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1 REVIEW ARTICLE pissn: eissn: Korean J Clin Geri 2018;19(2): 노인환자에게서영양평가와영양실조의적절한관리 전혜진 차의과학대학교분당차병원가정의학과 Nutritional Assessment and Proper Management of Malnutrition in Elderly Patients Hyejin Chun Department of Family Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea A weight loss of more than 5% in the period of 6 12 months in elderly patients is associated with higher rates of mortality and morbidity of chronic diseases. In addition, anorexia and malnutrition are common problems among the elderly. The structural approach is urgently warranted to identify the causes of weight loss and its treatment among the elderly. Brief screening of nutritional problems is a feasible clinical tool of predicting short-term mortality rate of elderly patients. Good nutrition status prevents the progression of chronic diseases, but also, promote physical independence and well-being in the elderly. In addition to the physiological factors associated with aging process, pathological factors (acute or chronic pathological conditions), environmental factors (limited income sources and amounts, impaired cognition or limited health literacy, social isolation, access to grocery store, cooking ability and transportation availability) and iatrogenic factors (adverse drug reactions) contribute to malnutrition as single or combination of these factors. In a real practice, it is not uncommon that these factors are underestimated or are unrecognized. Therefore, it is important to carry out the comprehensive evaluation of identifying these factors in the elderly to prevent or treat malnutrition in the elderly. We implement nutritional support interventions applying the algorithm combined with the above comprehensive evaluation. Various nutrition support interventions can be provided empirically to the malnourished elderly patients. Key Words: Anorexia, Elderly, Malnutrition, Weight loss 서론 현재우리나라는노인인구의급격한증가로고령화사회 (aging society) 를넘어 2017년고령사회 (aged society) 로진입함에따라 10년이내초고령사회 (super-aged society) 로진입할것으로예상되고있다. 이에따라노인의만성질환이환위험및의료비부담이증가하였고, 건강노화, 노인의질병예방및건강증진에대한사회적관심이증가되고있다. 노인건강증진과관련하여신체기능의저하, 치매, 우울증, 독거등과더불어식욕부진, 영양 Received August 24, 2018; revised September 17, 2018; accepted September 17, Corresponding author: Hyejin Chun, Department of Family Medicine, CHA Bundang Medical Center, CHA University, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Korea. fmewha@gmail.com This study was supported by a research grant from Agriculture Science & Technology Development (Project No. PJ ) of Rural Development Administration, Republic of Korea. Copyright C 2018 The Korean Academy of Clinical Geriatrics This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which perm its unrestricted non-comm ercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 전혜진 : 노인환자에게서영양평가와영양실조의적절한관리 73 실조등영양과관련된문제들은계속증가할것으로예상된다. 