Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Better nutrition trajectory improves recovery following a hip fracture surgery for older persons with diabetes mellitus

BACKGROUND

Influences of nutritional status on hip fractured persons with diabetes mellitus (DM) following surgery have not been reported.

AIMS

To explore the trajectory groups of nutritional status and their influences on post-operative recovery for older persons with hip fracture and DM.

METHODS

A total of 169 patients with DM and hip fracture from a clinical trial were included in this analysis. Mini Nutritional Assessment was used to assess the nutritional status of the participants. Outcome variables included self-care ability, muscle strength, depressive symptoms, health related quality of life, and cognitive function, which were collected before discharge and 1-, 3-, 6-, 12-, 18-, and 24-months following hospital discharge.

RESULTS

Among hip fractured older persons with DM, within two years following surgery there were three nutritional trajectory groups: malnourished (28.3%), at-risk of malnutrition (41.9%) and well-nourished (29.8%). A decline in nutritional status, especially for the malnourished group, was seen in the second year. A better nutritional trajectory was associated with better recovery outcomes, including self-care ability, health related quality of life, cognitive function and less depressive symptoms.

DISCUSSION

Close to 30% of hip fractured persons with DM were considered to have a malnourished trajectory over 2 years following surgery. A poor nutritional trajectory was associated with poor mental health and physical recovery.

CONCLUSIONS

Continuous nutrition assessment during the first 2 years following hip fracture surgery for older persons with DM is important. Development and implementation of interventions targeting the malnourished trajectory group are suggested.

Impact of malnutrition in surgically repaired hip fracture patients admitted for rehabilitation in a community hospital: A cohort prospective study

BACKGROUND

Malnutrition is common and associated with adverse outcomes in geriatric patients with hip fractures. The study aims to evaluate the relationship between the nutritional status and rehabilitation efficiency and functional outcome on discharge in postoperative hip fracture patients.

METHODS

We prospectively evaluated 172 postoperative hip fracture patients who were admitted to the community hospital from November 2019 to November 2020. Nutritional status was assessed by the 7-point Subjective Global Assessment (SGA) within 48 h of admission. Patients were assessed for rehabilitation efficiency and functional outcome at the end of their inpatient stay.

RESULTS

There were 172 patients recruited with 100 (58.1%) malnourished and 72 (41.9%) well-nourished patients. Patients in the malnourished group were significantly older, needed walking aid assistance prior to sustaining hip fracture, cognitively impaired and had more comorbidities. Malnourished patients had lower rehabilitation efficiency scores (0.27, 95% CI -0.12 - 0.67 vs 1.32, 95% CI 0.88-1.76) and poorer functional outcomes on discharge (OR 21.5, 95% CI 2.45-188.7, p-value <0.001), after adjustment for pre- and post-fracture confounders.

CONCLUSION

Malnutrition was present in more than half the postoperative hip fracture patients admitted to a community hospital in Singapore. This study showed that poor nutritional status is associated with significantly lower rehabilitation efficiency and functional outcome on discharge in hip fracture patients. Given the medical, social and economic stakes relating to hip fractures, it is essential to recognise and treat malnutrition in the hospital and community.

Impact of Rehabilitation Dose on Nutritional Status at Discharge from a Convalescent Rehabilitation Ward in Malnourished Patients with Hip Fracture

The object of this study is to determine the impact of the rehabilitation dose on the nutritional status at discharge from a convalescent rehabilitation ward in malnourished patients with hip fracture. This retrospective case-control study involved malnourished patients with hip fracture aged 65 years or older who had been admitted to a convalescent rehabilitation ward and whose data were registered in the Japan Rehabilitation Nutrition Database. The primary outcome was nutritional status at discharge. Patients were classified according to whether nutritional status was improved or not at discharge, according to the Mini Nutritional Assessment-Short Form^® (MNA-SF) score. The association between improved nutritional status and rehabilitation dose was assessed by a logistic regression analysis. Data were available for 145 patients (27 men, 118 women; mean age 85.1 ± 7.9 years). Daily rehabilitation dose was 109.5 (median 94.6–116.2) min and the MNA-SF score at admission was 5 (median 4–6). Nutritional status was improved in 97 patients and not improved in 48. Logistic regression analysis showed the following factors to be independently associated with nutritional status at discharge: Functional Independence Measure score (OR 1.042, 95% CI 1.016–1.068), energy intake (OR 1.002 CI 1.000–1.004), daily rehabilitation dose (OR 1.023, 95% CI 1.002–1.045), and length of hospital stay (OR 1.026, 95% CI 1.003–1.049). The daily rehabilitation dose in malnourished patients with hip fracture may positively impact nutritional status at discharge.

