Nutritional status, insulin-like growth factor-1 and quality of life in elderly women with hip fractures

The association between IGF-1 levels and four types of osteoarthritis: a bidirectional and two-step mendelian randomization study

Background

Insulin-like Growth Factor-1 (IGF-1) plays a crucial role in the growth and metabolic functions of various tissues and cells in the body. Recently, there has been increased attention to the association between IGF-1 and osteoarthritis (OA). However, there is controversy in current research regarding the correlation between IGF-1 levels and OA. Furthermore, the specific manner in which Body Mass Index (BMI), a key risk factor for OA, mediates the impact of IGF-1 levels on OA remains unclear.

Object

This study aimed to investigate the bidirectional causal link between IGF-1 levels and OA in four body regions, and to explore how BMI influences the impact of IGF-1 on these types of OA.

Method

Two-sample Mendelian Randomization (MR) and its combined forms were utilized to investigate the bidirectional relationship between IGF-1 levels and four types of OA, as well as the mediating role of BMI in the impact of IGF-1 levels on OA. Data from various Genome-Wide Association Studies (GWAS) and multiple analytical methods, including inverse variance weighted, MR-Egger regression, and weighted median were utilized. Sensitivity analyses, such as MR-Egger intercept, Cochran Q test, leave-one-out, and MR-PRESSO, were conducted to ensure the robustness of the results.

Results

Higher IGF-1 levels are correlated with an increased risk for knee (OR, 1.07; 95% CI, 1.01-1.03; p = 1.49e-01; q = 9.86e-03), hip (OR, 1.13; 95% CI, 1.06-1.20; p = 7.61e-05; q = 7.44e-05), and hand OA (OR, 1.09; 95% CI, 1.01-1.17; p = 1.88e-02; q = 1.15e-02), but not spine OA but not spine OA (OR, 1.05; 95% CI, 0.99-1.10; p = 9.20e-02; q = 5.52e-02). Different types of OA do not affect IGF-1 levels. BMI mediates the increase in OA risk associated with higher IGF-1, including indirect spine OA risk through BMI.

Conclusion

The study elucidates the bidirectional causality between IGF-1 levels and OA in various body parts, highlighting BMI's mediating role in the impact of IGF-1 levels on OA. This provides valuable insights for OA prevention, diagnosis, and treatment strategies. Future research will expand our study to include a broader spectrum of ethnicities and explore the underlying mechanisms involved.

Effects of Hochuekkito on Physical Activity and Appetite in Postoperative Elderly Patients with Hip Fractures: A Randomized Controlled Trial

Objectives

Hip fracture in the elderly involves two cases of invasive damage to the body within a short period of time: the fracture itself and subsequent surgery. This situation affects physical strength and presents a major challenge during convalescent rehabilitation. This study aimed to evaluate the effects of hochuekkito, a traditional Japanese herbal medicine, on physical activity, appetite, motivation, and quality of life (QOL) during inpatient rehabilitation treatment after hip surgery.

Methods

Thirty-eight patients with hip fracture who underwent postoperative convalescent rehabilitation were randomly assigned to either the hochuekkito group (n=20, daily hochuekkito administration from day 3 after surgery until discharge from hospital) or the control group (n=18). Physical activity was measured with a small tri-axial accelerometer worn by the patients; appetite was evaluated based on daily dietary calorie consumption; motivation was measured using the vitality index score; and QOL was measured using the European QOL 5-Dimensions 5-Levels questionnaire and its associated EQ-visual analog scale (EQ-VAS). All patients were assessed at day 3 (baseline) and 2, 4, 6, 8, and 10 weeks after surgery and at the time of discharge from hospital.

Results

The results for the hochuekkito group were significantly higher than the control group for walking exercise at 10 weeks, vigorous activity time at 8 weeks, dietary calorie consumption at 10 weeks and at discharge, and EQ-VAS score at 6 weeks.

Conclusions

In elderly hip fracture patients, a course of hochuekkito administration starting soon after surgery significantly improved QOL, physical activity, and appetite at 6 weeks after surgery.

Effects of protease-treated royal jelly on muscle strength in elderly nursing home residents: A randomized, double-blind, placebo-controlled, dose-response study

Although we have found that protease-treated royal jelly (pRJ) benefit for the skeletal muscle mass and strength in the aged animals, the potential beneficial effects have not been evaluated in humans. The aim of this study was to determine whether pRJ intake had beneficial effects on muscle strength in elderly nursing home residents. One hundred and ninety-four subjects enrolled into this multicenter, randomized, double-blind, placebo-controlled study. Subjects received either placebo(Group 1), pRJ 1.2 g/d(Group 2), or 4.8 g/d(Group 3). Data through 1 year are reported for 163 subjects. The primary outcome measure is handgrip strength. Secondary outcomes include several physical performance tests (six-minute walk test, timed up and go test, and standing on one leg with eyes closed). The dropout rate was 16.0%. The means (95% confidence interval) of change in handgrip strength for placebo, low-dose, and high-dose groups are −0.98(−2.04,0.08), 0.50(−0.65,1.65) and 1.03(−0.37,2.44) kg (P = 0.06, P for trend = 0.02), respectively. No significant effects of the interventions were observed for physical performances. These findings suggest that pRJ treatment might not improve, but rather attenuate the progression of decrease in muscle strength in elderly people. In addition, we have not found that pRJ intervention can achieve improvement or attenuating the decrease in physical performance.

Normal gastric emptying time of a carbohydrate-rich drink in elderly patients with acute hip fracture: a pilot study

Background

Guidelines for fasting in elderly patients with acute hip fracture are the same as for other trauma patients, and longer than for elective patients. The reason is assumed stress-induced delayed gastric emptying with possible risk of pulmonary aspiration. Prolonged fasting in elderly patients may have serious negative metabolic consequences. The aim of our study was to investigate whether the preoperative gastric emptying was delayed in elderly women scheduled for surgery due to acute hip fracture.

Methods

In a prospective study gastric emptying of 400 ml 12.6% carbohydrate rich drink was investigated in nine elderly women, age 77–97, with acute hip fracture. The emptying time was assessed by the paracetamol absorption technique, and lag phase and gastric half-emptying time was compared with two gender-matched reference groups: ten elective hip replacement patients, age 45–71 and ten healthy volunteers, age 28–55.

