[Faktoren, die sich negativ auf die Lebensqualität geriatrischer Patienten auswirken: Review]

 Krzysztof Marcinkowski ¹
Mateusz Muras ²
Maciej Michalik ³
Tomasz Lorenc ³
Natalia Mikszta ⁴
Jakub Mikszta ⁴
Julia Marcinkowska ⁵
Karolina Kantor <sup>5

1</sup> Szpital Specjalistyczny im. Ludwika Rydygiera w Krakowie, Kraków, Poland
² Wojewódzki Szpital Specjalistyczny nr 2 w Jastrzębiu Zdroju, Jastrzębie Zdrój, Poland
³ Warszawski Szpital Południowy, Warszawa, Poland
⁴ Samodzielny Publiczny Zakład Opieki Zdrowotnej Wojewódzki Szpital Specjalistyczny nr 3 w Rybniku, Rybnik, Poland
⁵ Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland

Zusammenfassung

Einleitung: Der Alterungsprozess wird von einer Vielzahl von Herausforderungen begleitet, die die Lebensqualität und das allgemeine Wohlbefinden älterer Menschen erheblich beeinträchtigen. In der Studie werden mehrere Schlüsselfaktoren untersucht, die sich negativ auf Senioren auswirken, darunter Einsamkeit, Gebrechlichkeitssyndrom, Stürze, Polypharmazie, Harninkontinenz, chronische Schmerzen und Mangelernährung.

Methode: Die Datenbanken PubMed und Google Scholar wurden nach wissenschaftlichen Artikeln durchsucht, in denen die Begriffe „ältere Menschen“ und „Lebensqualität“ im Titel, in der Zusammenfassung oder in den Schlüsselwörtern vorkommen.

Ergebnisse: Einsamkeit erweist sich als ein kritisches Problem, das zu psychischen Problemen wie Depressionen und kognitivem Abbau beiträgt. Stürze, eine der häufigsten Verletzungsursachen bei älteren Erwachsenen, haben oft langfristige physische und psychische Folgen. Die Polypharmazie, mit der mehrere chronische Erkrankungen behandelt werden sollen, erhöht das Risiko von unerwünschten Arzneimittelwirkungen und der Nichteinhaltung der Medikation. Das Gebrechlichkeitssyndrom verringert die Anfälligkeit der Patienten für Stressfaktoren. Harninkontinenz, die oft stigmatisiert wird, beeinträchtigt das körperliche Wohlbefinden und die sozialen Interaktionen und mindert die Würde der Betroffenen. Chronische Schmerzen beeinträchtigen das tägliche Funktionieren und verstärken das Gefühl der Hilflosigkeit, während Mangelernährung die körperliche Gesundheit untergräbt und zu Gebrechlichkeit und erhöhter Anfälligkeit für Krankheiten führt. All diese Faktoren wirken sich auf die Lebensqualität älterer Menschen aus.

Schlussfolgerungen: Die Studie identifiziert Schlüsselfaktoren, die sich negativ auf die Lebensqualität älterer Erwachsener auswirken, einschließlich physischer, psychologischer und sozialer Herausforderungen, die umfassende und gezielte Interventionen erfordern.

---

---

Introduction

The percentage of elderly people in the population is constantly increasing and, given the lengthening of the assumed lifespan, this process will intensify in the coming years [1], [2]. According to Główny Urząd Statystyczny, people aged ≥65 in 2050 will make up 31.5% of the population in Poland, and their numbers will increase by 5.1 million compared to 2014. In turn, the total number of people of retirement age could rise to as many as 10 million by 2050 [3]. The aging of the population calls for increased attention to the needs, functioning and quality of life of the elderly [4]. The incidence of diseases in the elderly is increasing significantly.

In the past, attempts have been made to define quality of life, such as: “a conscious cognitive judgment of satisfaction with one’s life” [5] or “an overall general well-being that comprises objective descriptors and subjective evaluations of physical, material, social, and emotional well-being together with the extent of personal development and purposeful activity, all weighted by a personal set of values” [6]. On the other hand, the WHO presented the concept of quality of life as “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broadly ranging concept affected in a complex way by the person’s physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment.” [7].

