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Resúmenes Epistemonikos
Medwave 2016;16(Suppl 1):e6368 doi: 10.5867/medwave.2016.6368
¿Es efectiva la suplementación con vitamina D para la prevención de caídas en pacientes geriátricos?
Is vitamin D supplementation effective for the prevention of falls in elderly people?
Franco Scheel, Marcela Carrasco
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Resumen

Las caídas en el adulto mayor son frecuentes y conllevan importante morbimortalidad, dependencia e institucionalización. Se ha planteado que la suplementación con vitamina D podría prevenir la ocurrencia de este evento. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, identificamos 18 revisiones sistemáticas que en conjunto incluyen 31 estudios aleatorizados. Realizamos un metanálisis y tablas de resumen de los resultados utilizando el método GRADE. Concluimos que el uso de vitamina D probablemente no disminuye el riesgo de caídas en adultos mayores.


 
Problema

El síndrome de caídas es un importante problema en la población geriátrica. Un tercio de los pacientes mayores de 65 años se caen cada año, y el riesgo de caídas aumenta con la edad [1],[2]. Aproximadamente una de cada diez caídas tiene consecuencias graves, como fractura, hematoma subdural, lesión de tejidos blandos o traumatismo craneal [3],[4],[5].  Por otra parte, se asocia a un deterioro en la funcionalidad de los sujetos y su institucionalización temprana [6].

La vitamina D tiene variados efectos fisiológicos debido a que la mayoría de los tejidos del cuerpo humano contiene receptores para 1,25-dihidroxi-vitamina D. La presencia de receptores en los músculos explicaría la relación de la deficiencia de esta vitamina con miopatía, debilidad y dolor muscular [7]. Se ha planteado que la suplementación resultaría en una mejora en la fuerza muscular y prevención de caídas [8],[9], incluso en pacientes sin déficit de vitamina D.

Métodos

Utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en 30 bases de datos, para identificar revisiones sistemáticas y sus estudios primarios incluidos. Con esta información generamos un resumen estructurado, siguiendo un formato preestablecido, que incluye mensajes clave, un resumen del conjunto de evidencia (presentado como matriz de evidencia en Epistemonikos), metanálisis del total de los estudios, tablas de resumen de resultados con el método GRADE, y tabla de otras consideraciones para la toma de decisión.

Mensajes clave

  • El uso de vitamina D probablemente no disminuye el riesgo de caídas en adultos mayores.  
  • Podrían existir subgrupos que se beneficien, como aquellos con hipovitaminosis D demostrada o clínicamente probable.
Acerca del conjunto de evidencia para esta pregunta

Cuál es la evidencia. 
Véase matriz de evidencia en Epistemonikos más abajo.

Encontramos 18 revisiones sistemáticas [10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] que en total incluyen 31 estudios controlados aleatorizados reportados en 66 referencias [8],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],
[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],
[65],[66],[67],[68],[69],[70],[71],[72][73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],
[86],[87],[88],[89],[90],[91].

Qué tipo de pacientes incluyeron los   estudios

Fueron incluidos pacientes adultos mayores (65 años o más) hospitalizados, institucionalizados o provenientes de la comunidad. Los estudios no restringieron sus criterios de inclusión en relación a la certificación de hipovitaminosis D previo al inicio de la suplementación.

En su mayoría correspondía a sexo femenino.

Qué tipo de intervenciones incluyeron   los estudios

Las intervenciones fueron variadas en cuanto a la combinación con calcio, dosis, esquemas y formas de administración de vitamina D. Se describen 24 formas distintas de intervención, todas incluyendo vitamina D de una u otra forma.

Trece estudios [9],[34],[39],[49],[51],[63],[64],[68],[69],[70],[75],[76], [83],[84] incluyeron calcio en el grupo de intervención. Se utilizaron variados esquemas de dosis de vitamina D; en seis estudios [34],[38], [49],[58],[60],[64] se utilizaron dosis menores de 800 UI diarias. En 22 estudios [8],[9],[30],[38],[39],[45],[49],[51],[58],[60],[61],[63],[64],[68],[69],[70],[75],[76],[84] se administró la vitamina D con dosis diaria, en dos [33],[91] con dosis semanal, en uno cada 3 meses [57], en uno cada 4 meses [90], en dos con dosis anual [82],[87] y en tres en dosis única [18],[43],[61].

