高齢者の転倒予防は運動とビタミンD

米国予防医療専門委員会(USPSTF)による、高齢者の転倒予防に対するプライマリ・ケアにおける介入の論文を紹介します。

Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25.

USPSTFは予防医療やスクリーニングなどに関してエビデンスに基づいた声明を紹介していて、予防医療に関して最も信頼できるサイトです。

USPSTFのHP
http://www.ahrq.gov/clinic/uspstfix.htm

今回はプライマリ・ケアにおける地域在住の高齢者の転倒予防に関するエビデンスの紹介をしています。一定以上の質のあるRCTのみをまとめた報告ですので、エビデンスレベルはかなり高いものになります。

結論として運動・理学療法とビタミンDに関しては、それぞれ転倒予防に有効としています。多方面からの介入（interventions with comprehensive management）は統計学的有意差は認めませんでしたが有効な傾向にあります。

これより転倒リスクがある高齢者には転倒予防として、運動・理学療法の指導とビタミンDの投与を行うべきといえます。高齢者にルーチンにビタミンDを投与するのは副作用も含めてどうなのだろうという思いは個人的にありますが、転倒予防に関するメリットは明らかです。

特にビタミンDが不足～欠乏している高齢者（25ハイドロキシビタミンDの血中濃度が30ng/ml以下）では投与すべきということになります。ただ、日本人の平均値で男性28.5g/ml、女性24.2ng/dlという論文がありますので、これを参考にすると大半の高齢者はビタミンD不足です。

ちなみに日本で医療保険で測定できる1,25ハイドロキシビタミンDでは、ビタミンDが本当に不足～欠乏しているかどうかの判断はできないというエビデンスがありますので、25ハイドロキシビタミンDの血中濃度を調べることが必要です。かなり高価ですが…。

Abstract

BACKGROUND: Falls among older adults are both prevalent and preventable.

PURPOSE: To describe the benefits and harms of interventions that could be used by primary care practitioners to prevent falling among community-dwelling older adults.

DATA SOURCES: The reviewers evaluated trials from a good-quality systematic review published in 2003 and searched MEDLINE, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL from the end of that review's search date to February 2010 to identify additional English-language trials. STUDY SELECTion: Two reviewers independently screened 3423 abstracts and 638 articles to identify randomized, controlled trials (RCTs) of primary care-relevant interventions among community-dwelling older adults that reported falls or fallers as an outcome. Trials were independently critically appraised to include only good- or fair-quality trials; discrepancies were resolved by a third reviewer.

DATA EXTRACTION: One reviewer abstracted data from 61 articles into standardized evidence tables that were verified by a second reviewer.

DATA SYNTHESIS: Overall, the included evidence was of fair quality. In 16 RCTs evaluating exercise or physical therapy, interventions reduced falling (risk ratio, 0.87 [95% CI, 0.81 to 0.94]). In 9 RCTs of vitamin D supplementation, interventions reduced falling (risk ratio, 0.83 [CI, 0.77 to 0.89]). In 19 trials involving multifactorial assessment and management, interventions with comprehensive management seemed to reduce falling, although overall pooled estimates were not statistically significant (risk ratio, 0.94 [CI, 0.87 to 1.02]). Limited evidence suggested that serious clinical harms were no more common for older adults in intervention groups than for those in control groups. Limitations: Interventions and methods of fall ascertainment were heterogeneous. Data on potential harms of interventions were scant and often not reported.

CONCLUSION: Primary care-relevant interventions exist that can reduce falling among community-dwelling older adults.