訪問栄養指導で機能と栄養状態改善

高齢患者の自宅退院後に管理栄養士が訪問栄養指導すると機能と栄養状態が改善するというRCTを紹介します。

Beck AM, Kjær S, Hansen BS, Storm RL, Thal-Jantzen K, Bitz C. Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge: a randomized controlled trial. Clin Rehabil. 2012 Dec 20. [Epub ahead of print]

リサーチクエスチョンは以下の通りです。

P：65歳以上で自宅退院した栄養リスクのある患者に
I：総合診療医の3回の訪問診療＋管理栄養士の3回の訪問栄養指導を行うと
C：総合診療医の3回の訪問診療のみと比較して
O：退院後半年間の再入院が減少する
D：ランダム化比較試験

結果ですが、一次アウトカムについては再入院のオッズ比1.62 (95%信頼区間0.85 to 3.10)、死亡のオッズ比0.60 (95%信頼区間0.17 to 2.13)と統計学的有意差を認めませんでした。

しかし二次アウトカムでは、訪問栄養指導群で機能（移動能力など）、栄養状態（体重、エネルギー摂取量、蛋白摂取量）が有意に改善しました。これより栄養リスクのある高齢者に対する自宅退院後の訪問栄養指導は機能と栄養状態を改善させるとおう結論です。

二次アウトカムですので参考程度の解釈にとどめるべきですが、栄養リスクのある高齢者に3回、管理栄養士が訪問栄養指導を行うことで機能と栄養状態によい影響を与えるというのは意味があります。継続介入するとどうかも知りたいですね。

Abstract

Objective:To assess the additional benefits of individualized nutritional counselling by a registered dietitian in geriatric patients' home after discharge from hospital, in relation to risk of re-admissions, functional status, nutritional status, use of social services and mortality.Design:Twelve-week single-blind randomized controlled study.Setting and subjects:Geriatric medical patients (65+ years) at nutritional risk.Interventions:Participants were randomly allocated to receive a visit in their homes, either three individualized nutritional counselling by a registered dietitian complemented with three follow-up visits by general practitioners or three follow-up visits by general practitioners alone.Main measures:Primary outcome was risk of re-admissions. Secondary outcomes were functional status (hand grip strength, chair stand, mobility, disability and tiredness in daily activities, rehabilitation capacity), nutritional status (weight, BMI, energy and protein intake), need of social services (home care, home nursing, meals-on-wheels) and mortality.Results:One hundred and fifty-two patients were included; 132 (87%) completed the first and 124 (82%) the second data collection after 12 weeks. Ten per cent of the participants had three contacts with their general practitioner, while compliance with the dietetic intervention was almost 100%. Odds ratio for re-admission and mortality after 26 weeks was 1.62 (95% confidence interval (CI) 0.85 to 3.10) and 0.60 (95% CI 0.17 to 2.13). The intervention had a positive effect on functional status (i.e. mobility, P = 0.029), and nutritional status (i.e. weight, P = 0.035; energy intake, P < 0.001; protein intake, P = 0.001) and the use of meals-on wheels was reduced (P = 0.084).Conclusion:Follow-up home visits with registered dietitians have a positive effect on the functional and nutritional status of geriatric medical patients after discharge.