영양소섭취량에차이가있을수있으나노인에게서경구섭취저하로인한영양부족은만성질환이환율, 입원율및사망률증가와밀접한관련이있다 [1]. 우리나라질병관리본부에서시행한노인의식품섭취조사에따르면, 65세이상노인 6명중 1명은하루권장열량섭취량 ( 남성 2,000 kcal, 여성 1,600 kcal) 의 75% 미만으로섭취하고있어영양섭취에문제가있는식욕부진과영양실조는노인에게서흔하게동반되는문제라고볼수있다 [2]. 영양실조란에너지, 단백질및기타영양소들의부족혹은과잉으로인한불균형때문에신체조직, 구성성분및기능에부정적인영향을초래하는상태이다. 노인에게서특히문제가되는영양실조는단백질에너지영양실조 (protein energy malnutrition) 로인체의기초적인대사요구량을충족시키기위한에너지또는단백질의양이불충분한영양상태를의미한다 [3,4]. 일반적으로노인인구에서영양실조유병률이일반성인집단에비해높은것으로알려져있으며, 노인집단에서도지역사회에거주하는건강한 75세미만의노인과비교하여장기요양시설에거주하고나이가많을수록영양실조위험이더증가한다 [5]. 노인에게서식욕부진으로인한영양실조는근감소증을유발하고, 이는다시근육량감소, 대사율저하로만성질환발병을가속화시킴으로써, 다시식욕부진을악화시켜더심한영양실조를유발한다 [3]. 그리고영양불균형은질병이발생하기전에이미존재하는것으로알려져있다. 본글에서는질환발생이전에영양불균형을해결하고식욕부진-영양실조-근감소증-만성질환으로이어지는악순환의고리를끊고노년기삶의질을높이며, 건강수명을연장하기위한효율적인영양평가및식생활관리에대해알아보고자한다 [6]. 본론 1. 식욕부진및영양실조의원인 노인에게서영양실조는영양소에따라다양하게보고되고있으며, 탄수화물, 단백질, 지방등의다량영양소 (macronutrients) 및비타민, 무기질과같은미량영양소 (micronutrients) 측면에서문제를가지는것으로보인다 [3]. 일반적으로 70세이상노인들은젊은사람들의 1/3 정도를섭취하며, 지역사회거주노인중 16 18% 가하 루 1,000 kcal 미만을섭취하고있으며, 노인의 50% 는칼로리뿐만아니라비타민및미네랄을영양권장량 (recommended dietary allowances) 미만으로섭취하고있다 [2]. 하지만노인의영양섭취부족에대한정확한원인은잘밝혀져있지않으며, 생리적, 심리적, 사회경제적및질환등다양한요인들이복합적으로작용하여경구섭취를감소시키는것으로보인다 (Table 1). 따라서다양한요인들에대해숙지하고있어야하며만약가역적원인들에의해경구섭취저하가발생한것으로확인되는경우에는원인에대한조치를시행하도록한다 [4]. 노인에게서치아를포함한구강상태는경구섭취량을감소시키는주요한원인므로노인환자를진료할때에는치아및구강상태확인이반드시필요하다. 노화에따른시각, 후각, 미각등감각기능의저하와과도한칼로리나염분의제한으로인한음식맛의저하역시경구섭취감소의원인이될수있다 [4]. 실제로노인환자에 Table 1. Factors contributing to inadequate nutrition in elderly Physiologic Impaired strength/aerobic capacity Impaired mobility/dexterity (arthritis, stroke) Impaired sensory input (smell, taste, sight) Poor dentition/oral health Malabsorption Chronic illness Alcohol Drugs (eg, SSRIs, NSAIDs, digoxin, opiates, levodopa, antibiotics, metformin, iron, others) Psychological Depression Bereavement Anxiety, fear, paranoia Dementia Socioeconomic Fixed income Reduced access to food (social isolation, inadequate storage facilities, inadequate cooking facilities) Poor knowledge of nutrition Dependence on others (caretakers, institutions) Acute illness/hospitalization Failure to monitor dietary intake and record weights Failure to consider increased metabolic requirements Iatrogenic starvation (eg, NPO for diagnostic tests) Delay in instituting nutritional support SSRI, selective serotonin reuptake intibitor; NSAID, nonsteroidal anti-inflammatory drugs. Adapted from the article of Morley JE. Curr Pharm Des 2007;13: [10].

