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Comité científico y organizador:
M. Paz Jiménez Jiménez Mercedes Hornillos Calvo
Matilde León Ortiz Pedro Manuel Sánchez Jurado
Nuria Fernández Martínez
Secretaría Técnica:
Secretaría técnica del congreso:
CONFOREM S. L.
Pº de los Olmos 6-5 E
28005
Tel y FAX: 91 517 1214
Móvil: 670486898
E-mail: [email protected]
Solicitada la Acreditación a la Comisión de Formación Continuada
de las Profesiones Sanitarias de Castilla la Mancha
CONGRESO DE LA SOCIEDAD
CASTELLANO MANCHEGA DE
GERIATRÍA Y GERONTOLOGÍA
“NUTRICIÓN Y ENVEJECIMIENTO, UN BINOMIO
INSEPARABLE”
Ciudad Real, 1 y 2 de Marzo de 2013. Salón de Actos del Hospital General Universitario.
XIII
Foto:
Fran
cisco
M. Ga
rcía-N
avas
Los abstracs para el congreso se deben enviar a través de la página w eb:
w w w .conforem.com/ SCMGG_13 antes del d ía 20 de enero de 2013.
El bolet ín de inscripción y la reserva hotelera se pueden encontrar también
en la página w eb del congreso: w w w .conforem.com/ SCMGG_13
Pedro Rozas Moreno FEA Endocrinología y Nutrición
HGUCR
AGENDA
• FRAGILIDAD
• Vitamina D
• Vitamina D y Fragilidad
Caso Clínico María, 78 años sin hábitos tóxicos ni alergias medicamentosas conocidas.
Antecedentes Personales:
Prótesis en cadera dcha hace tres meses por fractura pertrocantérea tras sufrir una caída en su
hogar.
Apendicectomía a los 32 años; colecistectomía a los 46 años; histerectomía con doble anexectomía a
los 47 años por fibroma.
Infecciones urinarias de repetición en los dos últimos años. Incontinencia urinaria.
HTA con episodios de dolor torácico inespecífico (pendiente de estudio por cardiología)
Tratamiento habitual con: omeprazol 20 mg (0-0-1) , venlafaxina 75 mg (1/2-0-0), loracepam 1
mg/noche, enalapril 20 mg (1-0-0)
Motivo de su consulta: Revisión en consulta tras alta hospitalaria
Acompañada de su hija y esposo, el cúal muestra signos de afectación (carga de cuidador). Desde la
cirugía de la cadera presenta tristeza, anhedonia, astenia, sensación de debilidad, anorexia con
adelgazamiento de 9 kgs. (peso habitual 59 kgs, talla 157). Paralelamente se queja de pérdida en la
memoria reciente. También ha sufrido varias caídas en el domicilio, precedidas en ocasiones de
sensación de inestabilidad. Refiere miedo a caerse y a fracturarse de nuevo, motivo por el que no
desea salir de su domicilio. No tiene contacto social excepto con su esposo.
Valoración diagnóstica: Osteoporosis senil establecida, DM2, osteoartrosis, hernia de hiato,
hipertensión arterial leve, intolerancia ortostática.
Síndromes geriátricos presentes: Polifarmacia, incontinencia vesical de esfuerzo, depresión reactiva,
deterioro cognitivo leve (posible pseudodemencia depresiva), caídas de repetición/inestabilidad,
malnutrición proteico-calórica, Cataratas seniles (visión reducida), Sd. de fragilidad con discapacidad
motora
Caso Clínico
27/ 02/ 13 20:55frailty - PubMed - NCBI
Página 1 de 3http:/ / www.ncbi.nlm.nih.gov/ pubmed/ ?term= frailty
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Results: 1 to 20 of 3154
Walking speed is a useful marker of frailty in older persons-reply.
Odden MC, Peralta CA, Covinsky KE.
JAMA Intern Med. 2013 Feb 25;173(4):325-6. doi: 10.1001/jamainternmed.2013.2542. No abstract available.
PMID: 23440241 [PubMed - in process]
Walking speed is a useful marker of frailty in older persons.
Yano Y, Inokuchi T, Kario K.
JAMA Intern Med. 2013 Feb 25;173(4):325-6. doi: 10.1001/jamainternmed.2013.1629. No abstract available.
PMID: 23440240 [PubMed - in process]
The NEDICES Study: Recent Advances in the Understanding of the Epidemiology of Essential Tremor.
Romero JP, Benito-León J, Bermejo-Pareja F.
Tremor Other Hyperkinet Mov (N Y). 2012;2. doi:pii: tre-02-70-346-2. Epub 2012 Jun 15.
PMID: 23439396 [PubMed - in process]
Changes in pituitary function with ageing and implications for patient care.
Veldhuis JD.