Clinical Practice Guideline for Postoperative Rehabilitation in Older Patients With Hip Fractures

OBJECTIVE

The incidence of hip fractures is increasing worldwide with the aging population, causing a challenge to healthcare systems due to the associated morbidities and high risk of mortality. After hip fractures in frail geriatric patients, existing comorbidities worsen and new complications are prone to occur. Comprehensive rehabilitation is essential for promoting physical function recovery and minimizing complications, which can be achieved through a multidisciplinary approach. Recommendations are required to assist healthcare providers in making decisions on rehabilitation post-surgery. Clinical practice guidelines regarding rehabilitation (physical and occupational therapies) and management of comorbidities/complications in the postoperative phase of hip fractures have not been developed. This guideline aimed to provide evidence-based recommendations for various treatment items required for proper recovery after hip fracture surgeries.

METHODS

Reflecting the complex perspectives associated with rehabilitation post-hip surgeries, 15 key questions (KQs) reflecting the complex perspectives associated with post-hip surgery rehabilitation were categorized into four areas: multidisciplinary, rehabilitation, community-care, and comorbidities/complications. Relevant literature from four databases (PubMed, EMBASE, Cochrane Library, and KoreaMed) was searched for articles published up to February 2020. The evidence level and recommended grade were determined according to the grade of recommendation assessment, development, and evaluation method.

RESULTS

A multidisciplinary approach, progressive resistance exercises, and balance training are strongly recommended. Early ambulation, weigh-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested. This multidisciplinary approach reduced the total healthcare cost.

CONCLUSION

This guideline presents comprehensive recommendations for the rehabilitation of adult patients after hip fracture surgery.

A Phase I Randomized Clinical Trial of Evidence-Based, Pragmatic Interventions to Improve Functional Recovery After Hospitalization in Geriatric Patients

BACKGROUND

Physical function declines during hospitalization in geriatric patients, increasing the risk of loss of independence. There is a need for evidence-based, pragmatic interventions to improve functional recovery of older adults following acute hospitalization. Here, we report the results of a Phase I randomized clinical trial designed to determine safety and effect size of protein supplementation, exercise, and testosterone interventions on 30-day post-discharge functional recovery and readmissions in geriatric patients.

METHODS

A total of 100 patients admitted to the University of Texas Medical Branch hospital for an acute medical illness were randomized to one of five intervention groups: isocaloric placebo, whey protein supplement, in-home rehabilitation + placebo, in-home rehabilitation + whey protein, or testosterone. Primary outcome measure was the change from baseline in short physical performance battery score at 1 and 4 weeks post-discharge. Secondary outcomes were changes in body composition, activities of daily living, and 30-day readmissions. Comparisons were made across study groups and between placebo and all active intervention groups.

RESULTS

Four weeks post-discharge, the short physical performance battery total score and balance score increased more in active intervention groups than placebo group (p < .05). There were no significant differences in change in body composition or activities of daily living across groups or between active intervention groups and placebo group. Readmission rates were highest in placebo (28%), followed by rehabilitation + placebo (15%), whey protein (12%), rehabilitation + whey protein (11%), and testosterone (5%). There was a trend for lower readmission rates in all active intervention groups (11%) versus placebo group (28%).

CONCLUSIONS

Findings from this Phase I clinical trial suggest that pragmatic, evidence-based interventions may accelerate recovery from acute hospitalization in geriatric patients. These data provide essential information to design larger randomized controlled trials to test the effectiveness of these interventions.

Weight changes and mobility in the early phase after hip fracture in community-dwelling older persons

Aim

To investigate body weight changes and their effect on mobility during the first two months following a hip fracture.

Findings

The loss of body weight was observed in three out of four patients in the early phase after hip fracture and was associated with decreased mobility measured by the NMS.

Message

Bodyweight loss is common and may further reduce mobility in hip fracture patients, but these findings need more research.

Purpose

Hip fractures in older persons are associated with reduced mobility and loss of independence. Few studies address the nutritional status and mobility in the early phase after hip fracture. The objective of the present study was, therefore, to investigate weight changes and their effect on mobility during the first two months following hip fracture in community-dwelling older persons without dementia.

Methods

Patients (> 60 years) admitted for a first hip fracture were recruited from two tertiary referral hospitals in Bergen, Norway. The patients' weights and dietary intakes were determined in the hospital and at home after two months. Mobility was assessed based on the New Mobility Score (NMS) (scale 0–9, with values > 5 regarded as sufficient mobility).

Results

We included 64 patients (median age 80 years, 48 women, 16 men) with information on weight collected in the hospital. Follow-up measurements were available for 32 patients, corresponding to an attrition rate of 50%. The patients had a median weight loss of 1.8 kg (IQR = − 3.7, 0 kg). Most of them had reduced mobility at two months after the surgery [median NMS = 5 (IQR = 3–6)]. Both age and the weight change after surgery were predictors of the NMS at follow-up.

Conclusion

Bodyweight loss was observed in three out of four patients in the early phase after hip fracture and was associated with decreased mobility measured by the NMS. The results should be interpreted with caution as half of the patients dropped out of the study and did not participate in the follow-up visit.