La comparación fue contra placebo, grupo control, estrategias anticaída y por último administración de calcio en dosis de 600 mg, 1000 mg y 1200 mg.

Qué tipo de desenlaces   midieron

En el presente resumen, al igual que en la mayoría de las revisiones identificadas, se analiza solamente el desenlace caídas.

[90
Resumen de los resultados

La información sobre los efectos de la vitamina D sobre las caídas está basada en 31 estudios aleatorizados que incluyen 45 616 pacientes. Sin embargo, tres estudios no presentaron sus datos de una forma que pudiera ser combinada [33],[51],[82].

  • El uso de vitamina D probablemente no disminuye el riesgo de caídas. La certeza de la evidencia es moderada.

Otras consideraciones para la toma de decisión

A quién se aplica y a quién no se aplica esta evidencia

  • Esta evidencia se aplica a pacientes de 65 años o más en la comunidad, institucionalizados u hospitalizados.
  • Esta evidencia no se aplica a pacientes seleccionados específicamente como pudieran ser aquellos con hipovitaminosis D demostrada, lo cual no ha sido abordado en este resumen. 
Sobre los desenlaces incluidos en este resumen
  • En base a la opinión de los autores de este resumen, se considera a las caídas como único desenlace crítico para la toma de decisión en la gran mayoría de los adultos mayores en que se plantea esta intervención. Los posibles beneficios de la vitamina D en otros desenlaces no son abordados en este resumen.
Balance riesgo/beneficio y certeza de la evidencia
  • Esta evidencia concluye que probablemente no existe beneficio al suplementar con vitamina D a población general adulta mayor para la prevención de caídas.
Consideraciones de recursos
  • Si bien se trata de una intervención de relativo bajo costo, dado que probablemente no tiene beneficio, el balance costo/beneficio no es favorable a su utilización. 

Diferencias entre este resumen y otras fuentes

  • Los mensajes claves de nuestro resumen son parcialmente concordantes con las conclusiones de las principales revisiones sistemáticas identificadas [12],[16],[17],[19],[20]. Estas han concluido que la suplementación de vitamina D no parece reducir las caídas, pero que podrían haber subgrupos que se beneficien, como aquellos con hipovitaminosis D [16],[19], en la suplementación conjunta con calcio [20] o en pacientes institucionalizados u hospitalizados [16].
  • La conclusion principal de este resumen es discordante con las guías clínicas actuales, tales como la de la Sociedad Americana de Geriatría [92]. En ésta se recomienda indicar la suplementación de vitamina D junto a calcio a todo adulto mayor ya sea proveniente de la comunidad como institucionalizado u hospitalizado con el objetivo de disminuir el riesgo de caídas.
¿Puede que cambie esta información en el futuro?
  • La probabilidad de que futura evidencia cambie las conclusiones principales de este resumen es baja, debido a la certeza de la evidencia.
  • Nuevas revisiones sistemáticas que incorporen el total de la evidencia existente podrían entregar mayor información sobre si algunos subgrupos podrían beneficiarse.

Cómo realizamos este resumen

Mediante métodos automatizados y colaborativos recopilamos toda la evidencia relevante para la pregunta de interés y la presentamos en una matriz de evidencia.

Siga el enlace para acceder a la versión interactiva: Vitamina D para la prevención de caídas

Notas

Si con posterioridad a la publicación de este resumen se publican nuevas revisiones sistemáticas sobre este tema, en la parte superior de la matriz se mostrará un aviso de “nueva evidencia”.  Si bien el proyecto contempla la actualización periódica de estos resúmenes, los usuarios están invitados a comentar en Medwave o contactar a los autores mediante correo electrónico si creen que hay evidencia que motive una actualización más rápida.