3 74 Korean J Clin Geri 2018;19(2):72-80 게서질환으로인해과도한제한식사를하는경우질환의예후는개선되지않고오히려경구섭취량만감소시킬수있다. 따라서음식의맛, 선호도, 단단한정도, 온도등을고려한식사준비로경구섭취를증가시키도록한다. 그외에도공복감에대한주관적상태, 식사전위용적, 식사를함께하는사람의여부및수에따라서도식욕에영향을미치는것으로알려져있다. 특히우울증은노인에게서체중감소의흔한원인으로알려져있으며배우자와의사별, 독거등으로더악화될수있으므로, 누군가가식사를함께하거나식사시간동안자리를지켜주는것만으로도영양학적위험을감소시킬수있다. 노인에게서급성질환의이환은열량과영양소에대한요구량을높이고, 소화기능과배설에변화를발생시킬수있다. 또한입원이나수술과같은환경적변화는경구섭취를감소시킬수있고질환으로인해신체예비력저하및급성질환회복의지연과같은악순환을일으킬수있어주의를요한다. 2. 식욕부진및영양실조의평가 1) 식욕부진평가식욕은일생동안계속변화하는데정상적으로노화 와함께경도의식욕감소가있고그로인한경구섭취의감소로 80세노인이되었을때평균에너지섭취는 20세성인에비해 30% 정도로감소한다 [7]. 하지만노인에게서식욕부진은단백칼로리영양실조와체중감소의주요한원인으로이어질수있어주의가필요하다. 만약급성질환의발병이나치아와구강장애가없는데 3일이상제공되는표준 1인분의 50% 이상음식섭취가감소하는경우는하나의증후군으로보고, 이를 노화에의한식욕부진 (anorexia of aging) 이라정의한다 [7]. 식욕부진의정의, 연령또는성별에따라유병률에차이가있지만, 평균 78세노인들을대상으로자가보고한결과에따르면평균 21.2% 의노인에게서식욕부진이있고, 지역사회에거주하는노인에비해급성질환혹은재활치료를위해입원한노인의경우에특히식욕부진유병률이높았다 ( 여성 33.3%, 남성 26.7%) [8]. 일반적으로식욕부진이있는경우연령이더높고음식재료를구입하고요리하는데더많은도움이요구된다. 식욕을평가하는도구로 Appetite, Hunger and Sensory Perception (AHSP), Simplified Nutritional Appetite Questionnaire (SNAQ) 등이있다. SNAQ은식욕에초점을맞춘평가도구로 AHSP와높은상관관계를보이며 14점이하일경우 6개월이내 5% 의체중감소위험이있을수있다 [9-11]. Figure 1. Weight loss evaluation algorithm. Adapted from the textbook of Jeffrey B Halter. Hazzard's Geriatric Medicine and Gerontology 2008: p [31].

4 전혜진 : 노인환자에게서영양평가와영양실조의적절한관리 75 2) 임상적영양상태평가불충분한에너지섭취로인한식욕부진외에근육량과피하지방량의감소로영양실조를의심해볼수있다. 특히관자놀이, 흉근, 등세모근및대퇴부사두근의근육량과눈가나삼두근의피하지방량을통해감소를확인할수있다. 체내수분이축적되는부종이동반되거나악력감소와같은기능저하가동반될경우에도영양실조를의심할수있다. 이외에도세포의재생이빠른피부, 모발, 구강점막등에대한관찰도영양상태를파악하는데도움이될수있다. 임상적으로가장간편하게영양문제를선별할수있는지표는체중감소이다 [4,8]. 6 12개월사이에 5% 이상의체중감소는유병률과사망률증가와관련있는것으로알려져있어체중감소와함께식욕부진, 오심, 구토, 설사등경구섭취가어려운증상이동반될경우적절한평가와집중적인영양관리가필요하다 (Figure 1). 하지만의미있는체중감소를동반한노인의 25% 정도에서체중감소에대한검사에도불구하고원인이밝혀지지않는것으로보고되고있어무분별한검사를시행하지않고임상소견에따라필요한검사를선별하여시행하고식사강화를권하면서주의깊게기다려보는것을우선권고한다 [4]. 3) 영양상태평가 (1) 식사섭취평가경구섭취량과식습관에대한평가는영양문제의원인을감별할수있는정보를제공하기때문에식사섭취에대한평가를필수적으로시행한다 [12,13]. 간단하게평소음식섭취량과변화여부를환자또는보호자와의면담을통해질문하는경우절대적인식사섭취량에대한정확한평가가어려울수있다. 정확한식사섭취에대한정보를파악하기위해 24시간회상법 (24 hour recall method), 음식일기 (food diary), 음식섭취빈도설문 (food frequency questionnaire) 등을이용한다 (2) 영양상태평가식욕부진과영양실조와같은영양상태를평가할수있는다양한도구들이개발되어이용하고있다 (Table 2) [14]. 간이영양평가 (mini nutritional assessment, MNA) 가대표적으로이용되고있으며, 노인에게서도타당성이입증되어포괄적으로노인영양상태를평가할수있다. MNA 18개의항목에대한평가에서 24점미만의경우영양문제가동반될가능성이높다. 하지만시간이부족 할경우식사량, 체질량지수, 체중감소, 신경정신과적문제, 거동여부및본인의건강인지도등 6개의문항으로구성된축약형간이영양평가 (mini nutritional assessment-short form, MNA-SF) 를시행하도록한다. MNA-SF 는 10분이내에평가가가능하기때문에진료에유용하게이용될수있다. MNA-SF 11점이하일경우영양문제가동반될가능성이높다 [13]. (3) 혈액학적평가혈청알부민은일반적으로영양상태와관련있는지표로이용되었지만반감기가약 20일로길어, 최근에는트랜스페린 ( 반감기 =10일 ) 또는프리알부민 ( 반감기 =2 3일 ) 검사를이용하여영양상태를평가하고영양보충에따른추적검사할것을권고한다 [15]. 