Poor nutritional status but not cognitive or functional impairment per se independently predict 1 year mortality in elderly patients with hip-fracture

Nutritional care in older adults: are we doing everything? An expert opinion review

Malnutrition is a prevalent, yet often underdiagnosed and undertreated, condition in older adults. It is characterized by weight loss and/or reduced muscle mass due to diminished caloric intake, inflammation, and/or disease burden. In return, malnutrition can lead to diminished skeletal muscle functionality and disability, among others. Malnutrition plays a crucial role in the pathogenesis of two prevalent geriatric syndromes, namely sarcopenia and frailty. The complex interplay between malnutrition, sarcopenia, and frailty significantly impacts the older population, leading to increased morbidity, mortality, hospitalization rates, quality-of-life, and healthcare costs. Given the prognostic significance of malnutrition in geriatric care, recent guidelines emphasized the role of nutritional support in vulnerable populations. A group of vulnerable populations to malnutrition, sarcopenia, and frailty are older patients with hip fractures, cancer patients, and those with sarcopenic dysphagia. This article highlights the importance of individualized nutritional assessment and treatment in the management of vulnerable populations such as older patients with hip fractures, cancer, and those suffering from sarcopenic dysphagia. It presents practical protocols and guidelines that can be instrumental in enhancing the nutritional care of these groups, thereby improving their overall health outcomes.

Malnutrition-Related Health Outcomes in Older Adults with Hip Fractures: A Systematic Review and Meta-Analysis

Hip fracture is a common condition in older adults, leading to disability and mortality. Several studies have demonstrated the association between nutritional status and the risk of a negative health outcome after fractures. In this systematic review, we evaluated the association between malnutrition and mortality, changes in mobility/living arrangements, and postoperative complications, such as delirium, in older patients with hip fractures. A literature search on the PubMed, Web of Science, and Scopus databases, up to September 2023, was conducted to identify all studies involving older subjects that reported an association between MNA/GNRI/PNI/CONUT and health outcome after hip fracture. Meta-analysis was performed by a random-effects model using risk values (RR, OR, and HR) extracted from the 14 eligible selected studies. Malnutrition significantly increased the risk of any analyzed adverse outcome by 70% at 1 month, and up to 250% at 1 year. Malnutrition significantly increased delirium risk by 275% (OR = 2.75; 95% CI 1.80-4.18; p ≤ 0.05), mortality risk by 342% (OR = 3.42; 95% CI 2.14-5.48; p ≤ 0.05), mortality hazard risk by 351% (HR = 3.51; 95% CI 1.63-7.55; p ≤ 0.05) at 1 month, and transfer-to-more-supported-living-arrangements risk by 218% (OR = 2.18; 95% CI 1.58-3.01; p ≤ 0.05), and declined mobility risk by 41% (OR = 1.41; 95% CI 1.14-1.75; p ≤ 0.05), mortality risk by 368% (OR = 3.68; 95% CI 3.00-4.52; p ≤ 0.05), and mortality hazard risk by 234% (HR = 2.34; 95% CI 1.91-2.87; p ≤ 0.05) at 1 year. Malnutrition of older patients increases the risk of death and worsens mobility and independence after hip fractures. The results of the present study highlight the importance of nutritional status evaluation of older subjects with hip fractures in order to prevent potential adverse outcomes (Registration No: CRD42023468751).

Systematic review and meta-analysis of preoperative predictors for early mortality following hip fracture surgery

