Las caídas en el adulto mayor son frecuentes y conllevan importante morbimortalidad, dependencia e institucionalización. Se ha planteado que la suplementación con vitamina D podría prevenir la ocurrencia de este evento. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos 18 revisiones sistemáticas que en conjunto incluyen 31 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de vitamina D probablemente no disminuye el riesgo de caídas en adultos mayores.
The 2010 clinical practice guideline for the diagnosis and management of osteoporosis in Canada1 focused on the care of adults living in the community. However, the fracture rate for adults living in long-term care (residents) is two to four times that of adults of similar age living in the community, and one-third of older adults who experience hip fracture are residents in long-term care.2 Hip fracture is one of the most serious consequences of osteoporosis and also one of the leading causes of admission to hospital.3 When residents return to long-term care after a hospital stay, they need additional hours of specialized care.4,5 In addition, fracture pain and delirium frequently associated with analgesia are distressing for residents and their families. Vertebral fractures are also a concern for residents, and the reported prevalence is up to 30% (for at least one moderate to severe fracture).6 Multiple vertebral fractures can be a substantial cause of pain, anxiety, depression, reduced pulmonary function7 and agitation.
Frail older adults at high risk of fracture in long-term care face other challenges. More than 40% have dementia,8 a similar percentage experience swallowing difficulties,9,10 and over 20% may have renal insufficiency.11,12
It may be difficult to identify residents at high risk of fracture, as the current fracture risk assessment tools (the Canadian Association of Radiologists and Osteoporosis Canada tool13 [CAROC; www.osteoporosis.ca/multimedia/pdf/CAROC.pdf] and the Canadian WHO Fracture Risk Assessment Tool [FRAX; www.shef.ac.uk/FRAX/]) provide 10-year fracture risk and have not been validated in long-term care, where over 20% of residents may die within one year of admission.14,15 Most research regarding risk assessment and pharmacologic therapies has not included those with multiple comorbidities.16,17
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
ANTECEDENTES: La prevención de caídas es una prioridad internacional. Hay una necesidad de sintetizar la más alta calidad cae evidencia la prevención en un lugar por los clínicos.
OBJETIVO: Realizar una revisión del paraguas de los meta-análisis (MA) de los ensayos controlados aleatorios (ECA) de las intervenciones de prevención caídas en la comunidad que habitan los adultos mayores.
FUENTES DE INFORMACIÓN: MEDLINE, EMBASE, CINAHL, AMED, BNI, PsycINFO, Cochrane Library, PubMed y la base de datos PEDro.
ESTUDIO DE SELECCIÓN: MA con un análisis combinado que contiene ≥ 3 ECAs que investigan cualquier intervención para prevenir las caídas en los adultos mayores de la comunidad de vivienda de edad ≥ 60 años de edad fueron elegibles. 16 MA representando 47 análisis agrupados fueron incluidos.
EXTRACCIÓN DE DATOS: Dos autores extrajeron los datos de forma independiente.
SÍNTESIS DE DATOS: Los datos se sintetizó de forma narrativa. La calidad metodológica de la MA fue moderada. 3 MA define una caída y 3 informó eventos adversos (aunque menor). No hay evidencia consistente de que el ejercicio reduce las caídas (incluyendo la tasa, el riesgo y las probabilidades de caer) con 13/14 análisis combinados (93%) de 7 MA demuestran una reducción significativa. La calidad metodológica de ejercicio meta-análisis de la investigación eran medio / alto y los tamaños del efecto varió de 0,87 (riesgo relativo (RR) IC del 95% 0,81-0,94, N = 18, n = 3568) a 0,39 (razón de tasas (RAR) 95% CI 0,23-0,66, N = 6). No hay evidencia consistente de que las intervenciones multifactoriales reducen las caídas (5/6, 83% reportaron reducción significativa). Hay pruebas contradictorias acerca de la influencia de la suplementación con vitamina D (07/12, 58,3% informó una reducción significativa).
LIMITACIONES: Ma menudo utilizan diferentes análisis y presentación de informes de las características clave menudo faltaba (por ejemplo, los participantes, la heterogeneidad, sesgo de publicación). Puede haber cierta superposición entre MA incluido.