하지만염증질환또는간질환이동반되어있거나급성스트레스의경우에도감소할수있어해석에주의를요한다 [16]. 비타민 A와아연등미량영양소의평가에레티놀결합단백질이이용될수있으나영양상태에대한평가지표로는근거가부족하다. 그외에도체내염증상태를반영하는백혈구, 총림프구수, C-반응단백질이나단백섭취량과질소의소변배출량을통해산출하는질소균형을통해서간접적으로영양상태를확인할수있다. (4) 기능학적평가영양실조위험이있는노인의경우근육강도가감소하고전반적인신체기능의감소가발생한다. 일어나걷기 (timed up and go) 를시행하거나, 보행속도, 의자에서 Table 2. Instruments for nutritional screening and assessment Screening tools Birmingham nutrition risk score Malnutrition screening tool Malnutrition universal screening tool Maastricht index Nutrition risk classification Nutritional risk index Nutritional risk screening 2002 Prognostic inflammatory and nutritional index Prognostic nutritional index Simple screening tool Short nutrition assessment questionnaire Nutrition assessment tools Mini nutritional assessment Subjective global assessment Adapted from the article of Benoist et al. J Visc Surg 2015; 152:S3-7 [3].

5 76 Korean J Clin Geri 2018;19(2):72-80 일어나기등근위부근력에대한평가로영양문제에대한위험도선별이가능하지만, 여러변수들이결과에영향을미칠수있다. 진료실에서가장유용하게영양위험을선별할수있는기능학적평가는악력계 (handgrip dynamometer) 를이용하여전완근육의악력을측정하는것이다 [17]. 3. 식욕부진및영양실조의치료영양학적중재는식욕부진이나영양실조를가지고있는노인환자에게서예후를향상시키기위해필수적이나, 부적절한처치는오히려예상못한부정적인결과를초래할수도있다. 따라서영양학적중재를고려할때는병태생리를고려하고현재의영양문제가지속되었던기간, 부족량을고려하여영양소를보충하고환자의선호도와삶의질을고려하여권장섭취량에맞는영양적조치로중재효과를극대화시켜야한다 (Table 3) [12]. 1) 식사에대한상담및교육경구섭취량증가를위해가장먼저시도할수있는방법은식사에대한상담과교육이다. 음식의형태, 맛, 질감및제공되는음식의농도, 온도에따라서섭취량에차이가있을수있다. 변화없는단조로운식사는식욕을오히려감소시켜영양불균형을초래할수있어주의를요한다. 단조로운식사에대한변화를주기위해음식에소스를사용하는것도음식섭취를증가시킬수있 으므로도움이될수있다. 소량씩식사를자주하고식사사이에간식을하는것도경구영양섭취를늘릴수있는방법이다. 단백질섭취의경우에도한번에많이섭취하는것보다식사때마다나누어섭취하는것이노쇠한노인환자의근육량유지에도움이된다 [18]. 노쇠한노인에게서는최소단백질권장량인체중 1 kg에 0.8 g 보다더많은양의단백질섭취를권한다. 고혈압, 당뇨병등기저질환때문에염분이나칼로리섭취를제한할경우질환으로인한예후를개선시키지못하면서오히려경구섭취량감소를야기시킬수있으므로식사제한은가능한최소화한다 [14,15]. 2) 경구영양보충제구강및치아에문제가있거나노쇠한노인에게경구영양보충제의공급은에너지, 단백질및영양소섭취증가로체중을증가시키는데도움이될수있다. 류신 (leucine) 과같은필수아미노산을강화한보충제를공급할경우식사상담보다영양섭취개선에우월한효과가있고신체기능이향상된다고알려져있다. 국내연구에서도노쇠한노인을대상으로 400 kcal 경구단백질보충제 200 ml를 12주간복용할경우복용하지않은군에비해서신체기능의향상이확인되었다 [19]. 경구영양보충제의공급은같은열량의음식을먹는것보다단백질을비롯한다른영양소들을잘공급할수있고신체기능외에도입원환자의재원기간을감소시키고사망률을비 Table 3. Approaches to implementing nutritional support Available interventions Enhance oral intake Frequent meals, snacks Provide favorite foods, fortified foods, minimize/remove dietary restrictions Feeding assistance Protein-calorie supplements Multivitamins Appetite stimulants Anabolic agents Enteral