具,但該量表未納入心理、社會(huì)和疾病因素。
2.2衰弱指數(shù)(Frailty Index,F(xiàn)I)該量表由Mitnitski等[36]根據(jù)加拿大健康和老齡化研究研發(fā),指病人存在的健康缺陷與基于缺陷累積理論的所有測(cè)量變量的比率,最初提出的衰弱指數(shù)包括70項(xiàng)變量,涵蓋了癥狀、臨床結(jié)果、社會(huì)支持、營(yíng)養(yǎng)攝入及實(shí)驗(yàn)室指標(biāo)等多維度內(nèi)容,從整體角度對(duì)衰弱進(jìn)行分層并將其量化。但其缺點(diǎn)為評(píng)估項(xiàng)目多且耗時(shí)長(zhǎng),為使其更具針對(duì)性,許多學(xué)者進(jìn)行了不同版本的改良,其中包含11個(gè)變量的11?mFI和5個(gè)變量的5?mFI,常用于結(jié)直腸癌病人的衰弱評(píng)估,11?mFI得分≥3分提示病人處于衰弱狀態(tài),5?mFI得分≥2分提示病人處于衰弱狀態(tài)。
2.3格羅寧根衰弱指標(biāo)(Groningen Frailty Indicator,GFI)該量表由Peters等[37]研制,主要包括生理、心理、社會(huì)與認(rèn)知4個(gè)方面的15項(xiàng)內(nèi)容,滿足1項(xiàng)計(jì)1分,總分15分,GFI≥4分病人處于衰弱狀態(tài)。較差的GFI評(píng)分與姑息性化療病人死亡率的風(fēng)險(xiǎn)增加密切相關(guān)。
2.4G?8老年篩查工具(Geriatric?8)該量表由Bellera[38]開(kāi)發(fā),用于快速識(shí)別需要進(jìn)一步老年綜合評(píng)估和適當(dāng)護(hù)理的衰弱腫瘤病人。包括8項(xiàng)內(nèi)容,其中1項(xiàng)為年齡,另外7 項(xiàng)來(lái)自微型營(yíng)養(yǎng)評(píng)價(jià)量表,能及時(shí)識(shí)別出病人營(yíng)養(yǎng)不良的風(fēng)險(xiǎn)。滿分為17分,得分≤14分為衰弱。
2.5其他評(píng)估工具除上述評(píng)估工具外,衰弱量表(FRAIL)、脆弱老年人調(diào)查?13問(wèn)卷(VES?13)、埃德蒙頓衰弱量表(EFS)、臨床衰弱量表(CFS)等也用于結(jié)直腸癌病人的衰弱評(píng)估。及時(shí)準(zhǔn)確的衰弱評(píng)估能對(duì)病人進(jìn)行風(fēng)險(xiǎn)分層并指導(dǎo)醫(yī)務(wù)人員采取有效的干預(yù)措施?;趯?duì)衰弱的不同定義、衰弱程度的不同分級(jí),評(píng)估量表種類多具有顯著的異質(zhì)性[39],選擇衰弱評(píng)估工具前要綜合考量評(píng)估工具的內(nèi)容、適用條件及病人的疾病狀態(tài)等情況。
3.1結(jié)直腸癌病人的衰弱干預(yù)措施通過(guò)增強(qiáng)術(shù)前機(jī)體功能能力使病人能夠承受手術(shù)壓力的過(guò)程稱為預(yù)康復(fù)[40],它從術(shù)前階段開(kāi)始,是一種多學(xué)科、多方面的干預(yù)措施,以預(yù)防或最大限度地減少與手術(shù)相關(guān)的功能衰退并改善圍術(shù)期結(jié)果[41],主要包括運(yùn)動(dòng)訓(xùn)練、營(yíng)養(yǎng)優(yōu)化和心理護(hù)理。即使是最衰弱的老年人也能從任何可耐受的體力活動(dòng)中受益[39],運(yùn)動(dòng)訓(xùn)練使病人反復(fù)承受身體活動(dòng)的生理壓力,提高對(duì)手術(shù)的耐受性[42]。