Luego de crear una cuenta en Epistemonikos, al guardar las matrices recibirá notificaciones automáticas cada vez que exista nueva evidencia que potencialmente responda a esta pregunta. El detalle de los métodos para elaborar este resumen están descritos aquí: http://dx.doi.org/10.5867/medwave.2014.06.5997.

La Fundación Epistemonikos es una organización que busca acercar la información a quienes toman decisiones en salud, mediante el uso de tecnologías. Su principal desarrollo es la base de datos Epistemonikos (www.epistemonikos.org).

Los resúmenes de evidencia siguen un riguroso proceso de revisión por pares interno.

Declaración de conflictos de intereses
Los autores declaran no tener conflictos de intereses con la materia de este artículo.

Licencia Creative Commons Esta obra de Medwave está bajo una licencia Creative Commons Atribución-NoComercial 3.0 Unported. Esta licencia permite el uso, distribución y reproducción del artículo en cualquier medio, siempre y cuando se otorgue el crédito correspondiente al autor del artículo y al medio en que se publica, en este caso, Medwave.

 

Falls in elderly people are common and come with important effects on morbidity and mortality, dependence and institutionalization. It has been proposed that supplementation of vitamin D could prevent the occurrence of this event. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 18 systematic reviews including 31 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded the use of vitamin D probably leads to little or no difference in the risk of falling in elderly people.

Autores: Franco Scheel[1,3], Marcela Carrasco[2,3]

Filiación:
[1] Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[2] Departamento de Geriatría, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
[3] Proyecto Epistemonikos, Santiago, Chile

E-mail: fcscheel@uc.cl

Correspondencia a:
[1] Facultad de Medicina
Pontificia Universidad Católica de Chile
Lira 63
Santiago Centro
Chile

Citación: Scheel F, Carrasco M. Is vitamin D supplementation effective for the prevention of falls in elderly people?. Medwave 2016;16(Suppl 1):e6368 doi: 10.5867/medwave.2016.6368

Fecha de publicación: 26/1/2016

Ficha PubMed

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Kärkkäinen MK, Tuppurainen M, Salovaara K, Sandini L, Rikkonen T, Sirola J, et al. Does daily vitamin D 800 IU and calcium 1000 mg supplementation decrease the risk of falling in ambulatory women aged 65-71 years? A 3-year randomized population-based trial (OSTPRE-FPS). Maturitas. 2010 Apr;65(4):359-65. | CrossRef | PubMed |

Larsen ER, Mosekilde L, Foldspang A. Vitamin D and calcium supplementation prevents osteoporotic fractures in elderly community dwelling residents: a pragmatic population-based 3-year intervention study. J Bone Miner Res. 2004 Mar;19(3):370-8. Epub 2003. | PubMed |

Larsen ER, Mosekilde L, Foldspang A. Vitamin D and calcium supplementation prevents severe falls in elderly community-dwelling women: a pragmatic population-based 3-year intervention study. Aging Clin Exp Res. 2005 Apr;17(2):125-32. | PubMed |

Latham NK, Anderson CS, Lee A, Bennett DA, Moseley A, Cameron ID; Fitness Collaborative Group. A randomized, controlled trial of quadriceps resistance exercise and vitamin D in frail older people: the Frailty Interventions Trial in Elderly Subjects (FITNESS). J Am Geriatr Soc. 2003 Mar;51(3):291-9. | PubMed |

Law M, Withers H, Morris J, Anderson F. Vitamin D supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in residential accommodation. Age Ageing. 2006 Sep;35(5):482-6. Epub 2006 Apr 26. | PubMed |

Minne HW, Pfeifer M, Begerow B, Nachtigall D, Hansen C. Vitamin D and calcium supplementation reduces falls in elderly women via improvement of body sway and normalisation of blood pressure; a prospective, randomised, and double-blind study. Osteoporosis International. 2000 2000;11(suppl 2):S115-s. | Link |