nutrition Parenteral nutrition Factors to consider Degree of baseline protein-calorie depletion Current intake relative to requirements Expected duration of inadequate nutrition Effect of intervention on clinical outcomes Potential benefits Potential adverse effects Burden of intervention Potential for reversibility Quality of life Patient care preferences Adapted from the article of Morley JE. Curr Pharm Des 2007;13: [10]. Table 4. Adverse effects of orexigenic agents Agent Adverse effects Cyproheptadine Dry mouth, drowsiness, dizziness, loss of coordination Megesterol Fluid retention, nausea, diarrhea, delirium, thrombosis Glucocorticosteroids High blood pressure, high blood sugar, gastritis, GI bleeding, osteoporosis, depression, decreased libido, adrenal insufficiency Cannabinoids Nausea, tachycardia, red eye, dependence Testosterone Erythrocytosis, benign prostate hypertrophy, stimulate growth of prostate cancer, liver toxicity, gynecomastia, fluid retention Growth hormone Arthralgia, edema, insulin resistance, tumor growth Adapted from the article of Morley JE. Clin Geriatr Med 2002;18: [21].

6 전혜진 : 노인환자에게서영양평가와영양실조의적절한관리 77 롯한합병증발생을감소시킬수있다 [20]. 경구영양보충제를처방할때에는에너지와단백질밀도가높은것을되도록적은양으로처방하고운동을하게할경우근육량증가와근력향상에도움이될수있다 [21]. 3) 약물요법 (1) 식욕촉진제 (orexigenic agents) 식사상담과교육에도경구섭취량이증가하지않는경우식욕촉진제를고려해볼수있다. 현재우리나라에서처방할수있는식욕촉진제들대부분은개발초기에사용되었을때목표로했던치료효과외에식욕또는체중증가작용이밝혀지면서식욕촉진을위해사용하게되었다. 하지만이들약제들로인한부작용위험도있으므로주의를요한다 (Table 4) [22]. Megesterol acetate는프로게스테론합성유도체로인터루킨-6, 종양괴사인자- 등식욕을억제하고체중감소를일으키는염증시토카인을억제하기때문에암이나후천성면역결핍증환자에게서식욕촉진효과를기대해볼수있다 [23]. 또한시상하부에서신경펩티드 Y의분비를촉진하기때문에식욕부진이있거나영양이부족한노인에게서도식욕을자극하여체중을증가시키거나삶의질을유지하는효과를기대해볼수있다. 하지만 8주복용후에도효과가없을경우체액저류및정맥혈전색전증의위험이증가할수있다. 1세대항히스타민제염산사이프로헵타딘은부가적으로세로토닌길항작용을가지고있어식욕부진환자에게서자주처방되는약물이다. 하지만진정, 어지럼, 소변저류, 추체외로증상및섬망등부작용발생의가능성이있어노인에게서투여금기약물로되어있다. Dronabinol, marinol, nabilone 등합성마리화나성분인 cannabinoids는아직국내에는도입되지않았다. 오심, 구토, 섬망및운동실조부작용이있으나, 암이나후천성면역결핍증과같은악액질 (cachexia) 환자에게서기분개선과식욕촉진효과를기대할수있다. (2) 단백동화제 (anabolic agents) 강력한항염증효과를가진글루코코르티코이드는사지를제외한복부에지방을축적하여체지방을재분배하고식욕을증가시켜체중증가효과를가진다 [24]. 노인에게서삶의질과기능상태의호전을가지고올수있지만장기간사용할경우이차성골다공증, 슬관절과고관절의골괴사, 소화성궤양, 감염및시상하부-뇌하수체- 부신축 (hypothalamic-pituitary-adrenal axis) 의억제를야기할수있어주의가필요하다. 테스토스테론은체중의증가없이근육량을증가시키고이와함께근력과골밀도를증가시킨다고보고되었다 [24]. 혈중테스토스테론이낮은노인남성에게서식욕저하및근육량감소가있다면고려해볼수있다. 성장호르몬과인슐린성장인자-1은인체에서다양한효과를나타내지만노화에따라감소하기때문에외부에서보충할경우근육에서단백질합성촉진효과를기대해볼수있다 [25]. 