Results

The mean gastric half-emptying time in the elderly study group was 53 ± 5 (39–82) minutes with an expected gastric emptying profile. The reference groups had a mean half-emptying time of 58 ± 4 (41–106) and 59 ± 5 (33–72) minutes, indicating normal gastric emptying time in elderly with hip fracture.

Conclusion

This pilot study in women with an acute hip fracture shows no evidence of delayed gastric emptying after an orally taken carbohydrate-rich beverage during the pre-operative fasting period. This implies no increased risk of pulmonary aspiration in these patients. Therefore, we advocate oral pre-operative management with carbohydrate-rich beverage in order to mitigate fasting-induced additive stress in the elderly with hip fracture.

Trial registration

ClinicalTrials.gov NCT02753010. Registered 17 April 2016, retrospectively. 

Increased 1-year survival and discharge to independent living in overweight hip fracture patients: A prospective study of 843 patients

BACKGROUND AND PURPOSE

Hip fracture patients usually have low body mass index (BMI), and suffer further postoperative catabolism. How BMI relates to outcome in relatively healthy hip fracture patients is not well investigated. We investigated the association between BMI, survival, and independent living 1 year postoperatively.

PATIENTS AND METHODS

This prospective multicenter study involved 843 patients with a hip fracture (mean age 82 (SD 7) years, 73% women), without severe cognitive impairment and living independently before admission. We investigated the relationship between BMI and both 1-year mortality and ability to return to independent living.

RESULTS

Patients with BMI > 26 had a lower mortality rate than those with BMI < 22 and those with BMI 22-26 (6%, 16%, and 18% respectively; p = 0.006). The odds ratio (OR) for 1-year survival in the group with BMI > 26 was 2.6 (95% CI: 1.2-5.5) after adjustment for age, sex, and physical status. Patients with BMI > 26 were also more likely to return to independent living after the hip fracture (OR = 2.6, 95% CI: 1.4-5.0). Patients with BMI < 22 had similar mortality and a similar likelihood of independent living to those with BMI 22-26.

INTERPRETATION

In this selected group of patients with hip fracture, the overweight and obese patients (BMI > 26) had a higher survival rate at 1 year, and returned to independent living to a higher degree than those of normal (healthy) weight. The obesity paradox and the recommendations for optimal BMI need further consideration in patients with hip fracture.

Low bone mineral density and fat-free mass in younger patients with a femoral neck fracture

BACKGROUND

Reduced bone mineral density (BMD) together with muscle wasting and dysfunction, that is sarcopenia, emerges as a risk factor for hip fracture. The aim of this study was to examine body composition and BMD and their relationship with trauma mechanisms in young and middle-aged patients with femoral neck fracture.

MATERIALS AND METHODS

Altogether, 185 patients with femoral neck fracture aged 20-69 were included. BMD, body composition and fat-free mass index (FFMI) were determined by dual-X-ray absorptiometry (DXA), and trauma mechanisms were registered.

RESULTS

Ninety per cent of the whole study population had a femoral neck BMD below the mean for age. In the young patients (< 50 years), 27% had a Z-score of BMD ≤ -2 SD. More than half of the middle-aged patients (50-69 years) had osteopenia, that is T-score -1 to -2.5, and 35% had osteoporosis, that is T-score < -2.5, at the femoral neck. Patients with low-energy trauma, sport injury or high-energy trauma had a median standardised BMD of 0.702, 0.740 vs. 0.803 g/cm(2) (P = 0.03), and a median FFMI of 15.9, 17.7 vs. 17.5 kg/m(2) (P < 0.001), respectively. FFMI < 10th percentile of an age- and gender-matched reference population was observed in one-third.

CONCLUSIONS

A majority had low BMD at the femoral neck, and one-third had reduced FFMI (i.e. sarcopenia). Patients with fracture following low-energy trauma had significantly lower femoral neck BMD and FFMI than patients with other trauma mechanisms. DXA examination of both BMD and body composition could be of value especially in those with low-energy trauma.

Cancer cachexia update in head and neck cancer: Pathophysiology and treatment

The pathophysiology of cancer cachexia remains complex. A comprehensive literature search was performed up to April 2013 using PubMed, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and the Google search engine. In this review, we focus on the different mediators of impaired anabolism and upregulated catabolism that alter the skeletal muscle homeostasis resulting in the wasting of cancer cachexia. We present recent evidence of targeted treatment modalities from clinical trials along with their potential mechanisms of action. We also report on the most current evidence from randomized clinical trials using multimodal treatments in patients with cancer cachexia, but also the evidence from head and neck cancer-specific trials. A more complete understanding of the pathophysiology of the syndrome may lead to more effective targeted therapies and improved outcomes for patients.

Anabolic steroids for rehabilitation after hip fracture in older people

BACKGROUND

Hip fracture occurs predominantly in older people, many of whom are frail and undernourished. After hip fracture surgery and rehabilitation, most patients experience a decline in mobility and function. Anabolic steroids, the synthetic derivatives of the male hormone testosterone, have been used in combination with exercise to improve muscle mass and strength in athletes. They may have similar effects in older people who are recovering from hip fracture.

OBJECTIVES

To examine the effects (primarily in terms of functional outcome and adverse events) of anabolic steroids after surgical treatment of hip fracture in older people.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (10 September 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013 Issue 8), MEDLINE (1946 to August Week 4 2013), EMBASE (1974 to 2013 Week 36), trial registers, conference proceedings, and reference lists of relevant articles. The search was run in September 2013.

SELECTION CRITERIA

Randomised controlled trials of anabolic steroids given after hip fracture surgery, in inpatient or outpatient settings, to improve physical functioning in older patients with hip fracture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials (based on predefined inclusion criteria), extracted data and assessed each study's risk of bias. A third review author moderated disagreements. Only very limited pooling of data was possible. The primary outcomes were function (for example, independence in mobility and activities of daily living) and adverse events, including mortality.