Reduced quality of life in elderly patients is largely due to functional limitations. These disorders are very common among the elderly, but they can be avoided to a certain extent, depending on the functionality of health care systems [8]. It is possible that loss of quality of life for seniors is perceived in the same way as loss of health [9]. In this article, some of the most important functional disorders that negatively affect patients’ quality of life are highlighted.

The purpose of the present article was to review and analyze the Polish and international literature on selected factors negatively affecting the quality of life of the elderly. .

Results

Frailty syndrome

This is a clinical condition in which, upon exposure to a stressor, an individual’s vulnerability for heightened dependency and/or mortality increases [10]. This syndrome is common in elderly population [4]. Vitamin D deficiency, sarcopenia, malnutrition, loneliness, multidrug use, or increased oxidative stress can be blamed for the development of frailty in the elderly [11], [12]. It is characterized by a decline in the body’s physiological reserves, leading to reduced physical fitness, chronic fatigue, slowed movement, reduced daily activity and weight loss. This is the stage between full fitness and disability, which significantly affects the overall functioning and quality of life of seniors [4], [11]. Frailty syndrome promotes falls in the elderly [13], and geriatric patients are at higher risk of dementia [14]. Although no standard diagnostic tests exist for frailty syndrome, systematic attempts should be made to prevent the occurrence of the syndrome, including a comprehensive guarantee of medical care and assistance in performing daily activities [3].

Chronic pain

Pain, according to the International Association for Study of Pain, is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or is described in terms of such damage [15]. Fundamentally, pain is essentially a warning function. However, in the case of chronic pain, that is, persistent or recurrent pain lasting more than 3 months [16], which is a common experience in the elderly, is devoid of a warning function, and is only a sensation that reduces the patients’ quality of life. As for the Polish population, the most common complaints of pain are in the lower extremities and lower spine [17]. Chronic pain is associated with another factor in reduced quality of life, such as falls, increasing its risk [18]. Chronic pain, and especially the timing and location of the pain, along with other factors such as diabetes and depression, negatively affect sensory abilities, autonomy, social activities, etc. [19]. Appropriate physical exercise can reduce chronic pain and improve patients’ quality of life [20].

Falls

Falls are among the most common problems in modern geriatrics and have a significant impact on the quality of life of seniors. According to the WHO, about 32–42% of people over 70 years of age fall each year, which is associated with increased health care costs for the elderly and greater involvement of family and medical staff [2]. In a 2014 survey, 28.7% of older adults reported falling; an estimated 29.0 million falls caused 7.0 million injuries in the US in 2014 [21]. Falls contribute in many ways to a negative impact on patients’ quality of life [22]. Both the number of risk factors for falls and the number of falls affect the quality of life of older people [23]. It has been noted that falls are more common in women, people who live alone, people who move slowly, and those with multiple diseases [24]. Falls can negatively affect quality of life to a similar degree as chronic diseases [25]. Falls are one of the leading causes of pain, disability and premature death in seniors [2]. Also, the very phenomenon of fear of falls can negatively affect quality of life in older patients [25], [26]. Geriatric individuals who have a higher education, engage in physical exercise, and are of normal weight who have experienced falls rate their quality of life better [27]. Interventions to prevent falls can significantly improve the quality of life for geriatric patients [28]. Such interventions include screening older adults for falls, reviewing and modifying existing treatments that may affect falls, and vitamin D supplementation to improve musculoskeletal health [21].

Urinary incontinence

Urinary incontinence is a bothersome condition involving involuntary urine leakage [29]. It is common in the elderly, an ailment that is a nuisance to patients and those around the patient [30]. People affected by the inability to hold urine are more likely to be depressed and have a poorer perception of their health [31]. Urinary incontinence is a disorder significantly associated with quality of life, significantly affecting reduced motor activity, life satisfaction, increased pain, discomfort, anxiety and depression in older patients [32], [33].