CONCLUSIONES: Existe evidencia consistente de que el ejercicio y adaptado individualmente intervenciones multifactoriales son eficaces en la reducción de las caídas en la comunidad.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
ABSTRACT: Overall the evidence base was large; we identified 43 systematic reviews covering hundreds of studies and thousands of participants. Evidence clustered around particular outcomes, interventions and populations. Outcomes The vast majority of evidence is on quality of life and prevention outcomes Evidence on satisfaction with services and safeguarding is severely limited Interventions Physical activity interventions are those most widely evaluated in systematic reviews, followed by occupational therapy interventions No evidence is available on some key social care interventions, e.g. direct payments Populations The majority of evidence concerns people with long-term conditions (e.g. dementia, cancer, stroke) There is much less evidence on older people or people with mental health problems Evidence on learning or physical disabilities is extremely limited. Interventions with evidence of positive effect Evidence of positive impact was found for seven of the 14 social care interventions examined in the included reviews: physical activity, occupational therapy, supported employment, lay/peer support, hip protectors, assistive devices and personal assistance. Evidence on the scale of positive impacts was available for five of these interventions. Larger positive impacts resulted from integrated employment and mental health support and from hip protectors. Both larger and smaller impacts were found across eight physical activity reviews and two occupational therapy reviews. Smaller impacts resulted from a lay-led self-management intervention. Interventions with evidence of harm Two reviews contained evidence that interventions shown to be effective for some populations could potentially cause harm to vulnerable social care recipients. Tai chi, though effective for older people in general, was found to increase the rate of falls among frail older people. Exercise was found to have positive impacts on people exercising for rehabilitation after a period of ill health, but a negative impact on the psychological QoL of people exercising to manage their condition. Interventions not shown to be effective There were seven interventions for which no conclusive positive evidence was found. All available evidence on the following interventions was inconclusive: structured communication, safeguarding training, home hazard assessment. All available evidence on case management and social support interventions showed no evidence of difference between intervention and control groups. Of two reviews on alternative therapies, one found no evidence of difference between groups and another found inconclusive evidence. Inconclusive evidence was also found for some interventions shown to be positive in other reviews: physical activity, occupational therapy, personal assistance, assistive devices, lay/peer support, supported employment. No evidence of difference was found in some reviews for interventions which were found in other reviews to have positive effects: physical activity, assistive devices, lay/peer support, supported employment. On balance, the overall evidence suggests that physical activity interventions and occupational therapy are effective. What are the implications? Implications for policy and practice The greatest portion of evidence included in this review of reviews is about physical activity – evidence suggests that these types of interventions can be effective for people with long-term conditions and non-frail older people and may address both quality of life and delay or reduce the need for social care support. Moreover, although physical activity interventions may typically be regarded as not within the remit of social care, they may be relatively cheap and easy to implement, and therefore worth considering. More complex and perhaps more recognisably social care interventions such as occupational therapy are also supported by the review-level literature. The large and medium effects resulting from integrated mental health and employment services also underscore the value of complex social care interventions. Moreover, the integrated nature of this particular intervention suggests that the current drive in the UK to integrate health and social services (Department of Health 2011) may prove to be successful. Wider evaluation of integrated services is certainly warranted. A last key message for policymakers and practitioners is the need to recognise the influence of contextual factors on the success of social care interventions, in particular the need for safety measures when implementing social care interventions with particularly vulnerable groups. Implications for research The great breadth and extent of evidence contained within this review of reviews is clear. However, assessing the available review-level evidence across the whole of social care also makes clear that there are significant gaps in the evidence examining impact on ASCOF outcomes. There is severely limited evidence on satisfaction with services and safeguarding outcomes in existing systematic reviews There is little use of quality of life measures designed to evaluate the impact of social care interventions included in reviews There is limited review-level evidence on many social care interventions, and none for some key intervention types There is scant evidence on key populations groups – people with physical and learning disabilities There is no review-level evidence on cost-effectiveness. How did we get these results? The research involved identifying and analysing evidence from systematic reviews to answer the following research questions: Which social care interventions can effectively improve outcomes for services users in the four outcome domains set out in the ASCOF: quality of life, prevention, satisfaction and safeguarding? How much impact do effective social care interventions have on ASCOF outcomes?
Revista»Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA
En este artículo se revisa el consenso de los diversos aspectos de la gestión no farmacológico de la osteoporosis, incluyendo los efectos de nutrientes, ejercicio físico, estilo de vida, prevención de caídas, y los protectores de cadera. La vertebroplastia también se revisa brevemente. Manejo no farmacológico de la osteoporosis es un concepto amplio. Debe ser visto como una parte esencial de la prevención de las fracturas de la niñez hasta la edad adulta y la vejez. El tema también incluye procedimientos quirúrgicos para el tratamiento de las fracturas vertebrales y periféricas y la rehabilitación post-fractura. El presente documento es el resultado de un consenso, basado en una revisión sistemática y una evaluación crítica de la literatura. Las dietas deficientes en calcio, proteínas o vitamina D menoscaben la integridad del esqueleto. El efecto de otros nutrientes es menos clara, aunque un consumo excesivo de sodio, cafeína, o fibras ejerce efectos negativos sobre el equilibrio del calcio. Los efectos nocivos del tabaco, el consumo excesivo de alcohol y un bajo índice de masa corporal son bien aceptados. La actividad física es de primordial importancia para alcanzar la masa ósea máxima óptima pero, si numerosos estudios han demostrado los efectos beneficiosos de los distintos tipos de ejercicio sobre la masa ósea, datos de fractura como un punto final son escasas. Las estrategias de prevención de caídas son especialmente eficientes en el entorno de la comunidad, pero menos evidencia disponible sobre su efectividad en la prevención de lesiones y fracturas relacionadas con caídas. La eficacia de los protectores de cadera sigue siendo controvertido. Esto también es cierto para la vertebroplastia y la cifoplastia. Varios estudios controlados aleatorios han informado de una ventaja a corto plazo de la vertebroplastia sobre el tratamiento médico para aliviar el dolor, pero estos hallazgos han sido cuestionados por los estudios clínicos aleatorizados falsamente controlado recientes.
Las caídas en el adulto mayor son frecuentes y conllevan importante morbimortalidad, dependencia e institucionalización. Se ha planteado que la suplementación con vitamina D podría prevenir la ocurrencia de este evento. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos 18 revisiones sistemáticas que en conjunto incluyen 31 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de vitamina D probablemente no disminuye el riesgo de caídas en adultos mayores.