MAIN RESULTS

We screened 1290 records and found only three trials involving 154 female participants, all of whom were aged above 65 years and had had hip fracture surgery. All studies had methodological shortcomings that placed them at high or unclear risk of bias. Because of this high risk of bias, imprecise results and likelihood of publication bias, we judged the quality of the evidence for all primary outcomes to be very low.These trials tested two comparisons. One trial had three groups and contributed data to both comparisons. None of the trials reported on patient acceptability of the intervention.Two very different trials compared anabolic steroid versus control (no anabolic steroid or placebo). One trial compared anabolic steroid injections (given weekly until discharge from hospital or four weeks, whichever came first) versus placebo injections in 29 "frail elderly females". This found very low quality evidence of little difference between the two groups in the numbers discharged to a higher level of care or dead (one person in the control group died) (8/15 versus 10/14; risk ratio (RR) 0.75, 95% confidence interval (CI) 0.42 to 1.33; P = 0.32), time to independent mobilisation or individual adverse events. The second trial compared anabolic steroid injections (every three weeks for six months) and daily protein supplementation versus daily protein supplementation alone in 40 "lean elderly women" who were followed up for one year after surgery. This trial provided very low quality evidence that anabolic steroid may result in less dependency, assessed in terms of being either dependent in at least two functions or dead (one person in the control group died) at six and 12 months, but the result was also compatible with no difference or an increase in dependency (dependent in at least two levels of function or dead at 12 months: 1/17 versus 5/19; RR 0.22, 95% CI 0.03 to 1.73; P = 0.15). The trial found no evidence of between-group differences in individual adverse events.Two trials compared anabolic steroids combined with another nutritional intervention ('steroid plus') versus control (no 'steroid plus'). One trial compared anabolic steroid injections every three weeks for 12 months in combination with daily supplement of vitamin D and calcium versus calcium only in 63 women who were living independently at home. The other trial compared anabolic steroid injections every three weeks for six months and daily protein supplementation versus control in 40 "lean elderly women". Both trials found some evidence of better function in the steroid plus group. One trial reported greater independence, higher Harris hip scores and gait speeds in the steroid plus group at 12 months. The second trial found fewer participants in the anabolic steroid group were either dependent in at least two functions, including bathing, or dead at six and 12 months (one person in the control group died) (1/17 versus 7/18; RR 0.15, 95% CI 0.02 to 1.10; P = 0.06). Pooled mortality data (2/51 versus 3/51) from the two trials showed no evidence of a difference between the two groups at one year. Similarly, there was no evidence of between-group differences in individual adverse events. Three participants in the steroid group of one trial reported side effects of hoarseness and increased facial hair. The other trial reported better quality of life in the steroid plus group.

AUTHORS' CONCLUSIONS

The available evidence is insufficient to draw conclusions on the effects, primarily in terms of functional outcome and adverse events, of anabolic steroids, either separately or in combination with nutritional supplements, after surgical treatment of hip fracture in older people. Given that the available data points to the potential for more promising outcomes with a combined anabolic steroid and nutritional supplement intervention, we suggest that future research should focus on evaluating this combination.

Limited utility of adipokine levels in the diagnosis of malnutrition in the elderly

BACKGROUND AND AIMS

Adipokine levels may have a role in the diagnostic and prognostic evaluation of malnutrition. The aim of the present study was to evaluate the correlation between malnutrition score and leptin, other biological markers, and body mass index (BMI) in the diagnosis of malnutrition in the elderly.

METHODS

In this cross-sectional observational study, we enrolled subjects over 70 years. Exclusion criteria were diabetes mellitus, obvious thyroid disorders, significant edema, renal dysfunction, chronic liver disease, symptomatic cardiovascular diseases, and malignity. Patients' demographic and medical data were recorded and anthropometric measurements were performed. Laboratory parameters including leptin, IGF-1, IGFBP-3, IL-6, TNF-α were measured. We defined malnutrition according to mini nutritional assessment (MNA) scale. Patients were divided into four groups according to BMI quartiles.

RESULTS

Average age of the patients was 81.9 ± 4.8 years, 68.2 % female and 31.8 % male. According to their MNA scores, 103 (66.9 %) were well nourished, 33 (21.4 %) were under malnutrition risk and 18 (11.7 %) were malnourished. MNA total and screening scores were positively correlated with albumin, BMI, high-density lipoprotein cholesterol and estimated glomerular filtration rate. Serum leptin levels (ng/ml) were 18.9 ± 22.6, 22.3 ± 21.9, 51.9 ± 85.5, and 61.7 ± 56.1 in BMI groups 1-4, respectively. BMI was positively correlated with leptin and triglyceride levels. Leptin levels were similar among nutritional state groups. Neither BMI nor MNA scores had any significant correlation with adiponectin, ghrelin, IGF-1, or IGFBP-3.

CONCLUSIONS

Adipokine levels do not seem to give relevant information in nutritional state assessment.

Are albumin and total lymphocyte count significant and reliable predictors of mortality in fractured neck of femur patients?

Hip fractures are a significant cause of mortality and morbidity in the elderly. It is important to identify factors that predict an increased mortality following hip fracture. The aim of this study was to identify significant predictors of mortality at 6 and 12 months following hip fractures. Three hundred patients above the age of 65 were identified who were admitted in to the hospital with fracture neck of femur. Two hundred and seventy-four patients were operated and were included into the study. Variables collected were age, gender, significant comorbidities, admission albumin level and admission total lymphocyte count (TLC). Admission time and subsequent time to surgery were also analysed. Our study showed that albumin and TLC were found to be the only clearly significant mortality predictors at 12 months and a delay of up to 4 days to surgery does not significantly increase the mortality at 12 months.

Royal jelly prevents the progression of sarcopenia in aged mice in vivo and in vitro

Sarcopenia is characterized by the age-related loss of muscle mass and strength. One of the mechanisms of sarcopenia is the loss in the function and number of muscle satellite cells. Royal jelly (RJ) is a health food used worldwide. To obtain better digestion and absorption than RJ, protease-treated RJ (pRJ) has been developed. RJ and pRJ have been suggested to have potential pharmacological benefits such as prolonging the life span and reducing fatigue. Because these effects may improve sarcopenia and the functions of satellite cells, we examined the effects of RJ or pRJ treatment on the skeletal muscles in an animal model using aged mice. In vivo, RJ/pRJ treatment attenuated the decrease in the muscle weight and grip strength and increased the regenerating capacity of injured muscles and the serum insulin-like growth factor-1 levels compared with controls. In vitro, using isolated satellite cells from aged mice, pRJ treatment increased the cell proliferation rate, promoted cell differentiation, and activated Akt intracellular signaling pathway compared with controls. These findings suggest that RJ/pRJ treatment had a beneficial effect on age-related sarcopenia.