Hip fractures are a global health problem with a high postoperative mortality rate. Preoperative predictors for early mortality could be used to optimise and personalise healthcare strategies. This study aimed to identify predictors for early mortality following hip fracture surgery. Cohort studies examining independent preoperative predictors for mortality following hip fracture surgery were identified through a systematic search on Scopus and PubMed. Predictors for 30-day mortality were the primary outcome, and predictors for mortality within 1 year were secondary outcomes. Primary outcomes were analysed with random-effects meta-analyses. Confidence in the cumulative evidence was assessed using the GRADE criteria. Secondary outcomes were synthesised narratively. Thirty-three cohort studies involving 462,699 patients were meta-analysed. Five high-quality evidence predictors for 30-day mortality were identified: age per year (OR: 1.06, 95% CI: 1.04-1.07), ASA score ≥ 3 (OR: 2.69, 95% CI: 2.12-3.42), male gender (OR: 2.00, 95% CI: 1.85-2.18), institutional residence (OR: 1.81, 95% CI: 1.31-2.49), and metastatic cancer (OR: 2.83, 95% CI: 2.58-3.10). Additionally, six moderate-quality evidence predictors were identified: chronic renal failure, dementia, diabetes, low haemoglobin, heart failures, and a history of any malignancy. Weak evidence was found for non-metastatic cancer. This review found relevant preoperative predictors which could be used to identify patients who are at high risk of 30-day mortality following hip fracture surgery. For some predictors, the prognostic value could be increased by further subcategorising the conditions by severity.

Femoral neck system versus multiple cannulated screws for the fixation of Pauwels classification type II femoral neck fractures in older female patients with low bone mass

BACKGROUND

Femoral neck fractures in older adult patients are a major concern and often necessitate surgical intervention. This study compared the clinical outcomes of 2 surgical techniques: the femoral neck system (FNS) and cannulated compression screws (CCSs).

METHODS

A total of 40 female patients (mean age 73.50 ± 11.55 years) with femoral neck fractures of Pauwels classification type II and receiving surgical fixation between 2020 and 2022 were enrolled. The patients were categorized into an FNS group (n = 12) or a CCS group (n = 28), and surgical duration, intraoperative blood loss, length of hospital stay, and incidence of postoperative adverse events were analyzed.

RESULTS

No significant intergroup differences in demographic characteristics were discovered. The mean surgical duration for all patients was 52.88 ± 22.19 min, with no significant difference between the groups. However, the FNS group experienced significantly higher intraoperative blood loss (P = 0.002) and longer hospital stay (P = 0.023) than did the CCS group. The incidence of osteonecrosis was higher in the CCS group, whereas the incidence of nonunion or malunion was higher in the FNS group. The surgical method did not appear to be a significant risk factor. The main risk factor for revision surgery was longer duration until the first adverse event (P = 0.015).

CONCLUSION

The FNS does not appear to provide superior surgical outcomes compared with CCSs in older adult women with Pauwels classification type II femoral neck fractures. A longer duration between surgical fixation and the first adverse event before stabilization of the fracture site may be a risk factor for revision surgery.

The Relationship between Handgrip Strength, Timed Up-and-Go, and Mild Cognitive Impairment in Older People during COVID-19 Pandemic Restrictions

The COVID-19 lockdown restrictions affected physical performance and cognitive function in older people as they were confined to their homes. There is an association between physical and cognitive functions. Mild Cognitive Impairment (MCI) is a condition that risks progressing to dementia. This study aimed to identify the relationship between handgrip strength (HGS), Timed Up-and-Go (TUG), and MCI in older people during the COVID-19 pandemic restrictions. The cross-sectional study recruited 464 eligible participants for an interview and anthropometric measurement. The Montreal Cognitive Assessment-Basic (MoCA-B), HGS, and TUG were measured in addition to demographic and health characteristics. A total of 398 participants (85.8%) were found to have MCI when screened with the MoCA-B. Their mean age was 71.09 ± 5.81 years. Forward multiple regression analysis demonstrated that HGS (β = 0.032, p < 0.001), education level (β = 2.801, p < 0.001), TUG (β = -0.022, p = 0.013), Thai Geriatric Depression Score, TGDS (β = -0.248, p = 0.011), and age (β = -1.677, p = 0.019) were associated with MCI. A decrease in HGS and an increased TUG might allow for the early detection of MCI and promote physical training in order to reduce the risk of MCI. Further studies can investigate multidomain indicators for MCI, for example, fine motor skills and pinch strength as components of the motor abilities.

Functional autonomy and 12-month mortality in older adults with proximal femoral fractures in an orthogeriatric setting: risk factors and gender differences

BACKGROUND

Proximal femur fractures have a negative impact on loss of functional autonomy and mortality.