Nat Rev Endocrinol. 2013 Feb 26. doi: 10.1038/nrendo.2013.38. [Epub ahead of print]
PMID: 23438832 [PubMed - as supplied by publisher]
Characterization of the role of distinct plasma cell-free DNA (cf-DNA) species in age-associated
inflammation and frailty.
Jylhävä J, Nevalainen T, Marttila S, Jylhä M, Hervonen A, Hurme M.
Aging Cell. 2013 Feb 25. doi: 10.1111/acel.12058. [Epub ahead of print]
PMID: 23438186 [PubMed - as supplied by publisher]
Pharmacokinetics of two common antiretroviral regimens in older HIV-infected patients: a pilot study.
Dumond J, Adams J, Prince H, Kendrick R, Wang R, Jennings S, Malone S, White N, Sykes C, Corbett A,
Patterson K, Forrest A, Kashuba A.
HIV Med. 2013 Feb 24. doi: 10.1111/hiv.12017. [Epub ahead of print]
PMID: 23433482 [PubMed - as supplied by publisher]
Thoracoscopic surgery for non-small-cell lung cancer: elderly vs. octogenarians.
Srisomboon C, Koizumi K, Haraguchi S, Mikami I, Iijima Y, Shimizu K.
Asian Cardiovasc Thorac Ann. 2013 Feb;21(1):56-60. doi: 10.1177/0218492312455528.
PMID: 23430421 [PubMed - in process]
Does frailty predict increased risk of falls and fractures? A prospective population-based study.
de Vries OJ, Peeters GM, Lips P, Deeg DJ.
Osteoporos Int. 2013 Feb 22. [Epub ahead of print]
PMID: 23430104 [PubMed - as supplied by publisher]
Display Settings: Summary, 20 per page, Sorted by Recently Added
PubMed frailty
• Frágil (Real Academia de la Lengua Española )
1. Quebradizo, y que con facilidad se hace pedazos.
2. Débil, que puede deteriorarse con facilidad.
3. Dicho de una persona: que cae fácilmente en algún
pecado, especialmente contra la castidad.
4. Caduco y perecedero.
¿Síndrome de Fragilidad?
Múltiples definiciones de fragilidad
Fragilidad • Disminución progresiva de la capacidad de reserva y adaptación de la
homeostasis del organismo que se produce con el envejecimiento, está
influenciada por factores genéticos (individuales) y es acelerada por
enfermedades crónicas y agudas, hábitos tóxicos, desuso y
condicionantes sociales y asistenciales.
Indicador Medida
Pérdida de peso Pérdida >4,5 kg (explicada) o pérdida >5% (medida)
en un año
Cansancio 2 preguntas en la escala CES-D
Puntuación >2 (0-8)
Debilidad Quintil inferior en la fuerza de prensión manual
(dinamómetro) ajustada por IMC y sexo
Enlentecimiento
psicomotor
>6 o 7 segundos (según sexo y talla) para recorrer
5 metros
Hipoactividad Quintil inferior del gasto calórico ajustado por sexo
(hombres 383 kcal/semana, mujeres 270 kcal/semana)
FRÁGIL: 3-5 puntos
PREFRÁGIL: 1-2 puntos
NO FRÁGIL: 0 puntos
Fragilidad (puntuación 3-5)
Aumenta su prevalencia con la edad
Asociada pero no concordante con discapacidad y comorbilidad
Puntuaciones de fragilidad predictivas de caídas, pérdida de movilidad,
institucionalización discapacidad AVD,
hospitalización y muerte
Prefrágiles: riesgo 2,5 veces superior de pasar a frágiles,
comparado con los no frágiles
Sarcopenia
19/ 02/ 13 19:55vitamin d - PubMed - NCBI
Página 1 de 3http:/ / www.ncbi.nlm.nih.gov/ pubmed/ ?term= vitamin+ d
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Results: 1 to 20 of 58094
1,25-Dihydroxyvitamin D and the Vitamin D Receptor Gene Polymorphism Apa1 Influence Bone Mineral
Density in Primary Hyperparathyroidism.
Christensen MH, Apalset EM, Nordbø Y, Varhaug JE, Mellgren G, Lien EA.
PLoS One. 2013;8(2):e56019. Epub 2013 Feb 13.
PMID: 23418495 [PubMed - as supplied by publisher]
Vitamin D insufficiency together with high serum levels of vitamin A increases the risk for osteoporosis in
postmenopausal women.
Mata-Granados JM, Cuenca-Acevedo JR, Luque de Castro MD, Holick MF, Quesada-Gómez JM.
Arch Osteoporos. 2013 Dec;8(1-2):124. Epub 2013 Feb 16.
PMID: 23417776 [PubMed - as supplied by publisher]
Autophagy during Mycobacterium tuberculosis infection and implications for future tuberculosis medications.