有研究對(duì)具有更差衰弱指標(biāo)的干預(yù)組結(jié)直腸癌病人進(jìn)行每周2次,每次30~45 min,持續(xù)4周的運(yùn)動(dòng)訓(xùn)練,結(jié)果證明運(yùn)動(dòng)訓(xùn)練可以預(yù)防術(shù)后并發(fā)癥的發(fā)生[43]。營(yíng)養(yǎng)優(yōu)化可以潛在地降低并發(fā)癥發(fā)生率和嚴(yán)重程度、減輕炎癥反應(yīng)及改善食欲,并為合成代謝提供足夠的蛋白質(zhì)[44],以改善肌肉質(zhì)量[45]。Achilli等[10]采用隨機(jī)對(duì)照試驗(yàn)證明術(shù)前補(bǔ)充免疫營(yíng)養(yǎng)(術(shù)前10 d給予精氨酸、ω?3脂肪酸和核苷酸等)有效地減少了結(jié)直腸癌衰弱病人的術(shù)后抗生素需求量及胃腸道功能恢復(fù)時(shí)間,并提高了病人接受新輔助放化療耐受性。營(yíng)養(yǎng)補(bǔ)充與運(yùn)動(dòng)訓(xùn)練具有協(xié)同作用,可增加肝臟和肌肉糖原的儲(chǔ)存,提高運(yùn)動(dòng)完成率[46]。抑郁情緒能升高體內(nèi)炎性因子,進(jìn)而引起機(jī)體力量下降及功能障礙[47],通過(guò)心理護(hù)理疏導(dǎo)病人不良情緒從而改善病人衰弱狀態(tài)。衰弱受多因素影響,病人往往存在不同維度的衰弱,Gillis等[48]通過(guò)實(shí)施術(shù)前4周持續(xù)至術(shù)后8周的運(yùn)動(dòng)、營(yíng)養(yǎng)及心理三聯(lián)預(yù)康復(fù)訓(xùn)練減少了結(jié)直腸癌衰弱病人術(shù)后體重的丟失,促進(jìn)了其功能恢復(fù)。但目前結(jié)直腸癌病人的衰弱干預(yù)措施并未達(dá)成共識(shí),今后應(yīng)綜合考慮多方面因素,探索結(jié)直腸癌病人的最佳衰弱干預(yù)方案,包括最佳干預(yù)措施及最佳干預(yù)時(shí)間等。
3.2結(jié)直腸癌病人的衰弱管理模式
3.2.1改良住院老年人生活計(jì)劃模式(mHELP)改良住院老年人生活計(jì)劃模式是一種由護(hù)士主導(dǎo)的衰弱管理模式,由臨床工作經(jīng)驗(yàn)豐富并接受HELP培訓(xùn)的護(hù)士進(jìn)行干預(yù)。①早期活動(dòng):協(xié)助病人每天進(jìn)行全范圍關(guān)節(jié)活動(dòng)練習(xí),包括臥床、起立、站立、行走及騎固定自行車,練習(xí)時(shí)間及次數(shù)根據(jù)病人的情況而定;②口腔護(hù)理及營(yíng)養(yǎng)宣教:每日進(jìn)行口腔護(hù)理及指導(dǎo)口腔?面部練習(xí)(嘴唇、舌頭及下巴),并進(jìn)行營(yíng)養(yǎng)健康教育,不提供營(yíng)養(yǎng)補(bǔ)充;③認(rèn)知刺激:在病人活動(dòng)過(guò)程中,護(hù)士有意地對(duì)其進(jìn)行認(rèn)知刺激,比如回憶手術(shù)當(dāng)天內(nèi)容或討論病人感興趣事情。有研究將mHELP管理模式用于377例接受胃腸道手術(shù)的病人(結(jié)直腸手術(shù)占56.5%),結(jié)果顯示,病人的衰弱發(fā)生率降低,并改善了病人住院期間的營(yíng)養(yǎng)下降程度[49]。