OBJECTIVE

The aim of this retrospective study was to evaluate functional autonomy and mortality in a group of older adults with hip fractures managed in an orthogeriatric setting 12 months after discharge and to determine if gender affected outcome.

METHODS

In all participants, we assessed clinical history, functional pre-fracture status using activities of daily living (ADL) and in-hospital details. At 12 months after discharge, we evaluated functional status, place of residence, hospital readmissions and mortality.

RESULTS

We studied 361 women and 124 men and we observed a significant reduction in the ADL score at 6 months (1.15 ± 1.58/p < 0.001 in women and 1.45 ± 1.66/p < 0.001 in men). One-year mortality (33.1% in men and 14.7% in women) was associated with pre-fracture ADL score and reduction in ADL at 6 months (HR 0.68/95%, CI 0.48-0.97/p < 0.05 and HR 1.70/95%, CI 1.17-2.48/p < 0.01, respectively) in women, and new hospitalisations at 6 months and polypharmacy in men (HR 1.65/95%, CI 1.07-2.56/p < 0.05 and HR 1.40/95%, CI 1.00-1.96/p = 0.05, respectively) in Cox's regression model.

DISCUSSION AND CONCLUSIONS

Our study suggests that functional loss in older adults hospitalised for proximal femur fractures is greatest in the first 6 months after discharge, and this increases the risk of death at 1 year. Cumulative mortality at 12 months is higher in men and appears to be related to polypharmacy and new hospital admissions 6 months after discharge.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Association of preoperative prognostic nutritional index with risk of postoperative delirium: A systematic review and meta-analysis

Study objective

To assess the association between prognostic nutritional index (PNI) and risk of postoperative delirium (POD) in adult patients.

Methods

MEDLINE, Google scholar, EMBASE, and Cochrane library databases were searched from inception till April 2022. The primary outcome was the association between PNI and the risk of POD, while the secondary outcomes were correlations of other prognostic factors with POD risk. The correlation between PNI and the incidence of POD was assessed with three approaches: Difference in preoperative PNI between POD and non-POD groups (Model 1) as well as the association of PNI as a continuous parameter (Model 2) or as a binary variable (i.e., low vs. high using a PNI cut-off value of 50) (Model 3) with POD risk.

Results

Analysis of nine observational studies published from 2010 to 2021 recruiting 3,743 patients showed a POD incidence of 6.4-35%. Our meta-analysis demonstrated a lower PNI among patients in the POD group (MD: -3.78, 95% CI: -4.85 to -2.71, p < 0.0001, I ² = 54.2%) compared to the non-POD group (Model 1). Pooled results revealed a negative association between PNI and POD risk for both Model 2 (OR: 0.91, 95% CI: 0.86-0.97, p = 0.002, I ² = 71%) and Model 3 (OR: 1.68, 95% CI: 1.26-2.23, p < 0.0001, I ² = 0%). Besides, while our results supported an age-dependent increase in POD risk, other factors including body-mass index, surgical time, health status, hypertension, diabetes mellitus, and male gender were non-significant predictors of POD.

Conclusion

Our results demonstrated a negative association between PNI and POD, which warrant further large-scale studies for validation.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022323809.

Combined Effects of Cognitive Impairment and Nutritional Trajectories on Functional Recovery for Older Patients after Hip-Fracture Surgery

OBJECTIVES

Malnutrition and cognitive impairment are associated with poor functional recovery in older adults following hip-fracture surgery. This study examined the combined effects of cognitive impairment and nutritional trajectories on postoperative functional recovery for older adults following hip-fracture surgery.

DESIGN

Prospective longitudinal correlational study.

SETTING AND PARTICIPANTS

This study recruited 350 older adults (≥60 years of age) who received hip-fracture surgery at a 3000-bed medical center in northern Taiwan from September 2012 to March 2020.

METHODS

Participant data were collected over a 2-year period after surgery for nutritional and cognitive status and activities of daily living (ADLs). Participants were grouped by type of nutritional trajectory using group-based trajectory modeling. Generalized estimating equations analyzed associations between trajectory groups/cognitive status at discharge and performance of ADLs.