Malnutrition and quality of life in older people: a systematic review and meta-analysis

Although the effects of malnutrition on morbidity and mortality of older people is well established, there has been little work done to investigate the relationship between malnutrition and quality of life (QoL) in this population. In order to facilitate further research and to aggregate existing evidence into a clear overview, a systematic review was conducted. The objective was to identify the literature on the topic, review the findings systematically, and assess the association between nutritional status and QoL. MEDLINE, EMBASE, CINAHL and Web of Science were searched for relevant studies published up to April 2011. References within identified studies also searched. The primary author extracted all data using a purpose-built form, and evaluated the quality of the studies using a published checklist. A second reviewer checked a random sample of articles independently. Evidence in the current review comes from both cohort studies and intervention trials. Results from the former suggested that individuals with malnutrition are more likely to experience poor QoL (OR: 2.85; 95% CI: 2.20-3.70, p<0.001). Consistent with this, interventions designed to improve nutritional status can also lead to significant improvements in QoL, both physical (standard mean difference 0.23, CI: 0.08-0.38, p=0.002) and mental aspects (standard mean difference 0.24, CI: 0.11-0.36, p<0.001). However, the results should be interpreted with caution in view of the poor quality of the included studies and the heterogeneity of methods employed in the assessment of both nutritional status and QoL. Future studies should carefully characterise their participants and use standardised parameters for nutritional and QoL assessments in order to achieve better evaluation and comparability of study results.

Increased energy intake in hip fracture patients affects nutritional biochemical markers

BACKGROUND AND AIMS

We have previously shown that nutritional guidelines decreased the incidence of pressure ulcers in hip fracture patients. In the present study, we evaluate whether the nutritional biochemical markers S-IGF-1 (Insulin-like Growth Factor 1), S-Transthyretin and S-Albumin are affected by patients' energy intake, and whether the markers are useful as predictors of postoperative complications.

MATERIAL AND METHODS

Quasi-experimental design, with one intervention and one control group, as well as pre- and post-study measurements. Eighty-eight hip fracture patients were included: 42 in the control group and 46 in the intervention group. The control group received regular nutritional support pre- and postoperatively, while the intervention group received nutritional support that followed new, improved clinical guidelines from admission to five days postoperatively. S-Albumin, S-Transthyretin, C-Reactive Protein (S-CRP) and S-IGF-1 were analysed at admission and five days postoperatively as well as complications like pressure ulcer and infection.

RESULTS

The intervention group had a significantly higher energy intake; for example, 1636 kcal versus 852 kcal postoperative day 1. S-IGF-1 levels decreased significantly in the control group, while no decrease in the intervention group. S-Albumin and S-Transthyretin decreased and S-CRP increased significantly in both groups, indicating that those markers were not affected short-term by a high-energy intake. There was no correlation between short-term post-operative complications and S-IGF-1, S-Transthyretin or S-Albumin at admission.

CONCLUSION

The results of our study showed that S-IGF-1 can be used as a short-term nutritional biochemical marker, as it was affected by a five-day high-energy regimen. However, neither S-IGF-1, S-Transthyretin or S-Albumin were useful in predicting postoperative complications within five days postoperatively.

Serum vitamin E concentrations among highly functioning hip fracture patients are higher than in nonfracture controls

Malnutrition after hip fracture is common and associated with poor outcomes and protracted recovery. Low concentrations of vitamin E have been associated with incident decline in physical function among older adults and may, therefore, be particularly important to functionally compromised patients hip fracture patients. Serum concentrations of α-tocopherol and γ-tocopherol, the 2 major forms of vitamin E, were assessed in 148 female hip fracture patients 65 years or older from the Baltimore Hip Studies cohort 4 around the time of fracture (baseline) and at 2, 6, and 12 month postfracture follow-up visits (recovery). It was hypothesized that mean concentrations of both forms of vitamin E among these hip fracture patients would be lowest at the baseline visit and increase at each study visit during the year after fracture. Linear regression and generalized estimating equations were used to assess changes in vitamin E concentrations after adjustment for covariates and to determine predictors of vitamin E concentrations at baseline and throughout recovery. It was also hypothesized that vitamin E concentrations shortly after hip fracture would be lower than those in nonfracture controls after adjustment for covariates. To evaluate this hypothesis, linear regression was used to perform adjusted comparisons of baseline vitamin E concentrations among Baltimore Hip Studies cohort 4 participants to 1076 older women without history of hip fracture from the Women's Health and Aging Study I, Invecchiare in Chianti Study, and the National Health and Nutrition Examination Surveys. Mean α-tocopherol was lowest at baseline, and time from fracture to blood draw was positively associated with baseline α-tocopherol (P = .005). Mean γ-tocopherol did not change appreciably throughout the year after fracture, although it fluctuated widely within individuals. Serum concentrations of α-tocopherol and γ-tocopherol were highest among the hip fracture population after adjustment (P < .0001). In general, highly cognitively and physically functioning hip fracture patients demonstrated higher vitamin E concentrations. Thus, the relatively high degree of function among this cohort of hip fracture patients may explain their higher-than-expected vitamin E concentrations.

Serum albumin and total lymphocyte count as predictors of outcome in hip fractures

BACKGROUND & AIMS

Hip fractures are a significant cause of mortality and morbidity in the elderly. Malnutrition is a significant contributor to this, however no consensus exists as to the detection or management of this condition. We hypothesise that results of admission serum albumin and total lymphocyte count (TLC), as markers of Protein Energy Malnutrition (PEM) can help predict clinical outcome in hip fracture patients aged over 60 years.

METHODS

This retrospective study evaluated the nutritional status of patients with hip fractures using albumin and TLC assays and analysed their prognostic relevance. Clinical outcome parameters studied were delay to operation, duration of in-patient stay, re-admission and in-patient, 3- and 12-month mortality.

RESULTS

Four hundred and fifteen hip fracture patients were evaluated. Survival data were available for 377 patients at 12 months. In-hospital mortality for PEM patients was 9.8%, compared with 0% for patients without. Patients with PEM had a higher 12-month mortality compared to patients who had normal values of both laboratory parameters (Odds Ratio 4.6; 95% CI: 1.0-21.3). Serum albumin (Hazard Ratio 0.932, 95% CI: 0.9-1.0) and age (Hazard Ratio 1.04, 95% CI: 1.0-1.1) were found to be significant independent prognostic factors of mortality by Cox regression analysis.