이러한호르몬치료들은항노화효과도함께기대할수있지만, 경제적비용이나투여의불편및부작용때문에고령환자에게서의임상적인사용은제한적이다. (3) 기타어유와견과류에들어있는 eicosapentaenoic acid와 docosahexaenoic acid 등 -3 고도불포화지방산 (polyunsaturated fatty acids, PUFAs) 는간에서초저밀도지질단백질과중성지방등지방생성을억제하고 nuclear factor-kappa B를억제하여항염증작용을하는것으로알려져있다 [26]. 진행된암으로체중감소를가진악액질환자에게서 -3 PUFAs는식욕과삶의질지표을개선시키고체중을증가시켰다. -3 PUFAs를적어도하루 1.5 g 이상섭취할때영양상태개선을기대할수있으나, 장기간혹은고용량 -3 PUFAs 공급에대한안전성은아직입증되지않았다. 노인에게서우울증은식욕저하와체중감소를야기하는것으로알려져있어노르아드레날린길항및세로토닌작용효과가있는 mirtazapine 투여로식욕상승을기대할수있다. 하지만우울증이없는노인환자에게서단순히식욕과체중증가를목적으로 mirtazapine을처방하는것은권장하지않는다. Metoclopramide, mosapride, domperidone 등도파민길항작용을하는위장관운동촉진제들 (gastroprokinetics) 은노화로인해위장관운동성이감소한노인환자에게서위배출속도를높이고식욕을증가시키는효과를기대해볼수있다. 하지만추체외로증상, 섬망등부작용이있으므로질병및현재상태에따라처방해야한다. 4. 영양지원 (nutritional support) 식욕개선을위한다양한접근에도불구하고경구영양섭취가불충분할경우장관영양 (enteral nutrition) 과비

7 78 Korean J Clin Geri 2018;19(2):72-80 Figure 2. Nutritional support algorithm. Adapted from the textbook of Jeffrey B Halter. Hazzard's Geriatric Medicine and Gerontology p [31]. 경구영양 (parenteral nutrition) 을통한영양지원을고려한다. 경구영양섭취가부족한환자에게서영양지원은예후를호전시키기위해필수적으로필요하지만, 적응증에해당하지않는환자를선택하거나주입방법을잘지키지않을경우오히려위험을초래할수있으므로기저질환종류, 중증도, 환자의선호도등을모두고려하여시행여부를결정한다 (Figure 2) [27]. 일반적으로비경구영양보다장관영양을선호하며, 영양상태가호전되어경구섭취가가능하면영양지원을중단한다. 1) 장관영양장관영양은 7일이상경구섭취가불충분할경우튜브를통해위장관에영양분을공급하는방법이다. 이를위한튜브는예상되는영양지원기간과흡인위험도및위장관상태에따라서결정한다 [28]. 30일이내영양지원이예상되는경우에는코위관 (nasogastric tube) 을사용한다. 위장관의구조와기능의유지측면에서볼때, 비경구영양에비해장관영양은보다생리적인영양공급방법으로고혈당위험이적고경제적이며비침습적인방법이다 [29]. 하지만 4주이상의장기간정맥영양이예측되는경우에는경피적으로위조루관 (percutaneous gastrostomy tube) 을삽입하여영양지원을한다. 비협조적이거나치매나섬망이있는환자의경우코위관을스스로뺄수있어단기간영양지원을계획하는경우라면비경구영양을병용하고장기간영양지원이예상된다면경피적위조루관삽입을계획한다. 위조루관은내시경이나투시 X 선혹은초음파와같은방사선검사를이용하여삽입한 다. 정해진주입방법을따르지않을경우튜브사용으로인해구역, 구토, 설사, 변비, 흡인, 고혈당및영양재개증후군등의부작용이발생할수있어주의가필요하다. 2) 비경구영양장관영양이불충분하거나불가능할경우중심정맥과말초정맥을통한영양지원을할수있다. 이를통해영양상태를호전시키고질병이환율과사망률감소를어느정도기대할수있지만, 고혈당, 전해질불균형, 감염과그로인한패혈증등합병증을유발할수있기때문에입원한노인환자에게서영양상태가나쁘지않은경우라면가능한경구섭취를권장한다 [30]. 그외에도비경구영양공급기간이 7일이내로예상되거나, 혈역학적으로불안정한경우에는비경구영양공급이금기이다. 하지만단백칼로리영양실조로경구섭취가불충분한경우에는빠른영양상태호전과신체기능회복을위해입원수일이내비경구영양을통한영양지원을시작한다. 중심정맥을통한비경구영양의경우기흉, 동맥파열, 출혈과혈흉등합병증의위험이있어만약 7 14일이내단기적인비경구영양공급이예상되는경우에는가능한말초정맥을통한영양공급을시행한다. 결론 노인에서영양실조는식욕부진에서시작하여체중감소, 근육감소, 기저질환의악화및만성질환발생으로진행할수있는흔한문제이다. 적절한영양관리가되지