3.2.2跨機(jī)構(gòu)、跨學(xué)科護(hù)理模式(STF)跨機(jī)構(gòu)理念強(qiáng)調(diào)以全面的方式為衰弱的老年外科手術(shù)病人提供康復(fù)目標(biāo),跨學(xué)科護(hù)理是多學(xué)科護(hù)理到更綜合、更協(xié)作的發(fā)展[50],兩者的結(jié)合可將預(yù)康復(fù)和術(shù)后康復(fù)無(wú)縫銜接起來(lái)。STF護(hù)理模式是不同等級(jí)醫(yī)療機(jī)構(gòu)和這些機(jī)構(gòu)中不同學(xué)科人員共同協(xié)作的管理模式。①風(fēng)險(xiǎn)分級(jí):根據(jù)病人衰弱評(píng)估、共病指數(shù)評(píng)分以及病人的活動(dòng)狀態(tài)進(jìn)行風(fēng)險(xiǎn)分級(jí)確定病人的康復(fù)地點(diǎn)(部分病人可在家進(jìn)行康復(fù)訓(xùn)練)。②術(shù)前2周預(yù)康復(fù)訓(xùn)練(非急癥社區(qū)醫(yī)院和病人家里):內(nèi)容包括健康教育、提高依從性、活動(dòng)鍛煉、增強(qiáng)心血管功能訓(xùn)練、肌力訓(xùn)練以及加強(qiáng)營(yíng)養(yǎng)等。③接受手術(shù)(急癥醫(yī)院):術(shù)前預(yù)康復(fù)訓(xùn)練完成后病人在急癥醫(yī)院接受手術(shù)。④術(shù)后康復(fù)治療(非急癥社區(qū)醫(yī)院和病人家里):術(shù)后早期轉(zhuǎn)至社區(qū)醫(yī)院或家里進(jìn)行術(shù)后康復(fù)治療,在術(shù)前康復(fù)的基礎(chǔ)上增加了平衡訓(xùn)練及功能性動(dòng)態(tài)練習(xí)等內(nèi)容。Chia等[51]將該模式用于結(jié)直腸癌衰弱病人中,結(jié)果顯示試驗(yàn)組病人住院天數(shù)低于對(duì)照組。
3.2.3老年綜合評(píng)估管理模式老年綜合評(píng)估(CGA)是一個(gè)多維度、跨學(xué)科的工具,能系統(tǒng)地、全面地對(duì)病人的功能狀態(tài)和跌倒、認(rèn)知功能、合并癥、心理狀態(tài)、營(yíng)養(yǎng)、社會(huì)經(jīng)濟(jì)問(wèn)題以及多重用藥情況等進(jìn)行評(píng)估[52],被視為評(píng)估老年人健康狀況和護(hù)理需求的最佳方式[53]。CGA管理模式是對(duì)CGA后存在的健康缺陷進(jìn)行多學(xué)科合作的管理模式,如內(nèi)科醫(yī)生穩(wěn)定病人基礎(chǔ)疾病、營(yíng)養(yǎng)師指導(dǎo)營(yíng)養(yǎng)攝入、康復(fù)師指導(dǎo)運(yùn)動(dòng)訓(xùn)練、心理專家進(jìn)行心理疏導(dǎo)等。該模式涉及老年病學(xué)醫(yī)生、臨床醫(yī)生及護(hù)士、營(yíng)養(yǎng)師、理療師、心理專家、藥劑師等多領(lǐng)域人員。Lund等[11]將CGA管理模式應(yīng)用于接受輔助或一線姑息化療的結(jié)直腸癌衰弱病人中發(fā)現(xiàn),CGA提高了病人的化療耐受性及活動(dòng)能力,降低了毒性反應(yīng)和病人的疾病負(fù)擔(dān)。但這種管理模式通常耗時(shí)且需要多學(xué)科協(xié)作,目前暫未能在臨床工作中推廣。
