大腿骨頸部骨折に対する外来での包括的介入

大腿骨頸部骨折に対する外来での筋トレを含めた包括的介入の有効性をみた論文を紹介します。

Singh NA, Quine S, Clemson LM, Williams EJ, Williamson DA, Stavrinos TM, Grady JN, Perry TJ, Lloyd BD, Smith EU, Singh MA. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2012 Jan;13(1):24-30.

リサーチクエスチョンは以下の通りです。

P：大腿骨頸部骨折術後の外来患者に
I：12ヶ月間の筋トレを含めた包括的介入を行うと
C：通常のケアと比較して
O：死亡率、老人ホーム入所率、障害が軽減する
D：ランダム化比較試験

抄録しか読んでいませんが、包括的介入には高負荷の筋トレ以外に、バランス、骨粗鬆症、栄養、ビタミンD・カルシウム、うつ、認知、視力、住環境、多剤内服、ヒッププロテクター、自己効力、社会的支援が含まれます。まさに老年医学的な包括的介入です。

結果ですが、12ヶ月後の死亡率、老人ホーム入所率、障害はいずれも介入群で有意に低飼ったです。栄養改善もADL改善と有意に関連していました。これより外来での包括的介入は有効という結論です。

包括的介入はどちらかというと悪液質の原因疾患（がん、慢性呼吸不全、慢性心不全、慢性腎不全など）に行うべきだと思っていましたが、大腿骨頸部骨折術後でも有用です。リハ栄養的には、筋トレ、バランス、骨粗鬆症、栄養、ビタミンD・カルシウムあたりの評価と介入が重要といえそうです。

Abstract

RATIONALE:

Excess mortality and residual disability are common after hip fracture.

HYPOTHESIS:

Twelve months of high-intensity weight-lifting exercise and targeted multidisciplinary interventions will result in lower mortality, nursing home admissions, and disability compared with usual care after hip fracture.

DESIGN:

Randomized, controlled, parallel-group superiority study.

SETTING:

Outpatient clinic

PARTICIPANTS:

Patients (n = 124) admitted to public hospital for surgical repair of hip fracture between 2003 and 2007.

INTERVENTION:

Twelve months of geriatrician-supervised high-intensity weight-lifting exercise and targeted treatment of balance, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy, and social support.

OUTCOMES:

Functional independence: mortality, nursing home admissions, basic and instrumental activities of daily living (ADLs/IADLs), and assistive device utilization.

RESULTS:

Risk of death was reduced by 81% (age-adjusted OR [95% CI] = 0.19 [0.04-0.91]; P < .04) in the HIPFIT group (n = 4) compared with usual care controls (n = 8). Nursing home admissions were reduced by 84% (age-adjusted OR [95% CI] = 0.16 [0.04-0.64]; P < .01) in the experimental group (n = 5) compared with controls (n = 12). Basic ADLs declined less (P < .0001) and assistive device use was significantly lower at 12 months (P = .02) in the intervention group compared with controls. The targeted improvements in upper body strength, nutrition, depressive symptoms, vision, balance, cognition, self-efficacy, and habitual activity level were all related to ADL improvements (P < .0001-.02), and improvements in basic ADLs, vision, and walking endurance were associated with reduced nursing home use (P < .0001-.05).

CONCLUSION:

The HIPFIT intervention reduced mortality, nursing home admissions, and ADL dependency compared with usual care.