Yu X, Li C, Hong W, Pan W, Xie J.
Cell Signal. 2013 Feb 14. doi:pii: S0898-6568(13)00051-X. 10.1016/j.cellsig.2013.02.011. [Epub ahead of print]
PMID: 23416463 [PubMed - as supplied by publisher]
Effects of estradiol on the endocytic transport of vitamin D carrier protein in hepatocytes.
Pirani T, Chen J, Vieira A.
Biochim Biophys Acta. 2013 Feb 12. doi:pii: S0304-4165(13)00038-X. 10.1016/j.bbagen.2013.01.025. [Epub ahead of print]
PMID: 23416408 [PubMed - as supplied by publisher]
The Rise and Fall of Photomutagenesis.
Müller L, Gocke E.
Mutat Res. 2013 Feb 13. doi:pii: S1383-5742(13)00024-0. 10.1016/j.mrrev.2013.02.002. [Epub ahead of print]
PMID: 23416274 [PubMed - as supplied by publisher]
Vitamin D status and gene transcription in immune cells.
Morán-Auth Y, Penna-Martinez M, Shoghi F, Ramos-Lopez E, Badenhoop K.
J Steroid Biochem Mol Biol. 2013 Feb 13. doi:pii: S0960-0760(13)00026-5. 10.1016/j.jsbmb.2013.02.005. [Epub ahead of
print]
PMID: 23416105 [PubMed - as supplied by publisher]
Synthesis of Novel C-2 Substituted Vitamin D Derivatives Having Ringed Side Chains and Their Biological
Evaluation on Bone.
Saito H, Takagi K, Horie K, Kakuda S, Takimoto-Kamimura M, Ochiai E, Chida T, Harada Y, Takenouchi K,
Kittaka A.
J Steroid Biochem Mol Biol. 2013 Feb 13. doi:pii: S0960-0760(13)00025-3. 10.1016/j.jsbmb.2013.02.004. [Epub ahead of
print]
PMID: 23416104 [PubMed - as supplied by publisher]
Maternal vitamin D deficiency: Fetal and neonatal implications.
Display Settings: Summary, 20 per page, Sorted by Recently AddedFilter your results: All (58094)
Manage Filters
PubMed vitamin d
Publicaciones de sociedades internacionales sobre vitamina D
Osteoporos Int 2010;21:1151-4.
¿VITAMINA D? Diccionario de la Lengua Española: (Del lat. vita, vida, y amina, término químico inventado por el bioquímico polaco C. Funk, 1884-1967). 1. f. Cada una de las sustancias orgánicas que existen en los alimentos y que, en cantidades pequeñísimas, son necesarias para el perfecto equilibrio de las diferentes funciones vitales. Existen varios tipos, designados con las letras A, B, C, etc.
ProD3 PreD3 Vitamina D3 o colecalciferol
PIEL
DIETA
Vitamina D3
Vitamina D2 hidroxilación
25 OH D
1α hidroxilasa (CYP27)
1,25 OH2 D - CALCITRIOL
Vitamina D activa
RVD
FGF23 -
Receptor de la Vitamina D
Hepatocitos
Hepático
Sistema nervioso central
Neuronas cerebrales
Suprime la síntesis y la secreción de hormona
paratiroidea y controla la hiperplasia
Glandula Paratiroidea
Riñón/Función renal
Intestino
Hueso
Sistema cardiovascular
Páncreas
Sistema inmunitario
Túbulos proximales y distales, túbulo colector
Reabsorción de calcio y fosfato
Reabsorción de calcio y fosfato Gastrointestinal
Esófago, estómago, intestino delgado, intestino
grueso, colon
Reabsorción de calcio y fosfato Osteoblastos,
osteocitos, condrocitos
Antiproliferación y diferenciación, Inhibición
de renina/angiotensina II, Células de músculo liso
vascular, células endoteliales
cardiomiocitos
Síntesis y secreción de insulina,
células β pancreáticas
Efectos inmunomoduladores en células T,
células B, macrófagos, monocitos y linfocitos,
timo, médula ósea
Piel, mama, folículos pilosos Epidermis/anejos
Músculo
Músculo estriado
Reproductor
Testículos, ovarios, placenta, útero,
endometrio, saco vitelino
Localización del RVD
Acciones de vitamina D
Principal efecto biológico:
Mantener la homeostasis del metabolismo fosfo-cálcico
•Estimula la absorción intestinal de calcio.
•Aumenta reabsorción del calcio del filtrado glomerular.
•Aumenta osteoclastos maduros a nivel óseo.