3.3結(jié)直腸癌病人的衰弱管理注意要點(diǎn)衰弱管理需醫(yī)患雙方共同努力,在了解衰弱病人的最優(yōu)需求下,能更好地進(jìn)行衰弱管理。有研究報(bào)道,醫(yī)務(wù)人員視衰弱為將會(huì)發(fā)生的“損失”,其管理策略通常包括主動(dòng)監(jiān)測(cè)、主動(dòng)規(guī)劃、多學(xué)科合作和加強(qiáng)誘因控制;相反,衰弱病人不愿正視自身這種即將發(fā)生的“損失”,認(rèn)為這會(huì)降低他們的自我認(rèn)同感、生活質(zhì)量和生活目標(biāo),他們把注意力集中在如何在現(xiàn)在彌補(bǔ)過(guò)去的“損失”上,常通過(guò)接納“損失”、正確看待自己的處境(與情況更差的人比較)、繼續(xù)做以前做的事情、沉浸于“損失”帶來(lái)的悲傷4種方式處理“損失”[54]。該研究指出,這種對(duì)衰弱的不同認(rèn)知代表了各自的首優(yōu)目標(biāo),承認(rèn)和尊重病人的最優(yōu)需求可促進(jìn)衰弱的有效管理。目前尚未檢索到針對(duì)衰弱管理視角下對(duì)結(jié)直腸癌衰弱病人進(jìn)行的質(zhì)性研究,今后可開(kāi)展相關(guān)研究了解結(jié)直腸癌衰弱病人的最優(yōu)需求,并鼓勵(lì)病人參與自身衰弱管理,將醫(yī)護(hù)人員主導(dǎo)的衰弱管理轉(zhuǎn)變成醫(yī)患共同努力的衰弱管理。
目前國(guó)內(nèi)外研究多集中于衰弱對(duì)結(jié)直腸癌病人手術(shù)結(jié)果的影響及衰弱干預(yù)研究,衰弱能加重結(jié)直腸癌病人的不良結(jié)局,嚴(yán)重影響了病人的生存質(zhì)量。結(jié)合國(guó)內(nèi)外研究現(xiàn)狀,發(fā)現(xiàn)存在以下問(wèn)題:①衰弱評(píng)估工具多,但沒(méi)有針對(duì)結(jié)直腸癌病人的特異性衰弱評(píng)估工具;②缺乏衰弱對(duì)急診結(jié)直腸癌切除術(shù)病人長(zhǎng)期結(jié)局影響的相關(guān)研究;③結(jié)直腸癌病人的衰弱干預(yù)措施的有效性存在爭(zhēng)議,且尚未形成最佳的衰弱干預(yù)方案;④缺乏從衰弱管理視角下對(duì)結(jié)直腸癌病人的質(zhì)性研究。今后應(yīng)結(jié)合病人最優(yōu)需求,啟用多學(xué)科聯(lián)動(dòng)方式,從醫(yī)患雙方衰弱視角下探索適合我國(guó)結(jié)直腸癌病人的最佳衰弱管理策略。
[1] SUNG H,FERLAY J,SIEGEL R L,.Global cancer statistics 2020:GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries[J].CA:a Cancer Journal for Clinicians,2021,71(3):209-249.
[2] FAGARD K,LEONARD S,DESCHODT M,.The impact of frailty on postoperative outcomes in individuals aged 65 and over undergoing elective surgery for colorectal cancer:a systematic review[J].Journal of Geriatric Oncology,2016,7(6):479-491.
[3] 陸瑋,肖乾,胡燁婷,等.微生物與結(jié)直腸癌的發(fā)病機(jī)制、早期診斷和治療的研究進(jìn)展[J].腫瘤防治研究,2020,47(12):909-914.
[4] 夏昌發(fā),陳萬(wàn)青.中國(guó)惡性腫瘤負(fù)擔(dān)歸因于人口老齡化的比例及趨勢(shì)分析[J].中華腫瘤雜志,2022,44(1):79-85.