RESULTS

Nutritional trajectories best fit a 3-group trajectory model: malnourished (19%), at-risk of malnutrition (40%), and well-nourished (41%). Nutritional status for the malnourished group declined from 12 months to 24 months following surgery; nutritional status remained stable for at-risk of malnutrition and well-nourished groups. Interactions for cognitive impairment-by-nutritional status were significant: the malnourished + intact cognition subgroup had significantly better ADLs than the malnourished + cognitive impairment subgroup (b = 27.1, 95% confidence interval = 14.0-40.2; P < .001). For at-risk of malnutrition and well-nourished groups, there were no significant differences between cognitive impairment and intact cognition in ADLs. These findings suggest that nutritional status may buffer the negative effect of cognitive impairment on ADLs.

CONCLUSIONS AND IMPLICATIONS

Better nutritional status over time for older adults following hip fracture can protect against adverse influences of cognitive impairment on ADLs during postoperative recovery. Participants with malnutrition and cognitive impairment had the poorest ADLs. These findings suggest interventions tailored to improving nutritional status may improve recovery for older adults following hip-fracture surgery.

Impact of dysphagia and malnutrition on the survival of hospitalized patients

INTRODUCTION

Oropharyngeal dysphagia (OD) and malnutrition (MN) are highly prevalent among hospitalized patients, with significant clinical repercussions.

OBJECTIVES

To assess the prevalence, survival and factors associated with OD and MN in hospitalized patients with a high risk of OD.

METHODS

A cross-sectional observational study with 82 patients aged ≥70 years and with the possibility of oral feeding admitted in 4 services of a third level hospital during 3 months. The Nutritional Risk Screening 2002 test (NRS-2002) was performed to detect nutritional risk and the volume-viscosity screening test (V-VST) for OD evaluation. Data were collected on the clinical suspicion of OD, days of hospital stay, the number of readmissions and other socio-demographic data.

RESULTS

50.6% had OD and 51.9% MN. In 48.8%, there was underdiagnosis of OD. The median number of days of admission was higher among patients with MN (19.5 days vs 13 days, p = 0.02). Of the total readmissions, 70.8% had MN compared to 29.2% that did not (p = 0.03). Survival among patients who did not survive one year after admission was lower when OD was given (Sig. = 0.04).

CONCLUSIONS

More than half of the population studied has OD, as well as DN, which increases the rate of readmission and decreases survival at the year of admission. Although there are specific screening methods, their use is not widespread, making it difficult to diagnose OD and its therapeutic intervention.

A New Random Forest Algorithm-Based Prediction Model of Post-operative Mortality in Geriatric Patients With Hip Fractures

Background

Post-operative mortality risk assessment for geriatric patients with hip fractures (HF) is a challenge for clinicians. Early identification of geriatric HF patients with a high risk of post-operative death is helpful for early intervention and improving clinical prognosis. However, a single significant risk factor of post-operative death cannot accurately predict the prognosis of geriatric HF patients. Therefore, our study aims to utilize a machine learning approach, random forest algorithm, to fabricate a prediction model for post-operative death of geriatric HF patients.

Methods

This retrospective study enrolled consecutive geriatric HF patients who underwent treatment for surgery. The study cohort was divided into training and testing datasets at a 70:30 ratio. The random forest algorithm selected or excluded variables according to the feature importance. Least absolute shrinkage and selection operator (Lasso) was utilized to compare feature selection results of random forest. The confirmed variables were used to create a simplified model instead of a full model with all variables. The prediction model was then verified in the training dataset and testing dataset. Additionally, a prediction model constructed by logistic regression was used as a control to evaluate the efficiency of the new prediction model.

Results

Feature selection by random forest algorithm and Lasso regression demonstrated that seven variables, including age, time from injury to surgery, chronic obstructive pulmonary disease (COPD), albumin, hemoglobin, history of malignancy, and perioperative blood transfusion, could be used to predict the 1-year post-operative mortality. The area under the curve (AUC) of the random forest algorithm-based prediction model in training and testing datasets were 1.000, and 0.813, respectively. While the prediction tool constructed by logistic regression in training and testing datasets were 0.895, and 0.797, respectively.