Hepatocitos
Hepático
Sistema nervioso central
Neuronas cerebrales
Suprime la síntesis y la secreción de hormona
paratiroidea y controla la hiperplasia
Glandula Paratiroidea
Riñón/Función renal
Intestino
Hueso
Sistema cardiovascular
Páncreas
Sistema inmunitario
Túbulos proximales y distales, túbulo colector
Reabsorción de calcio y fosfato
Reabsorción de calcio y fosfato Gastrointestinal
Esófago, estómago, intestino delgado, intestino
grueso, colon
Reabsorción de calcio y fosfato Osteoblastos,
osteocitos, condrocitos
Antiproliferación y diferenciación, Inhibición
de renina/angiotensina II, Células de músculo liso
vascular, células endoteliales
cardiomiocitos
Síntesis y secreción de insulina,
células β pancreáticas
Efectos inmunomoduladores en células T,
células B, macrófagos, monocitos y linfocitos,
timo, médula ósea
Piel, mama, folículos pilosos Epidermis/anejos
Músculo
Músculo estriado
Reproductor
Testículos, ovarios, placenta, útero,
endometrio, saco vitelino
Localización del RVD
Otras acciones de la vit D: •Inhibe la proliferación e induce una diferenciación de múltiples células normales y neoplásicas. •Modulación del sistema inmunológico (linfocitos B y T activados , macrófagos). •Inhibir angiogénesis •Estimula la producción de insulina. •Inhibe a producción de renina. Relacionada : •Enf autoinmunes: esclerosis múltiple, enf Crohn, artritis reumatoide, diabetes mellitus tipo 1. •Cáncer: colon, mama, próstata, otros •Enf cardiovasculares (HTA, ICC, IM) •Diabetes mellitus tipo 2.
Acciones Extraesqueléticas de la Vitamina D
Motivo de su consulta: Revisión en consulta tras alta hospitalaria
Acompañada de su hija y esposo, el cúal muestra signos de afectación (carga de cuidador). Desde la
cirugía de la cadera presenta tristeza, anhedonia, astenia, sensación de debilidad, anorexia con
adelgazamiento de 9 kgs. (peso habitual 59 kgs, talla 157). Paralelamente se queja de pérdida en la
memoria reciente. También ha sufrido varias caídas en el domicilio, precedidas en ocasiones de
sensación de inestabilidad. Refiere miedo a caerse y a fracturarse de nuevo, motivo por el que no
desea salir de su domicilio. No tiene contacto social excepto con su esposo.
Valoración diagnóstica: Osteoporosis senil establecida, DM2, osteoartrosis, hernia de hiato,
hipertensión arterial leve, intolerancia ortostática.
Síndromes geriátricos presentes: Polifarmacia, incontinencia vesical de esfuerzo, depresión reactiva,
deterioro cognitivo leve (posible pseudodemencia depresiva), caídas de repetición/inestabilidad,
malnutrición proteico-calórica, Cataratas seniles (visión reducida), Sd. de fragilidad con discapacidad
motora
Caso Clínico
¿Solicitarías niveles de vitamina D?
¿Cuándo solicitar niveles de vitamina D?
¿Solicitar 25-OH D o 1,25-(OH)2-D? 25-OH D:
• Vida media: 2-3 semanas
• 25-hidroxilasa hepática: no esta estrictamente regulada
• Es la mayor forma circulante de vitamina D
• Refleja con más precisión los almacenamientos corporales de la vitamina D
1,25-(OH)2 D:
• Vida media: 6-8horas
• 1 alfa hidroxilasasa renal : ↑ PTH e hipofosfatemia ,
↓ calcio y 1,25-(OH)2-D
• Síntesis esta muy regulada
• Niveles circulantes son 1000 veces más bajos que los niveles de 25-OH-D
• Puede ser normal o incluso elevada en casos de déficit de vitamina D (por el hiperpatiroidismo secundario)
• Solo solicitarla: IRC, enf perdedoras de fosfatos hereditarios, osteomalacia oncogénica, raquitismo por pseudo déficit de vit D, raquitismo por resistencia a vit D, enfermedades granulomatosas, linfomas)
¿Cúales son los niveles adecuados de Vitamina D ?
25OHD: 15 ng/ml, PTHi: 93 pg/ml, MDRD-4: 65 ml/min Calcio corregido por albúmina y fósforo normales.
La absorción de calcio fue un 65% mayor en las pacientes con niveles de 25-OH-D de media en 35ng/ml que las tenían niveles medios de 20ng/ml.
-n=319 -La absorción de Ca se mantiene hasta niveles de 10ng/ml
-59 estudios. -Niveles de 25-0H D con los cuales alcanza la meseta y/o la máxima supresión: 20ng/ml
Los MRO aumentaron con niveles de 25-OH D < 18ng/ml
No hay acumulación patológica de osteoide en ningún paciente: 25-OH D > 30ng/ml
Guías de práctica clínica: niveles óptimos
Vitamin D insufficiency: serum 25-hydroxyvitamin D (25(OH)D < 30 ng/ml (75nmol/L)]
Guías de práctica clínica: niveles óptimos
¿Podríamos haber evitado la Fx de cadera
suplementando con vitamina D a María?