[5] ARNOLD M,SIERRA M S,LAVERSANNE M,.Global patterns and trends in colorectal cancer incidence and mortality[J].Gut,2017,66(4):683-691.
[6] FRIED L P,TANGEN C M,WALSTON J,.Frailty in older adults:evidence for a phenotype[J].The Journals of Gerontology:Series A,2001,56(3):M146-M157.
[7] DENT E,MARTIN F C,BERGMAN H,.Management of frailty:opportunities,challenges,and future directions[J].Lancet,2019,394(10206):1376-1386.
[8] 張慧嬪,張海林,周曉敏,等.消化系統(tǒng)腫瘤患者衰弱現(xiàn)狀及影響因素[J].護(hù)理學(xué)雜志,2022,37(8):11-15.
[9] MICHAUD MATURANA M,ENGLISH W J,NANDAKUMAR M,.The impact of frailty on clinical outcomes in colorectal cancer surgery:a systematic literature review[J].ANZ Journal of Surgery,2021,91(11):2322-2329.
[10] ACHILLI P,MAZZOLA M,BERTOGLIO C L,.Preoperative immunonutrition in frail patients with colorectal cancer:an intervention to improve postoperative outcomes[J].International Journal of Colorectal Disease,2020,35(1):19-27.
[11] LUND C M,VISTISEN K K,OLSEN A P,.The effect of geriatric intervention in frail older patients receiving chemotherapy for colorectal cancer:a randomised trial(GERICO)[J].British Journal of Cancer,2021,124(12):1949-1958.
[12] 馬麗娜.老年衰弱綜合征的發(fā)病機(jī)制[J].中華老年醫(yī)學(xué)雜志,2021,40(3):379-382.
[13] CHAPPELL D,BRUEGGER D,POTZEL J,.Hypervolemia increases release of atrial natriuretic peptide and shedding of the endothelial glycocalyx[J].Critical Care,2014,18(5):538.
[14] CHEN S Y,STEM M,CERULLO M,.The effect of frailty index on early outcomes after combined colorectal and liver resections[J].Journal of Gastrointestinal Surgery,2018,22(4):640-649.
[15] TAN K Y,KAWAMURA Y J,TOKOMITSU A,.Assessment for frailty is useful for predicting morbidity in elderly patients undergoing colorectal cancer resection whose comorbidities are already optimized[J].American Journal of Surgery,2012,204(2):139-143.
[16] OKABE H,OHSAKI T,OGAWA K,.Frailty predicts severe postoperative complications after elective colorectal surgery[J].American Journal of Surgery,2019,217(4):677-681.
[17] 鄭佳.改良衰弱指數(shù)與老年患者結(jié)直腸癌手術(shù)術(shù)后譫妄及Klotho蛋白的相關(guān)性研究[D].延吉:延邊大學(xué),2021.
[18] REISINGER K W,VAN VUGT J L,TEGELS J J,.Functional compromise reflected by sarcopenia,frailty,and nutritional depletion predicts adverse postoperative outcome after colorectal cancer surgery[J].Annals of Surgery,2015,261(2):345-352.
[19] OMMUNDSEN N.Post-discharge complications in frail older patients after surgery for colorectal cancer[J].European Journal of Surgical Oncology,2018,44(10):1542-1547.
[20] 黃子譽(yù),趙紅,馮藝.衰弱對(duì)老年患者外科手術(shù)結(jié)局影響的研究進(jìn)展[J].臨床麻醉學(xué)雜志,2022,38(1):86-91.
[21] BOAKYE D,RILLMANN B,WALTER V,.Impact of comorbidity and frailty on prognosis in colorectal cancer patients:a systematic review and meta-analysis[J].Cancer Treatment Reviews,2018,64:30-39.
[22] OMMUNDSEN N,WYLLER T B,NESBAKKEN A,.Frailty is an independent predictor of survival in older patients with colorectal cancer[J].The Oncologist,2014,19(12):1268-1275.