8 전혜진 : 노인환자에게서영양평가와영양실조의적절한관리 79 않는다면이러한일련의과정은계속악순환되어노인에게서독립적인일상생활을저해하고기저질환의악화로인해입원율및사망률증가로이어질수있다. 따라서영양실조의다양한원인들에대해세밀한병력청취를비롯한평가가필요하다. 포괄적인영양학적평가에도불구하고 25% 정도에서는정확한원인이밝혀지지않지만, 노인의영양상태를파악하고적극적인관리를통해삶의질및기능상태를호전시키고건강노화를달성하도록노력해야할것이다. CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Kwon SC, Choe MA, Kim KS, Yi MS, Suh E, Suh M. Nutritional Status, Nutrients Intakes, and Health Status of Young-old and Old-old Homebound Elderly in Korea. J Korean Biol Nurs Sci 2012;14: So EJ, Joung H. Socio-economic status is associated with the risk of inadequate energy intake among Korean elderly. J Nutr Health 2015;48: Benoist S, Brouquet A. Nutritional assessment and screening for malnutrition. J Visc Surg 2015;152:S Wong CJ. Involuntary weight loss. Med Clin North Am 2014;98: Malafarina V, Uriz-Otano F, Iniesta R, Gil-Guerrero L. Sarcopenia in the elderly: diagnosis, physiopathology and treatment. Maturitas 2012;71: Bair MJ, Chen HL, Wu CH, Lee YK, Lin IT, Shih SC. Nutritional influences on age-related frailty. J Gerontol Geriatr Res 2016;5: Visvanathan R. Anorexia of Aging. Clin Geriatr Med 2015;31: Mathey MF. Assessing appetite in Dutch elderly with the Appetite, Hunger and Sensory Perception (AHSP) questionnaire. J Nutr Health Aging 2001;5: Rolland Y, Perrin A, Gardette V, Filhol N, Vellas B. Screening older people at risk of malnutrition or malnourished using the Simplified Nutritional Appetite Questionnaire (SNAQ): a comparison with the Mini-Nutritional Assessment (MNA) tool. J Am Med Dir Assoc 2012;13: Morley JE. Weight loss in older persons: new therapeutic approaches. Curr Pharm Des 2007;13: Jonnalagadda SS, Mitchell DC, Smiciklas-Wright H, Meaker KB, Van Heel N, Karmally W, et al. Accuracy of energy intake data estimated by a multiple-pass, 24-hour dietary recall technique. J Am Diet Assoc 2000;100: Jensen GL, Hsiao PY, Wheeler D. Adult nutrition assessment tutorial. JPEN J Parenter Enteral Nutr 2012;36: Mueller C, Compher C, Ellen DM. American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr 2011;35: White JV, Guenter P, Jensen G, Malone A, Schofield M. Academy Malnutrition Work Group; A.S.P.E.N. Malnutrition Task Force;A.S.P.E.N. Board of Directors. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 2012;36: Lee JL, Oh ES, Lee RW, Finucane TE. Serum albumin and prealbumin in calorically restricted, non-diseased individuals: a systematic review. Am J Med 2015;128:1023.e Curb JD, Ceria-Ulep CD, Rodriguez BL, Grove J, Guralnik J, Willcox BJ, et al. Performance-based measures of physical function for high-function populations. J Am Geriatr Soc 2006;54: Cesari M, Prince M, Thiyagarajan JA, De Carvalho IA, Bernabei R, Chan P, et al. Frailty: an emerging public health priority. J Am Med Dir Assoc 2016;17: Bauer JM, Verlaan S, Bautmans I, Brandt