Malnutrition

Malnutrition increases with age and is common in geriatric patients [34]. Malnourished patients are at greater risk because they require longer hospitalizations, more prescription drugs and are more susceptible to infections [35], such as pneumonia and wound infections . Malnutrition increases the incidence of hospitalization and risk of falls [36]. An important aspect of preventing malnutrition is the documentation of body weight and its changes [37]. Malnutrition reduces quality of life in geriatric patients [34]. Protein-energy malnutrition is associated with increased mortality [38]. Adequate nutrient supplementation of geriatric patients during hospitalization can contribute to a reduced risk of mortality and complications [39].

Polypharmacy

As patients age, the number of medications they take increases. Polypharmacy, or multidrug use, is defined as taking a minimum of five different medications per day [40]. Polypharmacy is a common phenomenon in the elderly, the risk of which is increased by the lack of or little coordination of patient care [41]. The risk of multidrug use increases with patient age, which also correlates with the number of comorbidities, especially among oncology patients, or those under palliative care [42]. Polypharmacy, due to the risk of side effects and drug interactions, can pose a real risk to the patient; hence, pharmacological management requires particular caution. Studies have shown an association between the use of polypharmacy and negative effects on renal excretory function [43], increased risk of falls, especially during the use of fall risk-increasing drugs (FRIDS) and bone-related medication (BRMs) [42], cognitive function, especially during long-term poly-pharmacy [44], hemorrhagic and thrombotic events, etc. [42]. Due to the many comorbidities in elderly patients, the use of multiple drugs is sometimes necessary. It is imperative to consider the possible complications of such intensified therapy and proceed in a manner which maximizes the therapeutic benefit to the patient.

Loneliness

At advanced ages, patients are more likely to suffer from morbidity, widowhood, restricted income and mobility limitations [45]. All of these factors have a role in increasing social isolation. Although social isolation is seen as an objective condition that limits interpersonal contact, it is not the same as loneliness, which is a subjective deficiency of interpersonal relationships; they are related concepts and are associated with negative consequences for the quality of life of older people [46]. Loneliness in older people is seen as a risk factor for depression and anxiety [47], and living alone is a risk factor with an increased mortality rate [48]. Loneliness among the elderly is linked to limited physical fitness, multimorbidity and the patient’s perception of illness. [49]. Even brief episodes of isolation can significantly affect the psychological well-being of the elderly [50].

Elderly patients experience an increased need for social contacts to support and assist them [51]. Activities which provide social and emotional attention can yield tangible benefits in improving the quality of life of elderly patients. The absence of loneliness can promote a good quality of life and help patients adapt to their disease state and related treatment [46].

Increased susceptibility to infections due to senescence

In general, all cells are affected by cellular aging processes. If, for example, the number of T lymphocytes decreases, this results in an increased susceptibility to infection. Age-associated diseases such as neurodegenerative or cardiovascular diseases, type 2 diabetes mellitus, tumor diseases, but also general frailty are directly associated with the impairment of the immune system and with changes in the gut microbiome [52], [53], [54]. An important feature of senescence is the transformation of certain body cells into a “senescence-associated phenotype”, which is associated with the production of inflammatory substances [55]. In the context of the aging process, the chronic exposure of the body to these inflammatory substances (interleukins, acute phase proteins, etc.) is referred to as “inflammaging” [56].

Visual impairment

Reduced visual ability results from the decreasing spectral transmissibility of the eye with increasing age with a reduction in the production of the sleep hormone melatonin, leading to sleep disorders and the restriction of anti-inflammatory regulatory processes [57], [58]. The light requirements of older people therefore increase not only for vision, but also for the function of circadian synchronization and the immune response [57].

Conclusions

The study highlights several risk factors that significantly diminish the quality of life in older patients, including loneliness, falls, polypharmacy, urinary incontinence, frailty syndrome, chronic pain and malnutrition. These factors are often interrelated, exacerbating their impact on physical and mental well-being. Recognizing these risks is crucial in providing appropriate care and support, as inadequate management can lead to a decline in overall health and independence. Proper care for older patients requires a comprehensive understanding of these challenges to mitigate their effects and safeguard the dignity and quality of life of this vulnerable population.

Notes

Competing interests

The authors declare that they have no competing interests.

Funding

None.