CONCLUSIONS

These results highlight the relevance of assessing the nutritional status of patients with hip fractures at the time of admission and emphasises the correlation between PEM and outcome in these patients.

Importance of dietary advice, nutritional supplements and compliance for maintaining body weight and body fat after hip fracture

OBJECTIVE

Poor nutritional status amongst elderly individuals with hip fractures is well documented. Studies have suggested that 30-50 % of patients admitted to orthopaedic departments suffer from protein-energy malnutrition (PEM).

DESIGN

An 6 month intervention study.

SETTING

The study was conducted in Sweden between February 2005 and October 2006.

PARTICIPANTS

Elderly patients with hip fractures (n=32).

METHODS

Evaluation of compliance with individual nutritional support and whether body weight and body fat (BF) could be maintained after six months. Evaluation of possible effects of nutritional supplements and dietary advice after hip fracture on BMI, BF, and Mini Nutritional Assessment (MNA).

RESULTS

Overall compliance with supplement intake was 73%. After six months, BMI was unchanged. Women's BF had decreased (P < 0.01), although the mean calorie intake with nutritional support was 34 calories per kg body weight/day. Three groups could be identified: one group with increased body weight and BF, one with loss of body weight and BF, and one with increased body weight together with increased TBW and loss of BF. PARTICIPANTS who consumed 0-1 supplements daily lost more weight than those who consumed 2 supplements daily. There was a positive difference (p= < 0.001) for women between MNA values at baseline and after six months.

CONCLUSION

In the present study compliance was satisfactory at the group level, and the energy and protein intake increased significantly. BMI was unchanged during the 6 months period. However, the women lost BF during the study period of with some had increasing total body water (TBW). MNA values for women changed in a positive direction.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea.

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Cachexia in rheumatoid arthritis is associated with inflammatory activity, physical disability, and low bioavailable insulin-like growth factor

OBJECTIVES

To examine the impact of inflammation, insulin-like growth factor (IGF-1) and its regulating binding protein (IGFBP-1) on lean body mass (LBM) in patients with rheumatoid arthritis (RA).

METHODS

In 60 inpatients (50 women), inflammatory activity was measured by Disease Activity Score 28 (DAS28), C-reactive protein (CRP), and interleukin (IL)-6, and physical disability by the Health Assessment Questionnaire (HAQ). LBM was assessed by dual-energy X-ray absorptiometry (DXA) and fat free mass index (FFMI; kg/m(2)) and fat mass index (FMI; kg/m(2)) were calculated.

RESULTS

Median age was 65 years and disease duration 13 years. Fifty per cent of the patients had FFMI below the 10th percentile of a reference population and 45% had FMI above the 90th percentile, corresponding to the condition known as rheumatoid cachexia (loss of muscle mass in the presence of stable or increased FM). DAS28, CRP, and IL-6 correlated negatively with LBM (p = 0.001, 0.001, and 0.018, respectively), as did HAQ (p = 0.001). Mean (confidence interval) IGF-1 was in the normal range, at 130 (116-143) microg/L. IGFBP-1 levels were elevated in patients (median 58 microg/L in women and 59 microg/L in men) compared with a normal population (33 microg/L in women and 24 microg/L in men). The ratio IGF-1/IGFBP-1, which reflects bioavailable IGF-1, was low (2.0 microg/L) and was positively correlated with LBM (p = 0.015). In multiple regression analysis, 42% of the LBM variance was explained by IGF-1/IGFBP-1, HAQ score, and DAS28.

CONCLUSION

A large proportion of RA inpatients, mainly women, had rheumatoid cachexia. The muscle wasting was explained by inflammatory activity and physical disability as well as low bioavailable IGF-1.

Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year

Hip fractures are a major cause of hospital stay among the elderly, and result in increased disability and mortality. In this study from 1 April 2003 to 31 March 2004, the influence of optimised treatment of hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year were investigated. Comparisons were made between the first 210 patients in the period and the last 210 patients, who followed the new clinical pathway introduced at the University Hospital in Lund, Sweden. Early surgery, within 24h, was not associated with reduced mortality, but was significantly associated with reduced length of stay (p<0.001). Significantly more cases of osteosynthesis for femoral neck fracture were reoperated compared with all other types of surgery (p<0.001) when reoperations with extraction of the hook pins in healed fractures were excluded. Mortality was significantly higher among men than women at 4 (p=0.025) and 12 (p=0.001) months after fracture and among medically fit patients with administrative delay to surgery compared with patients with no delay (p<0.001).

The role of IGF-I and IGFBP-1 status and secondary hyperparathyroidism in relation to osteoporosis in elderly Swedish women

IGFBP-1 showed a strong inverse relation to the BMD values. The IGF-I values had a significant positive relation to the BMD values at all sites with the exception of the lumbar spine. The use of loop diuretics was a more important cause of secondary hyperparathyroidism than vitamin D status.

INTRODUCTION

Our aim was to investigate among elderly women the relationship to osteoporosis of calcium-regulating hormones and insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding protein-1 (IGFBP-1).

METHODS

A population-based cross-sectional study of 350 elderly women (mean age 73 years). Measurements of bone mineral density (BMD) of the left hip, lumbar spine and heel and risk markers for osteoporosis were studied.

RESULTS

The BMD values showed significant inverse relationship with the values of IGFBP-1 at all sites of measurement and significant positive relationship with the values of IGF-I at all sites with the exception of the lumbar spine. There was no significant association between the values of BMD and the values of 25-hydroxy vitamin D (25(OH)D). The use of loop diuretics was strongly and significantly associated with elevated levels of PTH >65 pg/ml (OR 4.4, P < 0.001).

CONCLUSIONS

The anabolic growth factor IGF-I and its modulating binding protein IGFBP-1 showed a stronger association with the BMD values than the calcium regulating hormones 25(OH)D and PTH. In this study the use of loop diuretics was a more important cause of secondary hyperparathyroidism than vitamin D status.

Nutritional status among patients with hip fracture in relation to pressure ulcers

BACKGROUND & AIMS

Patients with a hip fracture often have a poor nutritional status that is associated with increased risk of complications, morbidity and mortality. The aim of this study was to investigate the effects of an improved care intervention in relation to nutritional status and pressure ulcers. An intervention of best practices for patients with hip fracture was introduced, using the available resources effectively and efficiently with a not too complicated or expensive intervention.