Pfeifer M, Begerow B, Minne HW, Abrams C, Nachtigall D, Hansen C. Effects of a short-term vitamin D and calcium supplementation on body sway and secondary hyperparathyroidism in elderly women. J Bone Miner Res. 2000 Jun;15(6):1113-8. | PubMed |

Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporos Int. 2009 Feb;20(2):315-22. | CrossRef | PubMed |

Pfeifer M, Begerow B, Nachtigall D, Hansen C. Prevention of falls-related fractures: vitamin D reduces body sway in the elderly - a prospective, randomized, double blind study. Bone. 1998 1998;23(5 Suppl 1):S175. | Link |

Pfeifer M, Dobnig H, Begerow B, Suppan K. Effects of vitamin D and calcium supplementation on falls and parameters of muscle function: a prospective randomized, double-blind multi-centre study. Annual Meeting of the American Society for Bone and Mineral Research (26th : October 1-5, 2004 in Seattle, Washington, USA); 20042004. p. [abstract] 1222. | Link |

Pfeifer M, Dobnig H, Minne HW, Suppan K. The effects of a supplementation with vitamin D and calcium on falls and muscle function parameters in older people - Results of a prospective, randomised, double-blind multi-centre study. Medizinische Klinik. 2005;100:28. | Link |

Porthouse J, Cockayne S, King C, Saxon L, Steele E, Aspray T. Randomised controlled trial of calcium and vitamin D supplementation for fracture prevention in primary care. Osteoporosis International. 2004;15(Suppl 2):s13. | Link |

Porthouse J, Cockayne S, King C, Saxon L, Steele E, Aspray T, et al. Randomised controlled trial of calcium and supplementation with cholecalciferol (vitamin D3) for prevention of fractures in primary care. BMJ. 2005 Apr 30;330(7498):1003. | PubMed |

Prince RL, Austin N, Devine A, Dick IM, Bruce D, Zhu K. Effects of ergocalciferol added to calcium on the risk of falls in elderly high-risk women. Arch Intern Med. 2008 Jan 14;168(1):103-8. | CrossRef | PubMed |

Ralston SH, Binkley N, Boonen S, Kiel DP, Reginster JY, Roux C, et al. Randomized trial of alendronate plus vitamin D3 versus standard care in osteoporotic postmenopausal women with vitamin D insufficiency. Calcif Tissue Int. 2011 Jun;88(6):485-94. | CrossRef | PubMed |

Salovaara K, Tuppurainen M, Kärkkäinen M, Rikkonen T, Sandini L, Sirola J, et al. Effect of vitamin D(3) and calcium on fracture risk in 65- to 71-year-old women: a population-based 3-year randomized, controlled trial--the OSTPRE-FPS. J Bone Miner Res. 2010 Jul;25(7):1487-95. | CrossRef | PubMed |

Sanders K, Stuart A, Williamson E, Simpson J, Kotowicz M, Nicholson G. The efficacy of high-dose oral vitamin D3 administered once a year: A randomised, double-blind, placebo-controlled trial (vital D study) for falls and fractures in older women. Journal of bone and mineral research. 2010 2010;25:S50. | Link |

Sanders KM, Stuart AL, Merriman EN, Read ML, Kotowicz MA, Young D, et al Trials and tribulations of recruiting 2,000 older women onto a clinical trial investigating falls and fractures: Vital D study. BMC Med Res Methodol. 2009 Nov 25;9:78. | CrossRef | PubMed |

Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Nicholson GC. Annual high-dose oral vitamin D for falls and fractures in elderly women: A randomised, double-blind, placebo-controlled trial (Vital D Study). Osteoporosis International. 2010 2010;21(Suppl 1):s30. | Link |

Sanders KM, Stuart AL, Williamson EJ, Simpson JA, Kotowicz MA, Young D, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010 May 12;303(18):1815-22. | CrossRef | PubMed |

Sato Y, Iwamoto J, Kanoko T, Satoh K. Low-dose vitamin D prevents muscular atrophy and reduces falls and hip fractures in women after stroke: a randomized controlled trial. Cerebrovasc Dis. 2005;20(3):187-92 | PubMed |

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