Conclusions

Compared with logistic regression, the random forest algorithm-based prediction model exhibits better predictive ability for geriatric HF patients with a high risk of death within post-operative 1 year.

Is Radiographic Osteoporotic Hip Morphology A Predictor For High Mortality Following Intertrochanteric Femur Fractures?: Osteoporotic Hip Morphology & Mortality

INTRODUCTION

Factors related to mortality after intertrochanteric femur fractures (ITFF) have been investigated intensively in the literature except for radiographic osteoporotic hip morphology. The aim of this study is to investigate the relationship between mortality and radiographic osteoporotic hip morphology of patients with ITFF.

PATIENTS AND METHODS

Patients who underwent surgery between the dates of January 2012 and June 2018 due to ITFF were retrospectively reviewed. Osteoporotic status of the proximal femur was determined based on Singh Index grading and Dorr classification systems on preoperative anteroposterior pelvis radiographs of contralateral hips. The mortality rates of the patients were measured at 1st, 3rd, 6th, and 12th months. For controlling the confounders, multiple regression analysis was performed.

RESULTS

A total of 321 consecutive ITFFs were included in the study. The mean age of the patients was 81.5 ± 6.6 years. All patients were treated with osteosynthesis utilizing a cephalomedullary nail. The overall mortality rates at 1st, 3rd, 6th, and 12th months were 7.2%, 13.4%, 16.2%, 22.7%, respectively. There was 2.196 (1.140 - 4.229) folds increase in the mortality rate of patients with the Dorr type C femurs at 6th month (p=0.019). However, Singh index grade was not significantly associated with mortality.

CONCLUSION

Patients with Dorr type C femur seem to have 2.1 times increased mortality at 6th months following ITFFs. A simple anteroposterior pelvis radiograph obtained during the initial evaluation of the patients may be used to estimate the mortality rate after ITFF.

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

BACKGROUND

Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls.

METHODS

In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF.

RESULTS

Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses.

CONCLUSION

Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.

Risk factors of hospitalization costs and length of stay for tibial plateau fractures

PURPOSE

This study aimed to analyze the factors influencing the length of stay (LOS) and the cost of hospital stay in patients with tibial plateau fractures (TPFs).

METHODS

We enrolled 233 patients with TPFs in this retrospective study. The general conditions, hematological indicators, and imaging data of hospitalized patients were collected. The factors influencing the cost and LOS were determined by a multivariate logistic regression model controlling confounding factors. Receiver operating characteristic (ROC) curve is used to determine the sensitivity and specificity of risk factors.

RESULTS

The hospitalization cost of hypoproteinemia was significantly higher than that of the standard group (OR 3.07; 95% CI 1.23-7.69; P = 0.017); Low hemoglobin levels in the male will significantly affect patient hospitalization costs (OR 8.32; 95% CI 2.82-24.57; P = 0.015), will also extend the LOS (OR 3.02; 95% CI 1.15-7.89; P = 0.024). Among Schatzker classification of the tibial plateau, hospitalization costs of type V, VI above fractures were significantly higher than those of class I, II, III, and IV fractures (OR 8.78; 95% CI 3.34-23.09; P < 0.001).

CONCLUSION

In this study, hypoproteinemia and the Schatzker classification appeared to be a useful indicator for predicting hospitalization costs for TPFs patients; Male hemoglobin level appears to be an independent risk factor for hospital cost and LOS.

For you were hungry and I gave you food: The prevalence and treatment of malnutrition in patients with acute hip fracture

Hip fractures are a common clinical problem with substantial morbidity and difficult recovery. Preexisting malnutrition has been shown to be common in those patients and a substantial risk factor for poorer outcomes, increased length of stay, and mortality. Additionally, great variability exists in reported malnutrition prevalence rates owing to the variety of nutrition screening and assessment tools utilized globally to identify malnutrition in these patients. Although previous data and a recent Cochrane review have not proven the value of nutrition supplements, we highlight several articles that show an opportunity for improvement in the nutrition care of patients sustaining hip fractures along with a multicenter randomized trial demonstrating the value of carefully designed nutrition intervention. There is also evidence that malnourished patients with hip fracture are still being undertreated. Current guidelines are reviewed, and continued efforts on the part of the clinicians to follow the guidelines as well as lowering the barriers to high-quality nutrition research is discussed.