METHODS

A quasi-experimental study of 478 patients consecutively included between April 1, 2003 and March 31, 2004. A new evidence-based clinical pathway was introduced on October 1, 2003. The results from the first 210 patients in the control group and the last 210 patients in the intervention group are presented in this article.

RESULTS

The total number of patients with a hospital-acquired pressure ulcer was in the intervention group, 19 patients, and in the control group, 39 patients (p = 0.007). No patient younger than 65 years developed a pressure ulcer. There were no statistical significant differences between the groups with respect to blood biochemical variables at inclusion. Patients in the control group had higher arm muscle circumference (AMC) (p = 0.05), calf circumference (CC) (p = 0.038) and body mass index (BMI) (p = 0.043) values. Abnormal anthropometrical tests of BMI, triceps skin fold (TSF) <10th percentile and AMC <10th percentile were found in 12 patients in the control group and in 4 patients in the intervention group. None of the 4 patients in the intervention group developed pressure ulcers. However, 2 of the 12 patients in the control group were affected.

CONCLUSIONS

It is possible to reduce the development of hospital-acquired pressure ulcers among elderly patients with a hip fracture even though they have poor prefracture nutritional status. Results in this study indicate the value of the new clinical pathway, as number of patients who have developed pressure ulcers during their stay in hospital has been reduced by 50%.

[Malnutrition as a prognostic factor in elderly patients with hip fractures]

BACKGROUND AND OBJECTIVE

Hip fracture occurs frequently in elderly patients, with devastating effects on the quality of life due to the high financial burden and the high mortality rate in patients with this condition. Malnutrition is prevalent in the elderly and it can negatively influence patients' recovery from hip fracture. Our proposal was to assess the relationship between malnutrition and the recovery of patients with hip fracture.

PATIENTS AND METHOD

A total of 110 patients with hip fractures who were admitted to the orthopedic unit at the Reina Sofía Hospital were reassessed one year after discharge. A prospective cohort design and logistic regression analysis was used.

RESULTS

Mean age was 81.4, and 80% of patients were women. After one year 19.7% of patients had died. A multivariate analysis showed a significant relationship between a poor functional recovery and age (odds ratio [OR] = 1.19), caloric malnutrition (OR = 290), protein malnutrition (OR = 125); and there was a significant relationship between being confined to bed and a worse situation before fracture (OR = 10.02); caloric malnutrition (OR = 9.57) and protein malnutrition (OR = 15.23).

CONCLUSIONS

Caloric and protein malnutrition were associated with a worse functional recovery in elderly patients with hip fracture.

Resting energy expenditure measured longitudinally following hip fracture compared to predictive equations: is an injury adjustment required?

The present study measuring resting energy expenditure (REE; kJ/d) longitudinally using indirect calorimetry in six elderly women aged ≥70 years following surgery for hip fracture, describes changes over time (days 10, 42 and 84 post-injury) and compares measured values to those calculated from routinely applied predictive equations. REE was compared to REE predicted using the Harris Benedict and Schofield equations, with and without accounting for the theoretical increase in energy expenditure of 35 % secondary to physiological stress of injury and surgery. Mean (95 % CI) measured REE (kJ/d) was 4704 (4354, 5054), 4090 (3719, 4461) and 4145 (3908, 4382) for days 10, 42 and 84, respectively. A time effect was observed for measured REE,P=0·003. Without adjusting for stress the mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Harris Benedict equation were 1 (−9, 12), 10 (2, 18) and 9 (1, 17) for days 10, 42 and 84, respectively. The mean difference and 95 % limits of agreement for measured and predicted REE (kJ/kg per d) for the Schofield equation without adjusting for stress were 8 (−3, 19), 16 (6, 26) and 16 (10, 22) for days 10, 42 and 84, respectively. After adjusting for stress, REE predicted from the Harris Benedict or Schofield equations overestimated measured REE by between 38 and 69 %. Energy expenditure following fracture is poorly understood. Our data suggest REE was relatively elevated early in recovery but declined during the first 6 weeks. Using the Harris Benedict or Schofield equations adjusted for stress may lead to overestimation of REE in the clinical setting. Further work is required to evaluate total energy expenditure before recommendations can be made to alter current practice for calculating theoretical total energy requirements of hip fracture patients.

Physiological functions should be considered as true end points of nutritional intervention studies

With the beginning of this millennium it has become fashionable to only follow ‘evidence-based’ practices. This generally-accepted approach cruelly negates experience or intelligent interpretation of pathophysiology. Another problem is that the great ‘meta-analysts’ of the present era only accept end points that they consider ‘hard’. In the metabolic and nutritional field these end points are infection-related morbidity and mortality, and all other end points are considered ‘surrogate’. The aim of this presentation is to prove that this claim greatly negates the contribution of more-fundamentally-oriented research, the fact that mortality has multifactorial causes, and that infection is a crude measure of immune function. The following problems should be considered: many populations undergoing intervention have low mortality, requiring studies with thousands of patients to demonstrate effects of intervention on mortality; nutrition is only in rare cases primary treatment, and in many populations is a prerequisite for survival rather than a therapeutic modality; once the effect of nutritional support is achieved, the extra benefit of modulation of the nutritional support regimen can only be modest; cost–benefit is not a valid end point, because the better it is done the more it will cost; morbidity and mortality are crude end points for the effect of nutritional intervention, and are influenced by many factors. In fact, it is a yes or no factor. In the literature the most important contributions include new insights into the pathogenesis of disease, the diminution of disease-related adverse events and/or functional improvement after therapy. In nutrition research the negligence of these end points has precluded the development and validation of functional end points, such as muscle, immune and cognitive functions. Disability, quality of life, morbidity and mortality are directly related to these functional variables. It is, therefore, of paramount importance to validate functional end points and to consider them as primary rather than surrogate end points.

Normal levels of serum IGF-I: determinants and validity of current reference ranges

Insulin like growth factor I (IGF-I) represents the key marker for the evaluation of Growth hormone (GH) status. As a large number of determinants including age, gender, genetic factors, nutrition, and disease states influence IGF-I serum levels, accurate normative data are essential to translate patient data into diagnostic meaning or even use IGF-I levels for adequate monitoring of patients with an over- or under-active GH axis. Even though reference ranges have been developed in large cohorts of healthy subjects, the dependency of these data on a given assay technology argues for assay specific normative data for IGF-I.