Authors’ ORCIDs

• Marcinkowski K: https://orcid.org/0009-0002-5759-7285
• Muras M: https://orcid.org/0009-0005-1392-3773
• Michalik M: https://orcid.org/0009-0009-7799-7252
• Lorenc T: https://orcid.org/0009-0008-9902-469X
• Mikszta N: https://orcid.org/0009-0003-8444-7650
• Mikszta J: https://orcid.org/0009-0000-4194-9915
• Marcinkowska J: https://orcid.org/0009-0005-7006-4303
• Kantor K: https://orcid.org/0009-0005-0484-2883

---

References

[1] Czarkowski W, Bisch S, Mleczko K, Dziadkiewicz, P., Agnieszka Kmita, D., Wójcik, M. et al. Polypragmasy as a therapeutic problem among palliative and geriatric patients. Medycyna Paliatywna/Palliative Medicine. 2021;13(1):24-31. DOI: 10.5114/pm.2021.103767
[2] World Health Organization (WHO). WHO Global Report on Falls Prevention in Older Age. Geneva: WHO; 2007.
[3] Główny Urząd Statystyczny. Prognosis of the resident population for Poland for 2015-2050. Warsaw: Central Statistical Office. Department of Demographic and Labor Market Research; 2014. p. 4-6. Available from: https://stat.gov.pl/obszary-tematyczne/ludnosc/prognoza-ludnosci/prognoza-ludnosci-rezydujacej-dla-polski-na-lata-2015-2050,8,1.html
[4] Deng Y, Zhang K, Zhu J, Hu X, Liao R. Healthy aging, early screening, and interventions for frailty in the elderly. Biosci Trends. 2023 Sep;17(4):252-261. DOI: 10.5582/bst.2023.01204
[5] Rejeski WJ, Mihalko SL. Physical activity and quality of life in older adults. J Gerontol A Biol Sci Med Sci. 2001 Oct;56 Spec No 2:23-35. DOI: 10.1093/gerona/56.suppl_2.23
[6] Felce D, Perry J. Quality of life: its definition and measurement. Res Dev Disabil. 1995;16(1):51-74. DOI: 10.1016/0891-4222(94)00028-8
[7] WHOQOL Group. Study protocol for the World Health Organization project to develop a Quality of Life assessment instrument (WHOQOL). Quality of Life Research. 1993; 2(2):153–9. DOI: 10.1007/BF00435734
[8] Blane D, Netuveli G, Montgomery SM. Quality of life, health and physiological status and change at older ages. Soc Sci Med. 2008 Apr;66(7):1579-87. DOI: 10.1016/j.socscimed.2007.12.021
[9] Xavier FM, Ferraz MP, Marc N, Escosteguy NU, Moriguchi EH. Elderly people's definition of quality of life. Braz J Psychiatry. 2003 Mar;25(1):31-9. DOI: 10.1590/s1516-44462003000100007
[10] Morley JE, Vellas B, van Kan GA, Anker SD, Bauer JM, Bernabei R, Cesari M, Chumlea WC, Doehner W, Evans J, Fried LP, Guralnik JM, Katz PR, Malmstrom TK, McCarter RJ, Gutierrez Robledo LM, Rockwood K, von Haehling S, Vandewoude MF, Walston J. Frailty consensus: a call to action. J Am Med Dir Assoc. 2013 Jun;14(6):392-7. DOI: 10.1016/j.jamda.2013.03.022
[11] Wróblewska ZM, Kowalczyk M, Chmielewski J. The impact of the environment on quality of life in the elderly. Med Srod. 2024; 27(3): 103-109. DOI: 10.26444/ms/190832
[12] Oliveira FMRL, Barbosa KTF, Rodrigues MMP, Fernandes MDGM. Frailty syndrome in the elderly: conceptual analysis according to Walker and Avant. Rev Bras Enferm. 2020;73 Suppl 3:e20190601. DOI: 10.1590/0034-7167-2019-0601
[13] Taguchi CK, Menezes PL, Melo ACS, Santana LS, Conceição WRS, Souza GF, Araújo BCL, Silva ARD. Síndrome da fragilidade e riscos para quedas em idosos da comunidade Frailty syndrome and risks for falling in the elderly community. Codas. 2022;34(6):e20210025. DOI: 10.1590/2317-1782/20212021025pt