-11 ensayos RCT -31 022 personas, >65 años (91% mujeres) Prevención de fracturas: > 24 ng/ml , dosis >800 Ui/d
Metanálisis 2012
¿Podemos evitar que María se vuelva a caer
dándole vitamina D ?
Vitamina D y caidas
Interventions for preventing falls in older people in care
facilities and hospitals (Review)
Cameron ID, GillespieLD, Robertson MC, Murray GR, Hill KD, Cumming RG, KerseN
Thisisareprint of aCochranereview, prepared and maintained byTheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue12
http://www.thecochranelibrary.com
Interventionsfor preventing falls in older people in care facilitiesand hospitals (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
Interventions for preventing falls in older people in care
facilities and hospitals (Review)
Cameron ID, GillespieLD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N
Thisisareprint of aCochranereview, prepared and maintained byTheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue12
http://www.thecochranelibrary.com
Interventionsfor preventing falls in older people in care facilitiesand hospitals (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
Interventionsfor preventing falls in older people in care
facilitiesand hospitals (Review)
Cameron ID, GillespieLD, Robertson MC, Murray GR, Hill KD, CummingRG, KerseN
Thisisareprint of aCochranereview, preparedandmaintained byTheCochraneCollaboration andpublished in TheCochraneLibrary
2012, Issue12
http://www.thecochranelibrary.com
Interventionsfor preventing falls in older people in care facilitiesand hospitals(Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
95% CI 0.94 to 1.23; 8 trials, 1887 participants). Post hoc subgroup analysisby level of caresuggested that exercisemight reducefalls
in peoplein intermediatelevel facilities, and increasefallsin facilitiesproviding high levelsof nursing care.
In carefacilities, vitamin D supplementation reduced therateof falls(RaR 0.63, 95% CI 0.46 to 0.86; 5 trials, 4603 participants), but
not risk of falling (RR 0.99, 95% CI 0.90 to 1.08; 6 trials, 5186 participants).
For multifactorial interventionsin carefacilities, therateof falls(RaR 0.78, 95% CI 0.59 to 1.04; 7 trials, 2876 participants) and risk
of falling(RR 0.89, 95% CI 0.77 to 1.02; 7 trials, 2632 participants) suggested possiblebenefits, but thisevidencewasnot conclusive.
In subacutewardsin hospital, additional physiotherapy (supervised exercises) did not significantly reducerateof falls(RaR 0.54, 95%
CI 0.16 to 1.81; 1 trial, 54 participants) but achieved asignificant reduction in risk of falling (RR 0.36, 95% CI 0.14 to 0.93; 2 trials,
83 participants).
In one trial in asubacute ward (54 participants), carpet flooring significantly increased therateof fallscompared with vinyl flooring
(RaR 14.73, 95% CI 1.88 to 115.35) and potentially increased therisk of falling (RR 8.33, 95% CI 0.95 to 73.37).
Onetrial (1822 participants) testing an educational session by atrained research nursetargeting individual fall risk factorsin patients
at high risk of falling in acutemedical wardsachieved asignificant reduction in risk of falling (RR 0.29, 95% CI 0.11 to 0.74).
Overall, multifactorial interventionsin hospitalsreduced therateof falls(RaR 0.69, 95% CI 0.49 to 0.96; 4 trials, 6478 participants)
and risk of falling(RR0.71, 95% CI 0.46 to1.09; 3 trials, 4824 participants), although theevidencefor risk of fallingwasinconclusive.
Of these, onetrial in asubacutesetting reported theeffect wasnot apparent until after 45 daysin hospital. Multidisciplinary carein a
geriatric ward after hip fracturesurgery compared with usual carein an orthopaedic ward significantly reduced rateof falls(RaR 0.38,
95% CI 0.19 to 0.74; 1 trial, 199 participants) and risk of falling (RR 0.41, 95% CI 0.20 to 0.83). Moretrialsareneeded to confirm
theeffectivenessof multifactorial interventionsin acuteand subacutehospital settings.
Authors’ conclusions
In care facilities, vitamin D supplementation is effective in reducing the rate of falls. Exercise in subacute hospital settings appears
effective but its effectiveness in care facilities remains uncertain due to conflicting results, possibly associated with differences in
interventions and levelsof dependency. There is evidence that multifactorial interventions reduce falls in hospitals but theevidence
for risk of falling was inconclusive. Evidence for multifactorial interventions in care facilitiessuggests possible benefits, but thiswas
inconclusive.