Leptin a new biological marker for evaluating malnutrition in elderly patients

BACKGROUND

There is no single universally accepted biochemical marker of nutritional status in the elderly. Many markers are affected by non-nutritional factors.

OBJECTIVE

The purpose of this study was to determine the biological parameters best related to anthropometric markers of malnutrition in an elderly polypathological population, and determine cutoff values for these potential parameters to diagnose malnutrition.

DESIGN

This prospective study enrolled 116 elderly hospitalized patients and 76 elderly outpatients. Nutritional status (albumin, transthyretin, body mass index (BMI), skinfold thickness) and biological parameters (leptin, insulin-like growth factor-1 (IGF-1), IGF binding protein-1 (IGFBP-1), IGFBP-3, C-reactive protein (CRP), orosomucoid) were assessed. We defined malnutrition according to the lowest quartile of BMI and skinfold thickness measured in a large healthy elderly French sample population.

RESULTS

In this sample of elderly patients (age: 85+/-7 years old), leptin concentration was the only biological parameter significantly related to nutrition status. Independent correlations were found between leptin concentration and BMI, skinfold thickness and sex. The relationship between nutritional status and leptin concentration is significantly different in each sex: the more the patients are undernourished, the lower the leptin concentration in both sexes. The optimal leptin cutoff value for the diagnosis of malnutrition in this population was 4 microg/l in men (sensitivity 0.89, specificity 0.82) and 6.48 microg/l in women (sensitivity 0.90, specificity 0.83).

CONCLUSION

Leptin concentration is highly correlated with anthropometric data whereas albumin or transthyretin are known to be also influenced by morbidity and inflammatory conditions. Serum leptin concentration could be used for nutritional assessment in elderly patients with acute diseases.

Nutritional supplementation decreases hip fracture-related complications

Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively.

The chrondoprotective actions of a natural product are associated with the activation of IGF-1 production by human chondrocytes despite the presence of IL-1beta

BACKGROUND

Cartilage loss is a hallmark of arthritis and follows activation of catabolic processes concomitant with a disruption of anabolic pathways like insulin-like growth factor 1 (IGF-1). We hypothesized that two natural products of South American origin, would limit cartilage degradation by respectively suppressing catabolism and activating local IGF-1 anabolic pathways. One extract, derived from cat's claw (Uncaria guianensis, vincaria), is a well-described inhibitor of NF-kappaB. The other extract, derived from the vegetable Lepidium meyenii (RNI 249), possessed an uncertain mechanism of action but with defined ethnomedical applications for fertility and vitality.

METHODS

Human cartilage samples were procured from surgical specimens with consent, and were evaluated either as explants or as primary chondrocytes prepared after enzymatic digestion of cartilage matrix. Assessments included IGF-1 gene expression, IGF-1 production (ELISA), cartilage matrix degradation and nitric oxide (NO) production, under basal conditions and in the presence of IL-1beta.

RESULTS

RNI 249 enhanced basal IGF-1 mRNA levels in human chondrocytes by 2.7 fold, an effect that was further enhanced to 3.8 fold by co-administration with vincaria. Enhanced basal IGF-1 production by RNI 249 alone and together with vincaria, was confirmed in both explants and in primary chondrocytes (P < 0.05). As expected, IL-1beta exposure completely silenced IGF-1 production by chondrocytes. However, in the presence of IL-1beta both RNI 249 and vincaria protected IGF-1 production in an additive manner (P < 0.01) with the combination restoring chondrocyte IGF-1 production to normal levels. Cartilage NO production was dramatically enhanced by IL-1beta. Both vincaria and RNI 249 partially attenuated NO production in an additive manner (p < 0.05). IL-1beta - induced degradation of cartilage matrix was quantified as glycosaminoglycan release. Individually RNI 249 or vincaria, prevented this catabolic action of IL-1beta.

CONCLUSION

The identification of agents that activate the autocrine production of IGF-1 in cartilage, even in the face of suppressive pro-inflammatory, catabolic cytokines like IL-1beta, represents a novel therapeutic approach to cartilage biology. Chondroprotection associated with prevention of the catabolic events and the potential for sustained anabolic activity with this natural product suggests that it holds significant promise in the treatment of debilitating joint diseases.

Acute cognitive dysfunction after hip fracture: frequency and risk factors in an optimized, multimodal, rehabilitation program

BACKGROUND

Patients undergoing hip fracture surgery often experience acute post-operative cognitive dysfunction (APOCD). The pathogenesis of APOCD is probably multifactorial, and no single intervention has been successful in its prevention. No studies have investigated the incidence of APOCD after hip fracture surgery in an optimized, multimodal, peri-operative rehabilitation regimen.

METHODS

One hundred unselected hip fracture patients treated in a well-defined, optimized, multimodal, peri-operative rehabilitation regimen were included. Patients were tested upon admission and on the second, fourth and seventh post-operative days with the Mini Mental State Examination (MMSE) score.

RESULTS

Thirty-two per cent of patients developed a significant post-operative cognitive decline, which was associated with several pre-fracture patient characteristics, including age and cognitive function, but also the number of peri-operative transfusions. The development of APOCD was also associated with impaired post-operative rehabilitation and an increased length of stay. APOCD was associated with the development of a major medical complication in 35% of all patients. In 65% of patients developing APOCD without a concomitant medical complication, the only risk factors were cognitive level and regular anti-psychotic treatment.

CONCLUSION

On the basis of current evidence, APOCD is prevalent amongst hip fracture patients despite multimodal intervention; future research should therefore focus on defining subgroups of hip fracture patients amenable to specific prophylactic or interventional measures against APOCD.

Cachexia: pathophysiology and clinical relevance

Cachexia causes weight loss and increased mortality. It affects more than 5 million persons in the United States. Other causes of weight loss include anorexia, sarcopenia, and dehydration. The pathophysiology of cachexia is reviewed in this article. The major cause appears to be cytokine excess. Other potential mediators include testosterone and insulin-like growth factor I deficiency, excess myostatin, and excess glucocorticoids. Numerous diseases can result in cachexia, each by a slightly different mechanism. Both nutritional support and orexigenic agents play a role in the management of cachexia.

Nutritional status, as determined by the Mini-Nutritional Assessment, and osteoporosis: a cross-sectional study of an elderly female population

OBJECTIVE

To investigate the relationship between osteoporosis and nutritional status as determined by the Mini-Nutritional Assessment (MNA).