Perioperative nutritional supplementation and skeletal muscle mass in older hip-fracture patients

Older people with hip fractures are often malnourished at the time of fracture, which can have substantial influence on mortality and clinical outcomes, as well as functional outcome and quality of life. A close relationship between protein intake and muscle maintenance has been demonstrated. Skeletal muscle weakness is an independent risk factor for falls and fall-related injuries in the elderly and is an independent marker of prognosis. However, the effect of perioperative nutritional interventions on outcomes in elderly hip-fracture patients remains controversial. In this narrative review, an overview is presented of the existing literature on nutritional status and sarcopenia in elderly hip-fracture patients, clinical outcomes, and the effects of nutritional intervention on outcome and rehabilitation in this patient group.

Nutritional status and functionality in geriatric rehabilitation patients: a systematic review and meta-analysis

PURPOSE

Since there is only limited evidence available for geriatric rehabilitation patients, this systematic review and meta-analysis aims to characterize the nutritional status in this population and its relationship with functionality.

METHODS

Eight databases were searched for full-text articles reporting baseline nutritional intake and status of adults ≥ 60 years in rehabilitation settings. Pooled estimates were calculated for prevalence of malnutrition and risk of malnutrition based on the Mini Nutritional Assessment (MNA) and for mean body mass index (BMI). Associations between nutritional status (MNA, MNA short form and BMI) and functional status (Barthel Index and Functional Independence Measure) and prevalence of sarcopenia were reviewed.

RESULTS

62 out of 1717 references were eligible for inclusion. Pooled prevalence [95% confidence interval (CI)] of malnutrition and risk of malnutrition were 13 (5-20) % and 47 (40-54) %. Pooled estimate (95% CI) for BMI was 23.8 (23.2-24.5) kg/m². Existing data suggest a risk for low protein and energy intake and vitamin D deficiency. Functional status differed widely. Seven out of ten studies reported significant associations between reduced nutritional status and reduced functionality, whilst two out of seven studies reported significant associations between higher BMI and functionality. Prevalence of sarcopenia was high with 40-76% in this population.

CONCLUSIONS

Although geriatric rehabilitation populations and settings were heterogeneous, a relevant percentage of geriatric rehabilitation patients were affected by a reduced nutritional status. Nutritional status was associated with decreased functionality. This emphasizes the need for screening for malnutrition and targeted nutritional intervention.

Pilot study on a new intervention programme for geriatric hip fracture patient with sarcopenia

Introduction:

Sarcopenia and osteoporosis increase the risk of fall, resulting in fragility fracture. Intervention programme on sarcopenic hip fracture was set up in our centre.

Method:

All patients aged ≥65 admitted to Caritas Medical Centre with operatively treated hip fracture and diagnosed with sarcopenia were included. Interventions include inpatient nursing education, dietary advice, therapist assessment and structured 12-week Geriatric Day Hospital (GDH) exercise programme. Those who are not eligible for GDH training were classified as control group. Changes in relative skeletal muscle mass index (RASM), muscle strength and functional scores were measured.

Results:

There were 11 intervention and 13 control patients. Both groups of patients were noted to have improvement in RASM, knee extension power of lower limbs and functional scores. Between-group analysis showed there was more improvement in injured limb extension power in the intervention group, although it is statistically insignificant (control group: 3.585 kg, intervention group: 5.827 kg, p = 0.147). There was no statistically significant difference in the 3-month change in RASM (control group: 0.581 kg/m2, intervention group: 0.347 kg/m2, p = 0.369) and functional scores.

Conclusion:

These sarcopenic hip fracture patients may be too frail to benefit from traditional exercise treatment for sarcopenia. However, more improvement in muscle strength was observed in the intervention group although not statistically significant. Intervention programme with exercise prescription in sarcopenic hip fracture patients may have the potential to improve the lower limb muscle strength. A more intensive and longer exercise training programme with incorporation into day rehabilitation model may be needed for these frail hip fracture patients.

Patient and Perioperative Factors Influencing the Functional Outcomes and Mortality in Elderly Hip Fractures