P L A I N L A N G U A G E S U M M A R Y
Interventionsfor preventing fallsin older people in care facilitiesand hospitals
Falls by older people in residential or nursing care facilities and hospitals are common events that may cause loss of independence,
injuries, and sometimesdeath asa result of injury. Effective interventions to prevent fallsare important as they will havesignificant
health benefits.
This review included 60 randomised controlled trials involving 60,345 participants. Forty-three trials (30,373 participants) were in
carefacilities, and 17 (29,972 participants) in hospitals. Despitethelargenumber of trials, therewaslimited evidenceto support any
oneintervention.
In care facilities, the prescription of vitamin D reduced the number of falls, probably because residents have low vitamin D levels.
Resultsfrom 13 trialstestingexerciseinterventionsin carefacilitieswereinconsistent and overall did not show abenefit. It may bethat
exerciseprogrammesincrease falls in frail residentsand reduce falls in lessfrail residents. Interventions targeting multiplerisk factors
may beeffectivein reducing thenumber of falls.
Additional physiotherapy reduced thenumber of people falling in hospital rehabilitation wardsand interventions targeting multiple
risk factorsreduced fallsin hospital.
Interventionsfor preventing falls in older people in care facilitiesand hospitals (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
Interventions for preventing falls in older people living in the
community (Review)
GillespieLD, Robertson MC, GillespieWJ, Sherrington C, GatesS, Clemson LM, Lamb SE
Thisisareprint of aCochranereview, prepared and maintained byTheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue11
http://www.thecochranelibrary.com
Interventionsfor preventing falls in older people living in the community (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
Main results
We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an
intervention not expected to reducefalls. Themost common interventionstested wereexerciseasasingle intervention (59 trials) and
multifactorial programmes(40 trials). Sixty-two per cent (99/159) of trialswereat low risk of bias for sequencegeneration, 60% for
attrition biasfor falls(66/110), 73% for attrition biasfor fallers(96/131), and only 38% (60/159) for allocation concealment.
Multiple-component group exercisesignificantly reduced rateof falls(RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants)
and risk of falling(RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), asdid multiple-component home-based exercise(RaR
0.68, 95% CI 0.58 to 0.80; 7 trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; 6 trials; 714 participants). For Tai Chi,
thereduction in rateof fallsbordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; 5 trials; 1563 participants) but Tai
Chi did significantly reducerisk of falling (RR 0.71, 95% CI 0.57 to 0.87; 6 trials; 1625 participants). Overall, exerciseinterventions
significantly reduced therisk of sustaining afall-related fracture(RR 0.34, 95% CI 0.18 to 0.63; 6 trials; 810 participants).
Multifactorial interventions, which includeindividual risk assessment, reduced rateof falls(RaR 0.76, 95% CI 0.67 to 0.86; 19 trials;
9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).
Overall, vitamin D did not reducerateof falls(RaR 1.00, 95% CI 0.90 to 1.11; 7 trials; 9324 participants) or risk of falling(RR 0.96,
95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in peoplewith lower vitamin D levelsbeforetreatment.
Home safety assessment and modification interventions were effective in reducing rate of falls (RaR 0.81, 95% CI 0.68 to 0.97; 6
trials; 4208 participants) and risk of falling(RR 0.88, 95% CI 0.80 to 0.96; 7 trials; 4051 participants). Theseinterventionsweremore
effectivein peopleat higher risk of falling, includingthosewith severevisual impairment. Homesafety interventionsappear to bemore
effectivewhen delivered by an occupational therapist.
An intervention to treat vision problems(616 participants) resulted in asignificant increasein therateof falls(RaR 1.57, 95% CI 1.19
to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearersof multifocal glasses(597 participants) weregiven
single lens glasses, all fallsand outside fallswere significantly reduced in the subgroup that regularly took part in outside activities.
Conversely, therewasasignificant increasein outsidefallsin intervention group participantswho took part in littleoutsideactivity.
Pacemakersreduced rateof fallsin peoplewith carotid sinushypersensitivity (RaR0.73, 95% CI 0.57 to0.93; 3 trials; 349 participants)
but not risk of falling. First eyecataract surgery in women reduced rateof falls(RaR0.66, 95%CI 0.45 to0.95; 1 trial; 306participants),
but second eyecataract surgery did not.
Gradual withdrawal of psychotropicmedication reduced rateof falls(RaR 0.34, 95% CI 0.16 to 0.73; 1 trial; 93 participants), but not
risk of falling. A prescribing modification programmefor primary carephysicianssignificantly reduced risk of falling (RR 0.61, 95%
CI 0.41 to 0.91; 1 trial; 659 participants).
An anti-slip shoedevice reduced rateof falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; 1 trial; 109 participants). One trial
(305 participants) comparingmultifaceted podiatry including foot and ankleexerciseswith standard podiatry in peoplewith disabling
foot pain significantly reduced therateof falls(RaR 0.64, 95% CI 0.45 to 0.91) but not therisk of falling.