DESIGN

A cross-sectional study.

SETTING

Stockholm, Sweden.

SUBJECTS

A total of 351 elderly free-living women (mean age 73+/-2.3 years).

METHODS

MNA (range 0-30 points; <17 indicates malnutrition, 17.5-23.5 risk of malnutrition and >or=24 well nourished), measurements of bone mineral density of the left hip and lumbar spine using Hologic QDR 4500, and of the heel using Calscan DEXA-T.

RESULTS

The median MNA score was 27 (range 12.5-30). One woman was classified as malnourished and 7.4% were at risk of malnutrition. Osteoporosis of the femoral neck was observed in 22% and a fracture after the age of 50 was reported by 31% of the participants. The following items in the MNA questionnaire exhibited an increased risk of having osteoporosis in the femoral neck and/or total hip: an MNA score of <27 (odds ratio (OR)=2.09; CI=1.14-3.83); a mid-arm circumference of less than 28 cm (OR=2.97; CI=1.29-6.81); and regular use of more than 3 drugs each day (OR=2.12; CI=1.00-4.50). A body weight of more than 70 kg exhibited a decreased risk of having osteoporosis (OR=0.31; CI=0.14-0.70).

CONCLUSIONS

In general, the nutritional status was good in this population of free-living elderly women. Nevertheless, half of the women who displayed an MNA score <27 points had a twofold increased risk of having osteoporosis.

SPONSORSHIP

Karolinska Institutet, Stockholm County Council.

Internal fixation versus hemiarthroplasty for displaced fractures of the femoral neck in elderly patients with severe cognitive impairment

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report). General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D(index) score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001). In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction.

Protein and energy supplementation in elderly people at risk from malnutrition

BACKGROUND

Evidence for the effectiveness of nutritional supplements containing protein and energy, which are often prescribed for older people, is limited. Furthermore malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition.

OBJECTIVES

This review examined the evidence from trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually in the form of commercial 'sip-feeds'.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. Date of most recent search: March 2004.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled trials of oral protein and energy supplementation in older people with the exception of groups recovering from cancer treatment or in critical care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary.

MAIN RESULTS

Forty-nine trials with 4790 randomised participants have been included in the review. Most included trials had poor study quality. The pooled weighted mean difference [WMD] for percentage weight change showed a benefit of supplementation of 2.3% (95% confidence interval (CI) 1.9 to 2.7) from 34 trials. There was a reduced mortality in the supplemented compared with control groups (relative risk (RR) 0.74, CI 0.59 to 0.92) from 32 trials. The risk of complications from 14 trials showed no significant difference (RR 0.95, 95% CI 0.81 to 1.11). Few trials were able to suggest any functional benefit from supplementation. The pooled weighted mean difference (WMD) for length of stay from 10 trials also showed no statistically significant effect (WMD -1.98 days, 95% CI -5.20 to 1.24).

AUTHORS' CONCLUSIONS

Supplementation produces a small but consistent weight gain in older people. There may also be a beneficial effect on mortality. However, there was no evidence of improvement in clinical outcome, functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.

Effects of protein-rich supplementation and nandrolone in lean elderly women with femoral neck fractures

AIM

To evaluate the effects of a protein-rich liquid supplementation, alone or in combination with the anabolic steroid nandrolone decanoate, on body composition, activities of daily living (ADL) status and the health-related quality of life (HRQoL) after a femoral neck fracture.

METHODS

Sixty women, aged 83 +/- 5 years (mean +/- SD), BMI < 24 kg/m2 (20.4 +/- 2 kg/m2 ) and capable of co-operating, with a femoral neck fracture treated with internal fixation, were randomised to open treatment during 6 months with a protein-rich liquid formula alone (PR, Fortimel, 200 ml/day, 20 g protein/day) or in combination with nandrolone decanoate (PR/N, Deca-Durabol 25 mg i.m./3 weeks) or to a control group (C). The patients were re-examined after 6 and 12 months regarding body weight (BW), lean body mass (LBM, DXA), ADL status according to Katz, HRQoL according to EQ 5-D and fracture healing.

RESULTS

LBM decreased in the C (-1.2 +/- 2 kg) and PR groups (-1.2 +/- 1 kg) but remained the same in the PR/N group (0.3 +/- 1 kg) (P < 0.05 between groups). ADL remained at a high level in the two intervention groups but declined significantly in the C group (P < 0.005 between groups). The decline in HRQoL was least pronounced in the PR/N group at 6 months (P < 0.05 between groups). Patients with fracture healing complications lost more BW (P < 0.05) and LBM (P < 0.01) than patients with uneventful fracture healing.

CONCLUSION

Protein-rich liquid supplementation in combination with nandrolone given for 6 months to lean elderly women after a femoral neck fracture may positively affect LBM, ADL and HRQoL.

Food habits and appetite of elderly women at the time of a femoral neck fracture and after nutritional and anabolic support

OBJECTIVE

To study appetite and food choices in lean elderly women at the time of a femoral neck fracture and after 6 months of nutritional and anabolic intervention.

SUBJECTS AND METHODS

Forty-five nondemented women >70 years of age (mean +/- SD: 83 +/- 5 years) with a recent hip fracture and body mass index <24 kg/m2 (mean: 20.5 +/- 2.3) were interviewed about their appetite and dietary habits prior to fracture. The patients were randomized to treatment with a protein-rich liquid supplement (PR; 200 kcal and 20 g protein day(-1)) alone or in combination with nandrolone decanoate injections (PR/N) 25 mg i.m. every third week or to a control group (C). A second interview was conducted 6 months later.

RESULTS

Reduced appetite before the fracture was reported by 60%. Half of the patients did not have dessert with any of their daily meals, one-third used low-fat margarines and one-third drank water with their meals. The estimated mean daily energy intake was 6.4 +/- 1.2 MJ (1541 +/- 304 kcal) indicating that three of four subjects did not meet their energy needs. At 6 months, 40% reported reduced appetite. There was no difference in the change of appetite between the three randomized groups. Still, half of the subjects appeared to not meet their energy needs. Protein intake increased in the PR and PR/N groups, in contrast to the controls (P = 0.002).

CONCLUSION

Reduced appetite and insufficient energy intake was recorded in lean elderly women with a femoral neck fracture. Nutritional supplementation alone or in combination with an anabolic steroid increased protein intake without adversely affecting appetite.