This study aimed to evaluate the functional outcomes and mortality following hip fracture surgery in elderly patients, and to identify the associated risk factors. Between January 2016 and December 2017, 480 consecutive patients were finally included for data analyses. The Harris score and Barthel index were used to evaluate the hip function and ability to perform activities of daily living (ADL). Univariate and multivariate logistics regression analyses were performed to determine the independent risk factors for mortality, poor hip function or poor ability to perform ADL. The mortality rate was 15.6% (75/480). In the survivors, poor outcome developed in 133 (32.8%) patients and poor ADL was in 72 (17.8%) patients. The independent factors that influenced mortality were advanced age (p = 0.033), male gender (0.031), living in rural area (p < 0.001), self-reported diabetes (p = 0.005), tumor (p = 0.024), preoperative delay >7 days (p = 0.020), postoperative drainage use (p = 0.034), WBC > 10 × 10⁹/L (p = 0.005), reduced RBC (p = 0.011), PLT < 100 × 10⁹/L (p < 0.001), ALB < 35 g/L (p < 0.001) and CK > 200 U/L (p = 0.003). The independent factors that influenced the hip function were male gender (p = 0.009), WBC > 10 × 10⁹/L (p < 0.001), lower HBG (p = 0.005), and ALB < 35 g/L (p < 0.001). The independent factors that influenced the ability to perform ADL were diagnosis of trochanteric fracture (p = 0.048), preoperative delay > 7 days (p = 0.027), postoperative drainage use (p = 0.010), elevated WBC (p = 0.020), lower HGB (p < 0.001), PLT < 100 × 10⁹/L (p = 0.002), and ALB < 35 g/L (p < 0.001). Although most of risk factors were not modifiable, they aid in patient individual risk evaluation, risk stratification, and counseling patients or relatives.

Effectiveness of home based intervention program in reducing mortality of hip fracture patients: A non-randomized controlled trial

PURPOSE

The study was done to investigate whether a postoperative intervention program is effective in reducing mortality and improving mobility in two comparative hip fracture patients over one year postoperatively.

METHODS

A non-randomized controlled trial study with an intervention group of hip fracture patients and historical control group with 12 months follow up. One hundred twenty four admitted hip fracture patients to the Trauma Unit of Assiut University Hospitals, aged 50 years and older were included from 1st July to 31st December 2014. They were divided into 64 and 60 patients as intervention and control groups respectively. Weight, height and bone mineral density were measured and baseline characteristics were taken. The intervention was a postoperative care program in the form of education sessions with an explanatory leaflet on discharge for nutrition and physical exercise program at home. Follow up phone calls were done at 3 months, 6 months and one year postoperatively by one assessor. Physical mobility was assessed by 24 items Western Ontario And McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

Mortality was significantly higher in the control group, WOMAC score was significantly better among intervention group through follow up. By multivariate Cox survival analysis, advancing age, no intervention, osteoporosis, postoperative complications, chest infections and heart attacks were significant predictors for mortality.

CONCLUSION

A significant improvement in mobility and reduction of mortality was achieved by application of a postoperative care program that could be incorporated into the hip fracture patients' care pathway.

Nutritional Status and Osteoporotic Fracture Rehabilitation Outcomes in Older Adults

To determine the impact of nutritional status and risk factors for undernutrition based on the changes in functional outcomes and rehabilitation success, defined as the ability of older adults to return as close as possible to their original functional state. Retrospective cohort study among 107 rehabilitation patients, aged ≥65 y. Data included demographics, Functional Independence Measure (FIM), Short Nutritional Assessment Questionnaire (SNAQ), reported weight, Mini-Mental Status Examination (MMSE), and Cumulative Illness Rating-Scale for Geriatrics (CIRS-G). Rehabilitation success was determined by delta-FIM. Higher vs. lower functioning patients were younger, had shorter hospitalization, and lower CIRS-G score with higher mean MMSE. Delta-FIM was significantly higher in patients with low malnutrition risk (SNAQ): 14.2 ± 10.5 vs. 6.9 ± 13.9 in undernourished patients, those who did not lose weight 14.5 ± 10.5 vs. 5.6 ± 12.8 in patients who lost weight with normal dietary intake, normal albumin, and lower CIES-G. Patients who achieved functional independence, FIM_DC ≥90, ate normally and experienced less "appetite loss" [40.5% vs. 68.4%; P = 0.048]. Weight loss was the strongest negative predictor of delta-FIM (B = -9.094; P = 0.007). To conclude, nutritional status, mainly weight change, is an independent negative predictor for rehabilitation success.

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

BACKGROUND & AIMS

Hip fractures are strongly associated with mortality in the elderly. Studies investigating predisposing factors have suggested a negative impact of poor nutritional, cognitive and functional status on patient survival, however their independent prognostic impact as well as their interactions remain undefined. This study aimed to determine whether poor nutritional status independently predicts 1 year post-fracture mortality after adjusting for cognitive and functional status and for other clinically relevant covariates.

METHODS

1211 surgically treated hip fracture elderly (age ≥ 65) patients consecutively admitted to the Orthopaedic Surgery Unit of the "Azienda Sanitaria Universitaria Integrata Trieste" (ASUITs), Cattinara Hospital, Trieste, Italy and managed by a dedicated orthogeriatric team. Pre-admission nutritional status was evaluated by Mini Nutritional Assessment (MNA) questionnaire, cognitive status by Short Portable Mental Status Questionnaire (SPMSQ) and functional status by Activity of Daily Living (ADL) questionnaire. All other clinical data, including comorbidities, type of surgery, post-operative complications (delirium, deep vein thrombosis, cardiovascular complications, infections, need for blood transfusions) were obtained by hospital clinical records and by mortality registry.