There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; 1 trial; 120
participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; 2 trials; 350 participants).
Trialstesting interventionsto increaseknowledge/educateabout fall prevention alonedid not significantly reducetherateof falls(RaR
0.33, 95% CI 0.09 to 1.20; 1 trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; 4 trials; 2555 participants).
Thirteen trialsprovided acomprehensiveeconomic evaluation. Threeof theseindicated cost savingsfor their interventionsduring the
trial period: home-based exercisein over 80-year-olds, homesafety assessment and modification in thosewith apreviousfall, and one
multifactorial programmetargeting eight specific risk factors.
Authors’ conclusions
Group and home-based exerciseprogrammes, and homesafety interventionsreducerateof fallsand risk of falling.
Multifactorial assessment and intervention programmesreducerateof fallsbut not risk of falling; Tai Chi reducesrisk of falling.
Overall, vitamin D supplementation doesnot appear to reduce fallsbut may beeffective in peoplewho havelower vitamin D levels
beforetreatment.
Interventionsfor preventing falls in older people living in the community (Review)
Copyright © 2012 The Cochrane Collaboration. Published by John W iley & Sons, Ltd.
¿Cuánto más mejor?
Guías de práctica clínica: niveles óptimos máximos
Serum 25OHD levels above 50 ng/ml (125 nmol/liter) should raise concerns among clinicians about potential adverse effects.
Thus, based on these and other studies, it has been suggested that vitamin D deficiency be defined as a 25(OH)D below 20 ng/ml, insufficiency as a 25(OH)D of 21–29ng/ml, and sufficiency as a 25(OH)D of 30–100 ng/ml
Sus niveles de Vitamina D no son adecuados
Esto no le viene bien para sus huesos ni para sus caidas
Y, aunque alguna duda me queda, le voy a poner un poco vitamina D (con
calcio) pero tampoco mucho.
Y me pregunto, estimada María, ¿tiene algo que ver sus niveles de vitamina D
con la fragilidad que padece?
Hasta ahora querida María
Gradiente Norte-Sur
FRAILTY IN EUROPEAN COUNTRIES 679
43.6%45.3%
38.4% 38.5%
34.6%
40.7%
46.5%45.6%
50.9%
44.9%
14.7%
27.3%
23.0%
15.0%
5.8%
10.8%12.1%
8.6%
12.4%11.3%
0%
10%
20%
30%
40%
50%
60%
Sw
eden
Den
mar
k
Net
herla
nds
Ger
man
y
Aus
tria
Sw
itzer
land
Fran
ce
Italy
Spa
in
Gre
ece
Pre-frail Frail
Figure 1. Percentage of the 65 years and older community-dwelling population classifi ed as prefrail and frail by country (weighted results).
prefrailty and frailty. Criteria in SHARE were not identical
to those defi ned in the Cardiovascular Health Study, except
for weakness ( 4 ), and may be less specifi c, leading to higher
prevalence estimates particularly for exhaustion, which was
common in the SHARE population. The longitudinal design
of SHARE will permit verifi cation of the predictive validity
of frailty criteria assessed in this survey. A third method-
ological difference is the treatment of missing information.
In the Cardiovascular Health Study, participants with miss-
ing information for less than two frailty components were
considered evaluable, whereas SHARE data were analyzed
only for participants with complete data for all components.
The sensitivity analysis conducted on SHARE data showed
that imputation tends to decrease the estimated proportion of
nonfrail slightly; however, this effect was negligible.
Variations between European countries in the frequency
of frailty are consistent with previous fi ndings of a north –
south gradient characterizing other health indicators in
SHARE ( 16 ). Lower rates of institutionalization of older dis-
abled persons in southern countries may be one explanation
43.7%
36.6% 37.4%
32.9%
41.2%
45.6%44.3%
48.8%
53.7%
45.8%
11.3%
21.0%
14.3%
9.3%
3.9%6.6%
8.2%8.5%8.8%
5.9%
0%
10%
20%
30%
40%
50%
60%S
wed
en
Den
mar
k
Net
herla
nds
Ger
man
y
Aus
tria
Sw
itzer
land
Fran
ce
Italy
Spa
in
Gre
ece
Pre-frail Frail
Figure 2. Percentage of the 65 years and older community-dwelling population without disability classifi ed as prefrail and frail by country (weighted results).
Sus niveles de Vitamina D no son adecuados
Esto no le viene bien para sus huesos ni para sus caidas
Y aunque alguna duda me queda le voy a poner un poco de esa vitamina, pero
tampoco mucho.
Si parece que tanto sus niveles de vitamina D cómo los de PTH no le sientan
muy bien a su fragilidad
¿Mejorará con la vitamina D?
Hasta ahora querida María
¿Discrepancias?