[14] Ward DD, Ranson JM, Wallace LMK, Llewellyn DJ, Rockwood K. Frailty, lifestyle, genetics and dementia risk. J Neurol Neurosurg Psychiatry. 2022 Apr;93(4):343-350. DOI: 10.1136/jnnp-2021-327396
[15] Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms. Prepared by the International Association for the Study of Pain, Subcommittee on Taxonomy. Pain Suppl. 1986;3:S1-226.
[16] Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Scholz J, Schug S, Smith BH, Svensson P, Vlaeyen JWS, Wang SJ. A classification of chronic pain for ICD-11. Pain. 2015 Jun;156(6):1003-1007. DOI: 10.1097/j.pain.0000000000000160
[17] Kozak-Szkopek E, Broczek K, Slusarczyk P, Wieczorowska-Tobis K, Klich-Raczka A, Szybalska A, Mossakowska M. Prevalence of chronic pain in the elderly Polish population - results of the PolSenior study. Arch Med Sci. 2017 Aug;13(5):1197-1206. DOI: 10.5114/aoms.2015.55270
[18] Leveille SG, Jones RN, Kiely DK, Hausdorff JM, Shmerling RH, Guralnik JM, Kiel DP, Lipsitz LA, Bean JF. Chronic musculoskeletal pain and the occurrence of falls in an older population. JAMA. 2009 Nov;302(20):2214-21. DOI: 10.1001/jama.2009.1738
[19] Paz MGD, Souza LAF, Tatagiba BDSF, Serra JRD, Moura LA, Barbosa MA, Pereira LV. Factors associated with quality of life of older adults with chronic pain. Rev Bras Enferm. 2021;74(suppl 2):e20200554. DOI: 10.1590/0034-7167-2020-0554
[20] Zhang SK, Gu ML, Zhang T, Xu H, Mao SJ, Zhou WS. Effects of exercise therapy on disability, mobility, and quality of life in the elderly with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res. 2023 Jul;18(1):513. DOI: 10.1186/s13018-023-03988-y
[21] Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Sep;65(37):993-998. DOI: 10.15585/mmwr.mm6537a2
[22] Michałowska M, Fiszer U, Krygowska-Wajs A, Owczarek K. Falls in Parkinson's disease. Causes and impact on patients' quality of life. Funct Neurol. 2005 Oct-Dec;20(4):163-8.
[23] Pérez-Ros P, Martínez-Arnau FM, Tarazona-Santabalbina FJ. Risk Factors and Number of Falls as Determinants of Quality of Life of Community-Dwelling Older Adults. J Geriatr Phys Ther. 2019;42(2):63-72. DOI: 10.1519/JPT.0000000000000150
[24] Stenhagen M, Ekström H, Nordell E, Elmståhl S. Accidental falls, health-related quality of life and life satisfaction: a prospective study of the general elderly population. Arch Gerontol Geriatr. 2014;58(1):95-100. DOI: 10.1016/j.archger.2013.07.006
[25] Thiem U, Klaaßen-Mielke R, Trampisch U, Moschny A, Pientka L, Hinrichs T. Falls and EQ-5D rated quality of life in community-dwelling seniors with concurrent chronic diseases: a cross-sectional study. Health Qual Life Outcomes. 2014 Jan;12:2. DOI: 10.1186/1477-7525-12-2
[26] Chang HT, Chen HC, Chou P. Factors Associated with Fear of Falling among Community-Dwelling Older Adults in the Shih-Pai Study in Taiwan. PLoS One. 2016;11(3):e0150612. DOI: 10.1371/journal.pone.0150612
[27] Song J, Lee E. Health-Related Quality of Life of Elderly Women with Fall Experiences. Int J Environ Res Public Health. 2021 Jul;18(15):. DOI: 10.3390/ijerph18157804
[28] Vaapio SS, Salminen MJ, Ojanlatva A, Kivelä SL. Quality of life as an outcome of fall prevention interventions among the aged: a systematic review. Eur J Public Health. 2009 Jan;19(1):7-15. DOI: 10.1093/eurpub/ckn099