RESULTS

Poor nutritional status (defined as MNA ≤23.5), increased cognitive and functional impairment were all associated with 3-, 6- and 12 month mortality (p < 0.001). Both cognitive and functional impairment were associated with poor nutritional status (p < 0.001). Logistic regression analysis demonstrated that the association between nutritional status and 3-, 6- and 12- month mortality was independent of age, gender, comorbidities, type of surgery and post-operative complications as well as of cognitive and functional impairment (p < 0.001). In contrast, the associations between mortality and cognitive and functional impairment were independent (p < 0.001) of demographic (age, gender) and clinical covariates but not of malnutrition. Kaplan-Meier analysis showed a lower mean survival time (p < 0.001) in patients with poor nutritional status compared with those well-nourished.

CONCLUSIONS

In hip fracture elderly patients, poor nutritional status strongly predicts 1 year mortality, independently of demographic, functional, cognitive and clinical risk factors. The negative prognostic impact of functional and cognitive impairment on mortality is mediated by their association with poor nutritional status.

Effects of Nutritional Status on 6-Month Outcome of Hip Fractures in Elderly Patients

Objective

To identify the prevalence of malnutrition in elderly hip fracture and to investigate the relationship between hip fracture patients and malnutrition on functional recovery and mortality.

Methods

All hip fracture patients age >65 years admitted to a rehabilitation unit were recruited from July 2015 to June 2016. Nutritional status was assessed by Mini-Nutritional Assessment Short-Form (MNA-SF) within 72 hours of admission. Patients were reassessed at 6 months for functional status and place of residence. Length of hospital stay, in-patient mortality rate, and 6-month mortality rate were also recorded.

Results

There were 218 patients recruited. The mean age was 83.5±7.5 years. According the MNA-SF, 46 (21.1%) were well nourished, 115 (52.6%) were at risk of malnutrition, and 57 (26.1%) were malnourished. Malnourished individuals were significantly older, had lower Mini-Mental State Examination score and albumin level, were functionally more dependent and were more likely to reside in elderly care facility. A higher proportion of elderly care residents were at-risk or were malnourished on admission, discharge and at 6 months. Functional recovery was slower in the malnourished group. In-patient mortality was higher in malnourished individuals compared to those at risk of malnourishment and well-nourished individuals.

Conclusion

The prevalence of malnutrition is high and is associated with poor functional recovery and elderly care placement. Residents of elderly care facilities are especially at risk due a higher prevalence of malnourishment. Health authorities are encouraged to evaluate the dietetic component in elderly care facilities and initiate nutrition supplementation in their planning of healthcare resources.

The relationship between protein quantity, BMD and fractures in older adults

BACKGROUND

Previously, no large-scale literature reviews have focussed on the relationship between dietary protein and its impact on bone mineral density (BMD) and fracture risk-as measures of bone health-in older adults and its potential impact as a primary prevention tool.

AIMS

The aim of this study was to assess the impact of varying dietary protein levels on bone health.

METHODS

A literature review of trials concerning older adults' (>50 years of age) and animals' varying protein intake in the diet and its effect on BMD (human and animal) and fracture risk (human only) was carried out. Additionally, a review of dietary assessment tools used in these studies was also analysed.

RESULTS

Ten out of fourteen trials assessing BMD and dietary protein quantity in humans and 3/4 in animal trials found a positive relationship between these two parameters. Four out of seven trials investigating the relationship between dietary protein quantity and fracture risk displayed a positive, protective effect of dietary protein levels on fracture risk. Sixty-two percent of studies used the Food-Frequency Questionnaire assessment method.

DISCUSSION

Increased protein intake in the diet is beneficial to bone health and reduces morbidity and mortality. The importance of using dietary protein, along with calcium and vitamin D, as a primary preventative strategy should be stressed, given the health and cost benefits that this would deliver, with a possible need for a higher level of protein in the diet of an elderly person than what is currently recommended.

Trajectories of Nutritional Status and Cognitive Impairment among Older Taiwanese with Hip Fracture

OBJECTIVE

This paper describes the trajectories of nutritional status and cognitive impairment and their correlation among older Taiwanese over 1 year after hip-fracture surgery.

DESIGN

Secondary analysis of data from a clinical trial evaluating the effects of three types of post-discharge care for 292 older hip-fracture patients (age >60 years).

MEASUREMENTS

Nutritional status was assessed by the Mini Nutritional Assessment before and 1, 3, 6, 12 months after hospital discharge. Cognitive function was measured by the Mini-Mental State Examination before surgery, at hospital discharge, 6 and 12 months after discharge. Trajectories of nutritional status and cognitive impairment were depicted by latent class growth modeling, whereas linkages between nutritional-status and cognitive-impairment trajectories were assessed by multinomial logistic regression.