¿Qué método utilizar para medir los niveles de
vitamina D?
MÉTODOS DE DETECCIÓN DIRECTA:
1. HPLC (cromotografía líquida de alto desempeño):
•Medición directa de 25(OH)D2 y 25(OH)D3.
•Requiere manejo por personal experto, complicada realización.
•No utilizada en laboratorios para muestras clínicas. GOLD ESTÁNDAR.
2. LC-MS/MS (Espectometría de masas):
•Medición directa de 25(OH)D2 y 25(OH)D3.
•Equipo costoso. Requiere personal experto.
IINMUNOENSAYO (RIA y EIA):
•Mide 25(OH)D2, 25(OH)D3 y otros metabolitos inactivos.
•Sobrestima los niveles de 25-OH-D en un 10-20%.
•Técnica simple. Automatizado. Ampliamente utilizado.
•Variabilidad entre diferentes lotes.
¿Y qué hacemos contigo María?
© 2013 Informa UK Ltd. This provisional PDF corresponds to the article as it appeared upon acceptance. Fully formatted PDF and full text (HTML) versions will be made available soon. DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles do not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal. The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles. The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be
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Just Accepted by Current Medical Research & Opinion
Vitamin D supplementation in elderly or postmenopausal women: A 2013 update of the 2008 recommendations from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)
R. Rizzoli, S. Boonen, M-L. Brandi, O. Bruyère, C. Cooper, J. A. Kanis, J-M. Kaufman, J. D. Ringe, G. Weryha, JY Reginster
doi: 10.1185/03007995.2013.766162
Abstract
Background Vitamin D insufficiency has deleterious consequences on health outcomes. In elderly or postmenopausal women, it may exacerbate osteoporosis.
Scope There is currently no clear consensus on definitions of vitamin D insufficiency or minimal targets for vitamin D concentrations and proposed targets vary with the population. In view of the potential confusion for practitioners on when to treat and what to achieve, the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) convened a meeting to provide recommendations for clinical
practice, to ensure the optimal management of elderly and postmenopausal women with regard to vitamin D supplementation.
Findings Vitamin D has both skeletal and extra-skeletal benefits. Patients with serum 25-hydroxyvitamin D (25-(OH)D) levels <50 nmol/L have increased bone turnover, bone loss, and possibly mineralization defects compared with patients with levels >50 nmol/L. Similar relationships have been reported for frailty, nonvertebral and hip fracture, and all-cause mortality, with poorer outcomes at <50 nmol/L.
Conclusion The ESCEO recommends that 50 nmol/L (i.e. 20 ng/mL) should be the minimal serum 25-(OH)D concentration at the population level and in patients with osteoporosis to ensure optimal bone health. Below this threshold, supplementation is recommended at 800 to 1000 IU/day. Vitamin D supplementation is safe up to 10 000 IU day (upper limit of safety) (resulting in an upper limit of adequacy of 125 nmol/L 25-(OH)D). Daily consumption of calcium- and vitamin D-fortified food products (e.g. yoghurt or milk) can help improve vitamin D intake. Above the threshold of 50 nmol/L, there is no clear evidence for additional benefits of supplementation. On the other hand, in fragile elderly subjects who are at elevated risk for falls and fracture, the ESCEO recommends a minimal serum 25-(OH)D level of 75 nmol/L (i.e. 30 ng/mL), for the greatest impact on fracture.
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Vitamin D supplementation in elderly or postmenopausal women:
A 2013 update of the 2008 recommendations from the European Society for
Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)
R. Rizzoli,1 S. Boonen,2 M-L. Brandi,3 O. Bruyère,4 C. Cooper,5 J. A. Kanis,6
J-M. Kaufman,7 J. D. Ringe,8 G. Weryha,9 JY Reginster4
Author affiliations
1. Division of Bone Diseases, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland
2. Center for Metabolic Bone Diseases and Division of Geriatric Medicine, Katholieke University Leuven,
Leuven, Belgium
3. Metabolic Bone Unit, Department of Internal Medicine, University of Florence, Florence, Italy
4. Department of Public Health, Epidemiology and Health Economics, University of Liège, Belgium
5. MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom
6. WHO Collaborating Centre for Metabolic Bone Diseases, University of Sheffield Medical School,
Sheffield, United Kingdom
7. Department of Endocrinology, Ghent University Hospital, Gent, Belgium
8. West German Osteoporosis Center at Medizin. Klinkik 4, Klinikum Leverkusen, University of Cologne,
Cologne, Germany
9. Department of Endocrinology, Nancy University Hospital, Vandoeuvre, France
Author for correspondence
Prof R. Rizzoli, Division of Bone Diseases, Department of Internal Medicine Specialties, Geneva
University Hospital and Faculty of Medicine, Geneva, Switzerland
Tel: +41 22 372 99 50
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