[29] Abrams P, Andersson KE, Apostolidis A, Birder L, Bliss D, Brubaker L, Cardozo L, Castro-Diaz D, O'Connell PR, Cottenden A, Cotterill N, de Ridder D, Dmochowski R, Dumoulin C, Fader M, Fry C, Goldman H, Hanno P, Homma Y, Khullar V, Maher C, Milsom I, Newman D, Nijman RJM, Rademakers K, Robinson D, Rosier P, Rovner E, Salvatore S, Takeda M, Wagg A, Wagner T, Wein A; members of the committees. 6th International Consultation on Incontinence. Recommendations of the International Scientific Committee: EVALUATION AND TREATMENT OF URINARY INCONTINENCE, PELVIC ORGAN PROLAPSE AND FAECAL INCONTINENCE. Neurourol Urodyn. 2018 Sep;37(7):2271-2272. DOI: 10.1002/nau.23551
[30] Ouslander JG. Urinary incontinence in the elderly. West J Med. 1981 Dec;135(6):482-91.
[31] Ko Y, Lin SJ, Salmon JW, Bron MS. The impact of urinary incontinence on quality of life of the elderly. Am J Manag Care. 2005 Jul;11(4 Suppl):S103-11.
[32] Kwon CS, Lee JH. Prevalence, Risk Factors, Quality of Life, and Health-Care Seeking Behaviors of Female Urinary Incontinence: Results From the 4th Korean National Health and Nutrition Examination Survey VI (2007-2009). Int Neurourol J. 2014 Mar;18(1):31-6. DOI: 10.5213/inj.2014.18.1.31
[33] Herzog AR, Fultz NH, Brock BM, Brown MB, Diokno AC. Urinary incontinence and psychological distress among older adults. Psychol Aging. 1988 Jun;3(2):115-21. DOI: 10.1037//0882-7974.3.2.115
[34] Agarwal E, Miller M, Yaxley A, Isenring E. Malnutrition in the elderly: a narrative review. Maturitas. 2013 Dec;76(4):296-302. DOI: 10.1016/j.maturitas.2013.07.013
[35] Edington J, Boorman J, Durrant ER, Perkins A, Giffin CV, James R, Thomson JM, Oldroyd JC, Smith JC, Torrance AD, Blackshaw V, Green S, Hill CJ, Berry C, McKenzie C, Vicca N, Ward JE, Coles SJ. Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group. Clin Nutr. 2000 Jun;19(3):191-5. DOI: 10.1054/clnu.1999.0121
[36] Visvanathan R, Macintosh C, Callary M, Penhall R, Horowitz M, Chapman I. The nutritional status of 250 older Australian recipients of domiciliary care services and its association with outcomes at 12 months. J Am Geriatr Soc. 2003 Jul;51(7):1007-11. DOI: 10.1046/j.1365-2389.2003.51317.x
[37] Kubrak C, Jensen L. Malnutrition in acute care patients: a narrative review. Int J Nurs Stud. 2007 Aug;44(6):1036-54. DOI: 10.1016/j.ijnurstu.2006.07.015
[38] Sullivan DH, Walls RC. Protein-energy undernutrition and the risk of mortality within six years of hospital discharge. J Am Coll Nutr. 1998 Dec;17(6):571-8. DOI: 10.1080/07315724.1998.10718805
[39] Milne AC, Avenell A, Potter J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med. 2006 Jan;144(1):37-48. DOI: 10.7326/0003-4819-144-1-200601030-00008
[40] Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct;17(1):230. DOI: 10.1186/s12877-017-0621-2
[41] Cuevas-Trisan R. Balance Problems and Fall Risks in the Elderly. Clin Geriatr Med. 2019 May;35(2):173-183. DOI: 10.1016/j.cger.2019.01.008
[42] Czarkowski W, Bisch S, Mleczko K, et al. Polypragmasy as a therapeutic problem among palliative and geriatric patients. Medycyna Paliatywna/Palliative Medicine. 2021;13(1):24-31. DOI: 10.5114/pm.2021.103767.