RESULTS

Nutritional status in general improved significantly, particularly during the first 3 months after discharge. We identified three trajectories of nutritional status: malnourished (15.4%), at risk for malnutrition (38.9%), and well-nourished (45.7%). In contrast, cognitive changes followed four largely linear but distinct trajectories: moderately impaired (12.2%), mildly impaired (27.8%), borderline impaired (21.8%), and cognitively intact (38.2%). Trajectories of nutritional status were significantly associated with cognitive-function trajectories. For instance, relative to malnourished patients, well-nourished patients were 95% less likely (OR=0.05, CI =0.01-0.24) to be moderately cognitively impaired.

CONCLUSION

A good nutritional-status trajectory after hip fracture was associated with better cognitive function. To treat and care for elderly hip-fractured patients, specific interventions need to target those who are malnourished or at risk of malnutrition to decrease their risk for cognitive impairment.

Identifying effective and feasible interventions to accelerate functional recovery from hospitalization in older adults: A randomized controlled pilot trial

Hospitalization induces functional decline in older adults. Many geriatric patients fail to fully recover physical function after hospitalization, which increases the risk of frailty, disability, dependence, re-hospitalization, and mortality. There is a lack of evidence-based therapies that can be implemented following hospitalization to accelerate functional improvements. The aims of this Phase I clinical trial are to determine 1) the effect size and variability of targeted interventions in accelerating functional recovery from hospitalization and 2) the feasibility of implementing such interventions in community-dwelling older adults. Older patients (≥65years, n=100) will be recruited from a single site during hospitalization for an acute medical condition. Subjects will be randomized to one of five interventions initiated immediately upon discharge: 1. protein supplementation, 2. in-home rehabilitation plus placebo supplementation, 3. in-home rehabilitation plus protein supplementation, 4. single testosterone injection, or 5. isocaloric placebo supplementation. Testing will occur during hospitalization (baseline) and at 1 and 4weeks post-discharge. Each testing session will include measures of muscle strength, physical function/performance, body composition, and psychological function. Physical activity levels will be continuously monitored throughout study participation. Feasibility will be determined through collection of the number of eligible, contacted, and enrolled patients; intervention adherence and compliance; and reasons for declining enrollment and study withdrawal. This research will determine the feasibility of post-hospitalization strategies to improve physical function in older adults. These results will also provide a foundation for performing larger, multi-site clinical trials to improve physical function and reduce readmissions in geriatric patents.

Effects of protein-rich nutritional supplementation and bisphosphonates on body composition, handgrip strength and health-related quality of life after hip fracture: a 12-month randomized controlled study

BACKGROUND

The catabolic state that follows hip fracture contributes to loss of muscle mass and strength, that is sarcopenia, which impacts functional ability and health-related quality of life. Measures to prevent such long-term postoperative consequences are of important concern. The aim of this study was to evaluate the combined effects of protein-rich nutritional supplementation and bisphosphonate on body composition, handgrip strength and health-related quality of life following hip fracture.

METHODS

The study included 79 men and women with hip fracture, mean age 79 years (SD 9), without severe cognitive impairment, who were ambulatory and living independently before fracture. Patients were randomized postoperatively to receive liquid supplementation that provided 40 g of protein and 600 kcal daily for six months after the fracture, in addition to bisphosphonates once weekly for 12 months (group N, n = 26), or bisphosphonates alone once weekly for 12 months (group B, n = 28). All patients, including the controls (group C, n = 25) received calcium 1 g and vitamin D3 800 IU daily. Body composition as measured by dual-energy X-ray absorptiometry (DXA), handgrip strength (HGS) and health-related quality of life (HRQoL) were registered at baseline, six and 12 months postoperatively.

RESULTS

There were no differences among the groups regarding change in fat-free mass index (FFMI), HGS, or HRQoL during the study year. Intra-group analyses showed improvement of HGS between baseline and six months in the N group (P = 0.04). HRQoL decreased during the first year in the C and B groups (P = 0.03 and P = 0.01, respectively) but not in the nutritional supplementation N group (P = 0.22).

CONCLUSIONS

Protein-rich nutritional supplementation was unable to preserve FFMI more effectively than vitamin D and calcium alone, or combined with bisphosphonate, in this relatively healthy group of hip fracture patients. However, trends toward positive effects on both HGS and HRQoL were observed following nutritional supplementation.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01950169 (Date of registration 23 Sept 2013).