The Effects of Lifestyle and Diet on Gut Microbiota Composition, Inflammation and Muscle Performance in Our Aging Society

Living longer is associated with an increased risk of chronic diseases, including impairments of the musculoskeletal and immune system as well as metabolic disorders and certain cancers, each of which can negatively affect the relationship between host and microbiota up to the occurrence of dysbiosis. On the other hand, lifestyle factors, including regular physical exercise and a healthy diet, can affect skeletal muscle and immune aging positively at all ages. Accordingly, health benefits could partly depend on the effect of such interventions that influence the biodiversity and functionality of intestinal microbiota. In the present review, we first discuss the physiological effects of aging on the gut microbiota, immune system, and skeletal muscle. Secondly, we describe human epidemiological evidence about the associations between physical activity and fitness and the gut microbiota composition in older adults. The third part highlights the relevance and restorative mechanisms of immune protection through physical activity and specific exercise interventions during aging. Fourth, we present important research findings on the effects of exercise and protein as well as other nutrients on skeletal muscle performance in older adults. Finally, we provide nutritional recommendations to prevent malnutrition and support healthy active aging with a focus on gut microbiota. Key nutrition-related concerns include the need for adequate energy and protein intake for preventing low muscle mass and a higher demand for specific nutrients (e.g., dietary fiber, polyphenols and polyunsaturated fatty acids) that can modify the composition, diversity, and metabolic capacity of the gut microbiota, and may thus provide a practical means of enhancing gut and systemic immune function.

Sarcopenia and Malnutrition Screening in Female Osteoporosis Patients-A Cross-Sectional Study

Sarcopenia and malnutrition are important determinants of increased fracture risk in osteoporosis. SARC-F and MNA-SF are well-established questionnaires for identifying patients at risk for these conditions. We sought to evaluate the feasibility and potential added benefit of such assessments as well as the actual prevalence of these conditions in osteoporosis patients. We conducted a cross-sectional, single-center study in female osteoporosis patients ≥ 65 years (SaNSiBaR-study). Results of the sarcopenia (SARC-F) and malnutrition (MNA-SF) screening questionnaires were matched with a functional assessment for sarcopenia and data from patients’ medical records. Out of 107 patients included in the analysis, a risk for sarcopenia (SARC-F ≥ 4 points) and a risk for malnutrition (MNA-SF ≤ 11 points) was found in 33 (30.8%) and 38 (35.5%) patients, respectively. Diagnostic overlap with coincident indicative findings in both questionnaires was observed in 17 patients (16%). As compared to the respective not-at-risk groups, the mean short physical performance battery (SPPB) score was significantly reduced in both patients at risk for sarcopenia (7.0 vs. 10.9 points, p < 0.001) and patients at risk for malnutrition (8.7 vs. 10.5 points, p = 0.005). Still, confirmed sarcopenia according to EWGSOP2 criteria was present in only 6 (6%) of all 107 patients, with only 3 of them having an indicative SARC-F score. Bone mineral density was not significantly different in any of the at-risk groups at any site. In summary, applying SARC-F and MNA-SF in osteoporosis patients appears to be a complementary approach to identify individuals with functional deficits.

Osteoporosis in older adults

The incidence of fragility fractures increases progressively with advance in age after 50 years, and the phenomenon of population ageing will lead to an increased proportion of the world population having osteoporosis and fractures. The consequences of fractures are more serious in older adults: all low-trauma fractures were associated with increased mortality risk and the risk of a second major osteoporotic fracture after a first one also increased with advance in age. Along with the decrease in bone mineral density, falls play an essential role in the occurrence of fragility fractures in older adults, and the assessment of the risk of falling is part of the fracture risk assessment. Despite advances in the diagnosis of osteoporosis, the assessment of fracture risk, and a wide range of effective anti-osteoporosis medications, with parenteral route which can improve observance, many data indicate that the therapeutic care gap is particularly wide in the elderly in whom the importance and impact of a treatment are high and even more in those living in institutions.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.

