大腿骨頸部骨折に対する多職種栄養ケアの効果

大腿骨頸部骨折に対する多職種栄養ケアの効果を見た論文を紹介します。

Hoekstra JC, et al., Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: A controlled prospective cohort study, Clinical Nutrition (2011), doi:10.1016/j.clnu.2011.01.011

リサーチクエスチョンをPICOで書くと

P：65歳以上の大腿骨頸部骨折で手術を受けた患者
I：入院中と退院後の栄養サポートに集中した多職種の栄養ケア（看護師、医師、栄養士が必ず栄養評価・介入を行う）
C：標準的な栄養ケア（MNAが24未満なら栄養士は栄養介入。看護師と医師は時に栄養評価・介入を行う）
O：栄養状態（MNA、BIA）とQOL（EQ-5D）の改善

になります。研究デザインは前向きコホート研究ですが、前後研究（Iが後、Cが前）でもあります。

結果は介入群でエネルギー摂取量と蛋白質摂取量が有意に多くなりました。介入群では発症3か月後のQOLの低下が対照群より有意に少なく、MNAで低栄養もしくは低栄養のおそれありと判定される割合も有意に少ないという結果でした。ただ、BIAによる体組成に関しては両群で有意差を認めませんでした。

これより標準的な栄養ケアより、退院時の栄養連携も含めた多職種の栄養ケアのほうが優れているという結論です。栄養状態そのものの改善が得られていないのは残念ですが、大腿骨頸部骨折患者での栄養介入の有効性を示すエビデンスの1つになると思います。

Abstract
BACKGROUND & AIMS: The purpose of this study was to determine the effectiveness of a multidisciplinary intervention program on nutritional intake and of nutritional intake on nutritional status and quality of life in older patients treated for a hip fracture.

METHODS: A controlled prospective cohort study included 66 patients in the control group and 61 patients in the intervention group, aged over 65 and sustaining a hip fracture with subsequent operative intervention. Postoperatively, the control group received standard nutritional care and the intervention group multidisciplinary nutritional care that focused on nutritional support during hospitalisation and a transfer of nutritional care after discharge. Nutrient intakes were monitored with food records. Nutritional status was determined by the Mini Nutritional Assessment (MNA), and bioelectrical impedance analysis was used to assess body cell mass (BCM). The EuroQol (EQ-5D) was used to assess quality of life. Patients were evaluated at admission and three months postoperatively.

RESULTS: There was a significant difference in the daily energy intake of patients between both groups during the first seven days postoperatively: 1127 kcal (±309) in the control group and 1292 kcal (±280) (P = 0.002) in the intervention group. Mean protein intake in the intervention group (57 g (±12)) was significantly higher than in the control group (48 g (±14), P = 0.000). The intervention group demonstrated a significantly lower reduction of EQ-5D index scores compared with the control group (P = 0.004) after three months. At three months, significantly fewer patients in the intervention group were classified as malnourished or at risk of malnutrition.

CONCLUSIONS: Among elderly patients with a hip fracture, a multidisciplinary postoperative approach of nutritional care was associated with an increase of energy and protein intake during hospitalisation. After three months follow-up there were fewer malnourished patients in the intervention group, and the decline in quality of life was lower than in the control group. There were no advantages of multidisciplinary nutritional care on body cell mass.