[23] ROBINSON T N,WU D S,POINTER L,.Simple frailty score predicts postoperative complications across surgical specialties[J].American Journal of Surgery,2013,206(4):544-550.
[24] RICHARDS S J G,CHERRY T J,FRIZELLE F A,.Pre-operative frailty is predictive of adverse post-operative outcomes in colorectal cancer patients[J].ANZ Journal of Surgery,2021,91(3):379-386.
[25] 王淑強(qiáng),鐘文洲.結(jié)直腸癌患者住院費(fèi)用構(gòu)成分布及其影響因素分析[J].中國(guó)醫(yī)藥導(dǎo)報(bào),2019,16(23):118-121.
[26] FELIU J,ESPINOSA E,BASTERRETXEA L,.Prediction of chemotoxicity unplanned hospitalizations and early death in older patients with colorectal cancer treated with chemothearpy[J].Cancer,2021,14(1):127.
[27] BARRET M,ANTOUN S,DALBAN C,.Sarcopenia is linked to treatment toxicity in patients with metastatic colorectal cancer[J].Nutrition and Cancer,2014,66(4):583-589.
[28] ANTOUN S,BORGET I,LANOY E.Impact of sarcopenia on the prognosis and treatment toxicities in patients diagnosed with cancer[J].Current Opinion in Supportive and Palliative Care,2013,7(4):383-389.
[29] ALEXANDRE J,REY E,GIRRE V,.Relationship between cytochrome 3A activity,inflammatory status and the risk of docetaxel-induced febrile neutropenia:a prospective study[J].Annals of Oncology,2007,18(1):168-172.
[30] RETORNAZ F,GUILLEM O,ROUSSEAU F,.Predicting chemotherapy toxicity and death in older adults with colon cancer:results of MOST study[J].The Oncologist,2020,25(1):e85-e93.
[31] AALDRIKS A A,VAN DER GEEST L G,GILTAY E J,.Frailty and malnutrition predictive of mortality risk in older patients with advanced colorectal cancer receiving chemotherapy[J].Journal of Geriatric Oncology,2013,4(3):218-226.
[32] MEYERS B M,AL-SHAMSI H O,RASK S,.Utility of the Edmonton Frail Scale in identifying frail elderly patients during treatment of colorectal cancer[J].Journal of Gastrointestinal Oncology,2017,8(1):32-38.
[33] BEUKERS K,BESSEMS S A M,VAN DE WOUW A J,.Associations between the Geriatric-8 and 4-meter gait speed test and subsequent delivery of adjuvant chemotherapy in older patients with colon cancer[J].Journal of Geriatric Oncology,2021,12(8):1166-1172.
[34] CONGIUSTA D V,PALVANNAN P,MERCHANT A M.The impact of frailty on morbidity and mortality following open emergent colectomies[J].BioMed Research International,2017,2017:5126452.
[35] SIMON H L,PAULA T,LUZ M M,.Frailty in older patients undergoing emergency colorectal surgery:USA National Surgical Quality Improvement Program analysis[J].British Journal of Surgery,2020,107(10):1363-1371.
[36] MITNITSKI A B,MOGILNER A J,ROCKWOOD K.Accumulation of deficits as a proxy measure of aging[J].The Scientific World Journal,2001,1:323-336.
[37] PETERS L L,BOTER H,BUSKENS E,.Measurement properties of the Groningen Frailty Indicator in home-dwelling and institutionalized elderly people[J].Journal of the American Medical Directors Association,2012,13(6):546-551.
[38] BELLERA C A.Screening older cancer patients:first evaluation of the G-8 geriatric screening tool[J].Annals of Oncology,2012,23(8):2166-2172.
[39] AGUAYO G A,DONNEAU A F,VAILLANT M T,.Agreement between 35 published frailty scores in the general population[J].American Journal of Epidemiology,2017,186(4):420-434.