K, Donini LM, Maggio M, et al. Effects of a vitamin D and leucine-enriched whey protein nutritional supplement on measures of sarcopenia in older adults, the PROVIDE study: a randomized, double-blind, placebo-controlled trial. J Am Med Dir Assoc 2015;16: Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in need of nutritional support: review of current treatment options and factors influencing nutritional intake. Clin Nutr 2010;29: Kim HK, Suzuki T, Saito K, Yoshida H, Kobayashi H, Kato H, et al. Effects of exercise and amino acid supple-mentation on body composition and physical function in community-dwelling elderly Japanese sarcopenic women: a randomized controlled trial. J Am Geriatr Soc 2012;60: Morley JE. Orexigenic and anabolic agents. Clin Geriatr Med 2002;18: Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, Gonzalvez Perales JL, Bort-Marti S. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev 2013;3:CD Yavuzsen T, Davis MP, Walsh D, LeGrand S, Lagman R. Systematic review of the treatment of cancer-associated anorexia and weight loss. J Clin Oncol 2005;23: O Connell MD, Wu FC. Androgen effects on skeletal muscle: implications for the development and management of frailty. Asian J Androl 2014;16: Kaiser FE, Silver AJ, Morley JE. The effect of recombinant human growth hormone on malnourished older individuals. J

9 80 Korean J Clin Geri 2018;19(2):72-80 Am Geriatr Soc 1991;39: Colomer R, Moreno-Nogueira JM, García-Luna PP, García-Peris P, García-de-Lorenzo A, Zarazaga A, et al. N-3 fatty acids, cancer and cachexia: a systematic review of the literature. Br J Nutr 2007;97: Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, et al. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clin Nutr 2006;25: Pichard C, Kyle UG, Morabia A, Perrier A, Vermeulen B, Unger P. Nutritional assessment: lean body mass depletion at hospital admission is associated with an increased length of stay. Am J Clin Nutr 2004;79: Sobotka L, Schneider SM, Berner YN, Cederholm T, Krznaric Z, Shenkin A, et al. ESPEN. ESPEN Guidelines on Parenteral Nutrition: geriatrics. Clin Nutr 2009;28: Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011;365: Jeffrey B Halter. Hazzard's Geriatric Medicine and Gerontology: Malnutrition and Enteral/Parenteral Alimentation. 6th ed. New York: The McGraw-Hill Company; p

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서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of