Low postoperative dietary intake is associated with worse functional course in geriatric patients up to 6 months after hip fracture

We examined the relationship between postoperative dietary intake (DI) of geriatric hip fracture (HF) patients and their functional and clinical course until 6 months after hospital discharge. In eighty-eight HF patients ≥ 75 years, postoperative DI was estimated with plate diagrams of main meals over four postoperative days. DI was stratified as >50, >25–50, ≤ 25 % of meals served. Functional status according to Barthel index (activities of daily living) and patients' mobility level before fracture, postoperatively, at discharge and 6 months later were assessed and related to DI levels. In-hospital complications were recorded according to clinical diagnosis. Associations were evaluated using χ2and Kruskal–Wallis tests, and repeated-measures ANOVA and ANCOVA. Postoperatively, 28 % of participants ate >50 %, 43 % ate >25–50 % and 28 % ≤ 25 % of meals served. Irrespective of pre-fracture functional status, patients with DI ≤ 25 % had significantly lower Barthel index scores at all times after surgery (allP< 0·05) and ANOVA revealed a significant time × DI interaction effect (P= 0·047) on development of Barthel index scores that remained significant after adjustment for potential confounders. Patients with DI >50 % more often had regained their pre-fracture mobility level than those with DI ≤ 25 % at discharge (>50 %: 36 %; >25–50 %: 10 %; ≤ 25 %: 0 %;P= 0·001) and 6 months after discharge (88; 87; 68 %;P= 0·087) and had significantly less complications (median 2 (25th–75th percentile 1–3); 3 (25th–75th percentile 2–4); 3 (25th–75th percentile 3–4);P= 0·012). To conclude, geriatric HF patients had very low postoperative voluntary DI and thus need specific nutritional interventions to achieve adequate DI to support functional and clinical recovery.

Prevalence of protein-energy malnutrition in hospital patients over 75 years of age admitted for hip fracture

INTRODUCTION

One percent of falls in over-75 years old cause hip fracture (HF). Protein-energy malnutrition (PEM) is associated with falls and fracture. PEM screening and perioperative nutritional management are recommended by the European Society of Parenteral and Enteral Nutrition, yet data on nutritional status in elderly HF patients are sparse. The Mini Nutritional Assessment (MNA) score is presently the most effective screening tool for PEM in over-75 years old.

OBJECTIVE

The principal objective of the present study was to determine the prevalence on MNA of PEM in patients aged over 75 years admitted for HF. Secondary objectives were to identify factors associated with PEM and its role as a factor of evolution.

MATERIALS AND METHODS

A prospective observational epidemiological study included 50 patients aged over 75 years admitted for HF in an 8-bed orthopedic surgery department with a geriatric follow-up unit. PEM was defined by MNA<17/30. Assessment systematically comprised associated comorbidity (Cumulative Illness Rating Scale-Geriatric [CIRS-G]), cognitive status on the Mini Mental State Examination (MMSE), functional status on activities of daily life (ADL), and mean hospital stay (MHS). Scores were compared on quantitative tests (Student t) with the significance threshold set at P<0.05.

RESULTS

Mean age for the 50 patients was 86.1 years (range, 77-94 years). Prevalence of PEM was 28%; a further 58% of patients were at risk for PEM. PEM was associated with elevated CIRS-G (P<0.006), greater numbers of severe comorbidities (P=0.006), more severe cognitive disorder (P=0.005) and functional dependence (P=0.002), and 8 days' longer MHS (P=0.012).

DISCUSSION

The present study confirmed the high prevalence of PEM in HF patients aged over 75 years, supporting longer hospital stay. MNA is a diagnostic gold standard, not to be replaced by albuminemia or body-mass index in this perioperative clinical situation. Given the present economic stakes relating to geriatric trauma patients' hospital stay, it is essential to prevent, diagnose and treat PEM in elderly subjects.

LEVEL OF EVIDENCE

Level IV; prospective cohort study.

Tight calorie control in geriatric patients following hip fracture decreases complications: a randomized, controlled study

BACKGROUND & AIMS

Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known.

METHODS

A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure.

RESULTS

50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049).

CONCLUSION

We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

Cost-effectiveness of nutritional intervention in elderly subjects after hip fracture. A randomized controlled trial

Hip fracture patients can benefit from nutritional supplementation during their recovery. Up to now, cost-effectiveness evaluation of nutritional intervention in these patients has not been performed. Costs of nutritional intervention are relatively low as compared with medical costs. Cost-effectiveness evaluation shows that nutritional intervention is likely to be cost-effective.

INTRODUCTION

Previous research on the effect of nutritional intervention on clinical outcome in hip fracture patients yielded contradictory results. Cost-effectiveness of nutritional intervention in these patients remains unknown. The aim of this study was to evaluate cost-effectiveness of nutritional intervention in elderly subjects after hip fracture from a societal perspective.

METHODS

Open-label, multi-centre randomized controlled trial investigating cost-effectiveness of intensive nutritional intervention comprising regular dietetic counseling and oral nutritional supplementation for 3 months postoperatively. Patients allocated to the control group received care as usual. Costs, weight and quality of life were measured at baseline and at 3 and 6 months postoperatively. Incremental cost-effectiveness ratios (ICERs) were calculated for weight at 3 months and quality adjusted life years (QALYs) at 6 months postoperatively.