[40] CARLI F,SILVER J K,FELDMAN L S,.Surgical prehabilitation in patients with cancer:state-of-the-science and recommendations for future research from a panel of subject matter experts[J].Physical Medicine and Rehabilitation Clinics of North America,2017,28(1):49-64.
[41] MINNELLA E M.Prehabilitation and functional recovery for colorectal cancer patients[J].European Journal of Surgical Oncology,2018,44(7):919-926.
[42] SUN F,NORMAN I J,WHILE A E.Physical activity in older people:a systematic review[J].BMC Public Health,2013,13:449.
[43] VAN DER HULST H C.Can physical prehabilitation prevent complications after colorectal cancer surgery in frail older patients? [J].European Journal of Surgical Oncology,2021,47(11):2830-2840.
[44] KAMEL H K.Sarcopenia and aging[J].Nutrition Reviews,2003,61(5):157-167.
[45] BREEN L,PHILLIPS S M.Skeletal muscle protein metabolism in the elderly:interventions to counteract the 'anabolic resistance' of ageing[J].Nutrition & Metabolism,2011,8:68.
[46] HARGREAVES M.Pre-exercise nutritional strategies:effects on metabolism and performance[J].Revue Canadienne De Physiologie Appliquee,2001,26(Suppl):S64-S70.
[47] WESTBURY L D,FUGGLE N R,SYDDALL H E,.Relationships between markers of inflammation and muscle mass,strength and function:findings from the Hertfordshire cohort study[J].Calcified Tissue International,2018,102(3):287-295.
[48] GILLIS C,FENTON T R,SAJOBI T T,.Trimodal prehabilitation for colorectal surgery attenuates post-surgical losses in lean body mass:a pooled analysis of randomized controlled trials[J].Clinical Nutrition,2019,38(3):1053-1060.
[49] CHIA-HUI CHEN C,YANG Y T,LAI I R,.Three nurse-administered protocols reduce nutritional decline and frailty in older gastrointestinal surgery patients:a cluster randomized trial[J].Journal of the American Medical Directors Association,2019,20(5):524-529.
[50] CARAMANICA L,ANDERSON R.Transdisciplinary teams:lessons learned[J].Seminars for Nurse Managers,2001,9(2):77-78.
[51] CHIA C L K,MANTOO S K,TAN K Y.'Start to finish trans-institutional transdisciplinary care':a novel approach improves colorectal surgical results in frail elderly patients[J].Colorectal Disease,2016,18(1):O43-O50.
[52] LOH K P,SOTO-PEREZ-DE-CELIS E,HSU T,.What every oncologist should know about geriatric assessment for older patients with cancer:young international society of geriatric oncology position paper[J].Journal of Oncology Practice,2018,14(2):85-94.
[53] PUTS M T E,ALIBHAI S M H.Fighting back against the dilution of the comprehensive geriatric assessment[J].Journal of Geriatric Oncology,2018,9(1):3-5.
[54] LA GROUW Y,BANNINK D,VAN HOUT H.Care professionals manage the future,frail older persons the past.explaining why frailty management in primary care doesn't always work[J].Frontiers in Medicine,2020,7:489.
Research progress of frailty management in patients with colorectal cancer
XUXiaoyan, ZHANGYongmei
Zunyi Medical University, Guizhou 563099 China
colorectal cancer; frailty; adverse outcome; frailty management; review
ZHANG Yongmei, E?mail: hulizym@yeah.net
10.12102/j.issn.1009-6493.2023.03.020
2022年遵義市科技計(jì)劃項(xiàng)目,編號(hào):遵市科合HZ字(2022)337號(hào)
徐小艷,護(hù)師,碩士研究生在讀
張?jiān)伱罚珽?mail:hulizym@yeah.net
徐小艷,張?jiān)伱?結(jié)直腸癌病人衰弱管理研究進(jìn)展[J].護(hù)理研究,2023,37(3):492?496.
(收稿日期:2022-05-06;修回日期:2023-01-18)
(本文編輯 蘇琳)