XIII Congreso SCMGG 'Nutrición y envejecimiento un binomio ... · C o m it p c ie n t tfic o y o r...

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

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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

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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.


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.


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]


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]


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.


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]


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

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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.


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.


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]


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]


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]


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]


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]


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 -

http://blogs.hoy.es/blogfiles/erasmus-en-estonia/sol1.bmp

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


2012, Issue12




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


Interventionsfor preventing falls in older people in care facilitiesand hospitals(Review)


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.



Interventions for preventing falls in older people living in the

community (Review)

GillespieLD, Robertson MC, GillespieWJ, Sherrington C, GatesS, Clemson LM, Lamb SE


2012, Issue11


Interventionsfor preventing falls in older people living in the community (Review)


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)


¿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

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Den

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Italy

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Gre

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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

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nds

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land

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Italy

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Gre

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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

administered to verify the dosages, the method and duration of administration, and contraindications. It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient. Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner. There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article. Any use of the

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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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XIII Congreso SCMGG 'Nutrición y envejecimiento un binomio ... · C o m it p c ie n t tfic o y o r...

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