Undernutrition, Sarcopenia, and Frailty in Fragility Hip Fracture: Advanced Strategies for Improving Clinical Outcomes

Geriatric patients with hip fractures often experience overlap in problems related to nutrition, including undernutrition, sarcopenia, and frailty. Such problems are powerful predictors of adverse responses, although few healthcare professionals are aware of them and therefore do not implement effective interventions. This review aimed to summarize the impact of undernutrition, sarcopenia, and frailty on clinical outcomes in elderly individuals with hip fractures and identify successful strategies that integrate nutrition and rehabilitation. We searched PubMed (MEDLINE) and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant literature published over the last 10 years and found that advanced interventions targeting the aforementioned conditions helped to significantly improve postoperative outcomes among these patients. Going forward, protocols from advanced interventions for detecting, diagnosing, and treating nutrition problems in geriatric patients with hip fractures should become standard practice in healthcare settings.

Geriatric Nutritional Risk Index as a Screening Tool to Identify Patients with Malnutrition at a High Risk of In-Hospital Mortality among Elderly Patients with Femoral Fractures-A Retrospective Study in a Level I Trauma Center

BACKGROUND

Malnutrition is frequently underdiagnosed in geriatric patients and is considered to be a contributing factor for worse outcomes during hospitalization. In addition, elderly patients who undergo trauma are often malnourished at the time of incurring fractures. The geriatric nutritional risk index (GNRI), calculated based on the serum albumin level and the ratio of present body weight to ideal body weight, was proposed for the assessment of the nutritional status of elderly patients with various illnesses. This study aimed to investigate whether the GNRI has a prognostic value that links the nutritional status and mortality outcomes of elderly patients who have previously undergone trauma with femoral fractures.

METHODS

From January 1, 2009 to December 31, 2019, a total of 678 elderly patients with femoral fractures were categorized into four nutritional risk groups: a major-risk group (GNRI <82; group 1, n = 127), moderate-risk group (GNRI 82- <92; group 2, n = 179), low-risk group (GNRI 92-98; group 3, n = 123), and no-risk group (GNRI >98; group 4, n = 249). To minimize the confounding effects of sex, age, preexisting comorbidities, and injury severity of patients on outcome measurements, propensity score-matched patient cohorts were created to assess the impact of patients being in different nutritional risk groups on the in-hospital mortality outcomes against the no-risk group.

RESULTS

The patients in groups 1-3 were significantly older and presented a significantly lower body mass index and lower serum albumin levels than those in group 4. Compared with patients in group 4 (3.6%), a significantly higher mortality rate was found in the patients in group 1 (17.3%, p < 0.001), but not in those in group 2 (6.7%) or group 3 (2.4%). The study of propensity score-matched patient cohorts provided similar results; group 1 patients had significantly higher odds of mortality than group 4 patients (odds ratio, 6.3; 95% confidence interval, 1.34-29.37; p = 0.009), but there were no significant differences in mortality risks among patients in groups 2 and 3 compared with those in group 4.

CONCLUSIONS

This preliminary study suggested that the GNRI may be used as a screening tool to identify patients with malnutrition at a high risk of mortality among elderly patients with femoral fractures. A prospective study is needed to validate the suggestion.

Rapid nutritional assessment and intervention in orthopedic rehabilitation patients

OBJECTIVES

The aim of this study was to identify the effect of early nutritional assessment and nutritional intervention on outcomes of older adult patients after discharge from an acute care hospital following fall related fracture.

METHODS

This was a feasibility pilot study with post intervention data. One group pretest-posttest study design was implemented. All participants were admitted to a rehabilitation facility in the Southwestern US after a fall related fracture.

MEASURES

Discharge destination, Functional Independence Measure (FIM), and length of stay (LOS).