[43] Kang H, Hong SH. Risk of Kidney Dysfunction from Polypharmacy among Older Patients: A Nested Case-Control Study of the South Korean Senior Cohort. Sci Rep. 2019 Jul;9(1):10440. DOI: 10.1038/s41598-019-46849-7
[44] Rawle MJ, Cooper R, Kuh D, Richards M. Associations Between Polypharmacy and Cognitive and Physical Capability: A British Birth Cohort Study. J Am Geriatr Soc. 2018 May;66(5):916-923. DOI: 10.1111/jgs.15317
[45] Wethington E, Pillemer K. Social Isolation among Older People. In: Coplan RJ, Bowker JC, editors. The Handbook of Solitude. 2013. p. 242–59. DOI: 10.1002/9781118427378.ch14
[46] Vespa A, Spatuzzi R, Fabbietti P, Di Rosa M, Bonfigli AR, Corsonello A, Gattafoni P, Giulietti MV. Association between Sense of Loneliness and Quality of Life in Older Adults with Multimorbidity. Int J Environ Res Public Health. 2023 Feb;20(3):. DOI: 10.3390/ijerph20032615
[47] Zhang Y, Kuang J, Xin Z, Fang J, Song R, Yang Y, Song P, Wang Y, Wang J. Loneliness, social isolation, depression and anxiety among the elderly in Shanghai: Findings from a longitudinal study. Arch Gerontol Geriatr. 2023 Jul;110:104980. DOI: 10.1016/j.archger.2023.104980
[48] Henriksen J, Larsen ER, Mattisson C, Andersson NW. Loneliness, health and mortality. Epidemiol Psychiatr Sci. 2019 Apr;28(2):234-239. DOI: 10.1017/S2045796017000580
[49] Jessen MAB, Pallesen AVJ, Kriegbaum M, Kristiansen M. The association between loneliness and health - a survey-based study among middle-aged and older adults in Denmark. Aging Ment Health. 2018 Oct;22(10):1338-1343. DOI: 10.1080/13607863.2017.1348480
[50] Newman-Norlund RD, Newman-Norlund SE, Sayers S, McLain AC, Riccardi N, Fridriksson J. Effects of social isolation on quality of life in elderly adults. PLoS One. 2022;17(11):e0276590. DOI: 10.1371/journal.pone.0276590
[51] Kristensen K, König HH, Hajek A. The longitudinal association of multimorbidity on loneliness and network size: Findings from a population-based study. Int J Geriatr Psychiatry. 2019 Oct;34(10):1490-1497. DOI: 10.1002/gps.5158
[52] Fülöp T, Dupuis G, Witkowski JM, Larbi A. The Role of Immunosenescence in the Development of Age-Related Diseases. Rev Invest Clin. 2016 Mar-Apr;68(2):84-91.
[53] Sharma R. Emerging Interrelationship Between the Gut Microbiome and Cellular Senescence in the Context of Aging and Disease: Perspectives and Therapeutic Opportunities. Probiotics Antimicrob Proteins. 2022 Aug;14(4):648-663. DOI: 10.1007/s12602-021-09903-3
[54] Hahne D. Mikrobiom und intestinale Gesundheit: Eine hohe Diversität von Darmbakterien ist günstig. Dtsch Arztebl. 2017;114(5):A-222/B-200/C-200
[55] von Kobbe C. Cellular senescence: a view throughout organismal life. Cell Mol Life Sci. 2018 Oct;75(19):3553-3567. DOI: 10.1007/s00018-018-2879-8
[56] Franceschi C, Zaikin A, Gordleeva S, Ivanchenko M, Bonifazi F, Storci G, Bonafè M. Inflammaging 2018: An update and a model. Semin Immunol. 2018 Dec;40:1-5. DOI: 10.1016/j.smim.2018.10.008
[57] Lerman S. An experimental and clinical evaluation of lens transparency and aging. J Gerontol. 1983 May;38(3):293-301. DOI: 10.1093/geronj/38.3.293
[58] Anghel L, Baroiu L, Popazu CR, Pătraș D, Fotea S, Nechifor A, Ciubara A, Nechita L, Mușat CL, Stefanopol IA, Tatu AL, Ciubara AB. Benefits and adverse events of melatonin use in the elderly (Review). Exp Ther Med. 2022 Mar;23(3):219. DOI: 10.3892/etm.2022.11142