RESULTS

A total of 69% of the participants were discharged home. Total FIM scores improved (p<0.01). No significant association was identified between prealbumin change and total FIM change. Patients who had improved prealbumin experienced improved FIM and shorter LOS; however, no significant correlations were determined between LOS and prealbumin change.

CONCLUSION

Nutritional interventions are important for recovery during rehabilitation of a fall-related fracture.

SUMMARY

This project supports early nutritional evaluation and intervention for older adult patients after major orthopedic procedure. Participants who received early intervention had improved outcomes. (194 characters).

Epidemiology and risk factors for contralateral proximal femur fracture: a single center retrospective cohort study on 1022 patients

Summary.

BACKGROUND AND AIM OF THE WORK

Given the high impact of proximal femur fractures (PFFs) on elderly patients and healthcare systems, the burden of contralateral PFFs might be overlooked. Aim of the study is to analyze the epidemiology and risk factors of contralateral proximal femur fractures. Secondary aim is to detect mortality rate differences in first and contralateral PPF.

METHODS

A population of 1022 patients admitted for proximal femur fractures in a single center was studied. Prevalence at admission as well as incidence of contralateral PFF during a 18 to 36 months follow-up was recorded. Epidemiology of contralateral PFF was studied recording number of events, time to second fracture and fracture type. Mortality at 1-year was recorded for all patients and compared between first and second PFF patients. Comorbidities, pharmacotherapy, BMI, MNA and SPMSQ were studied as possible risk factors.

RESULTS

Prevalence and incidence of contralateral PFFs were 9.4% and 6.5% respectively. Median time to second fracture was 12 months. One-year mortality of contralateral PFFs was significantly lower (20.5% vs 25.1%, p 0.003) than first PFF. Contralateral fracture patients had a significantly lower BMI and a significantly lower proportion of malnourished patients.

CONCLUSIONS

The incidence and prevalence of contralateral PFFs is relevant. Mortality of contralateral PFFs results to be lower than first PFF. Patients with higher BMI and malnourished patients have a lower risk of contralateral PFF.

Role of dietary protein and exercise on biomarkers of immune activation in older patients during hospitalization

The aim of this study was to examine the effect of short-term protein supplementation (aiming to consume 1.2 g protein/kg body weight per day) combined with moderate resistance training on 3 days of the week on tryptophan-kynurenine metabolism in 40 older patients with hip fracture. Secondary outcomes for physical recovery were hand-grip strength and chair-rise score. Older patients with hip fracture exhibited higher degrees of immune activation, detected by increased neopterin and kynurenine to tryptophan levels compared with reference values for healthy elderly with no significant differences between those who received the exercise-protein intervention compared to the control. Increasing dietary protein intake during hospitalization did not alleviate the Th1-type immune response in the elderly patient. On the other hand, muscularity per se may affect immune activation responses following injury, as improvements in maximum hand-grip strength with the intervention were related to decreases in neopterin levels.

Changing trends in the mortality rate at 1-year post hip fracture - a systematic review

BACKGROUND

Traditionally, the mortality rate at 1-year post hip fracture was quoted as approximately 30% of all hip fractures. There have been recent improvements in hip fracture care in the main driven by national hip fracture registries with reductions in 30-d mortality rates reported.

AIM

To address recent 1-year post hip fracture mortality rates in the literature.

METHODS

Systematic literature review, national hip fracture registries/databases, local studies on hip fracture mortality, 5 years limitation (2013-2017), cohorts > 100, studies in English. Outcome measure: Mortality rate at 1-year post hip fracture.

RESULTS

Recent 1-year mortality rates were reviewed using the literature from 8 National Registries and 36 different countries. Recently published 1-year mortality rates appear lower than traditional figures and may represent a downward trend.

CONCLUSION

There appears to be a consistent worldwide reduction in mortality at 1-year post hip fracture compared to previously published research. Globally, those which suffer hip fractures may currently be benefiting from the results of approximately 30 years of national registries, rigorous audit processes and international collaboration. The previously quoted mortality rates of 10% at 1-mo and 30% at 1-year may be outdated.