RESULTS

Of 152 patients enrolled, 73 were randomized to the intervention group and 79 to the control group. Mean costs of the nutritional intervention was 613 Euro. Total costs and subcategories of costs were not significantly different between both groups. Based on bootstrapping of ICERs, the nutritional intervention was likely to be cost-effective for weight as outcome over the 3-month intervention period, regardless of nutritional status at baseline. With QALYs as outcome, the probability for the nutritional intervention being cost-effective was relatively low, except in subjects aged below 75 years.

CONCLUSION

Intensive nutritional intervention in elderly hip fracture patients is likely to be cost-effective for weight but not for QALYs. Future cost-effectiveness studies should incorporate outcome measures appropriate for elderly patients, such as functional limitations and other relevant outcome parameters for elderly.

[Comparative study of dietary intake and nutritional status in elderly women with and without hip fracture]

AIM

To compare the nutritional status and dietary intake of elderly women admitted with hip fracture (HF) versus a control group without fracture and without known abnormalities of bone mineral density.

DESIGN

Descriptive and observational study.

LOCATION

Hospital Neurotraumatológico in Jaen (Spain) and three urban Primary Health Care centers in Jaen city (San Felipe, Virgen de la Capilla and El Valle).

PARTICIPANTS

A total of 44 women with HF, which was considered osteoporotic, and a control group composed of 42 women with a similar age range, selected randomly from the medical outpatients who visit their Primary Health Care centers.

MEASUREMENTS

We record sociodemographic data. Dietary intake before the fracture and anthropometric variables in the first 72hours after admission were assessed.

RESULTS

Patients with HF had lower weight (67.2±10.1kg versus 72.0±10.1kg, P<.05), BMI (27.6±3.7kg/m(2) versus 31.3±4.6kg/m(2), P<.001), as well as lower arm and leg circumferences than the control patients. A significantly higher intake, in terms of macronutrients and energy consumption, was detected in the control group, as well as lower than recommended intake of calcium and vitamin D in both groups, which was more marked in patients with HF. Logistic regression found that the HF was associated with a lower BMI as well as lower intakes of protein, carbohydrates and calcium.

CONCLUSIONS

Adequate nutritional status and adequate intake of essential macro- and micronutrients seem to prevent osteoporotic HF.

Efficacy and cost-effectiveness of nutritional intervention in elderly after hip fracture: design of a randomized controlled trial

Background

Hip fracture patients often have an impaired nutritional status at the time of fracture, which can result in a higher complication rate, prolonged rehabilitation time and increased mortality. A study was designed to evaluate the effect of nutritional intervention on nutritional status, functional status, total length of stay, postoperative complications and cost-effectiveness.

Methods

Open-labelled, multi-centre, randomized controlled trial in hip fracture patients aged 55 years and above. The intervention group receives dietetic counselling (by regular home visits and telephone calls) and oral nutritional supplementation for three months after surgery. The control group receives usual dietetic care as provided by the hospital. Outcome assessment is performed at three and six months after hip fracture.

Discussion

Patient recruitment has started in July 2007 and has ended in December 2009. First results are expected in 2011.

Trial registration

ClinicalTrials.gov NCT00523575

[Acute orthogeriatric care (II). Clinical aspects]

The present article reviews the clinical principles of acute orthogeriatric care. The application of geriatric medicine to patients with hip fracture is explained. The principal stages of geriatric intervention in this process are mentioned, as are the interventions to be carried out by the geriatric team. Subsequently, we discuss the management of several frequent problems in these patients, such as high surgical risk, pain management, anaemia, delirium, malnutrition, and discharge planning. Lastly, the characteristics of several kinds of patients with special characteristics are mentioned, such as those diagnosed with dementia, nursing home residents or the oldest-old. Areas of improvement in the acute phase are also reviewed, such as mortality reduction, functional outcome improvement and the need for more efficient resource use in patients in the acute phase of hip fracture.

Individual nutrition therapy and exercise regime: a controlled trial of injured, vulnerable elderly (INTERACTIVE trial)

Background

Proximal femoral fractures are amongst the most devastating consequences of osteoporosis and injurious accidental falls with 25–35% of patients dying in the first year post-fracture. Effective rehabilitation strategies are evolving however, despite established associations between nutrition, mobility, strength and strength-related functional outcomes; there has been only one small study with older adults immediately following fragility fracture where a combination of both exercise and nutrition have been provided. The aim of the INTERACTIVE trial is to establish whether a six month, individualised exercise and nutrition program commencing within fourteen days of surgery for proximal femur fracture, results in clinically and statistically significant improvements in physical function, body composition and quality of life at an acceptable level of cost and resource use and without increasing the burden of caregivers.

Methods and Design

This randomised controlled trial will be performed across two sites, a 500 bed acute hospital in Adelaide, South Australia and a 250 bed acute hospital in Sydney, New South Wales. Four hundred and sixty community-dwelling older adults aged > 70 will be recruited after suffering a proximal femoral fracture and followed into the community over a 12-month period. Participants allocated to the intervention group will receive a six month individualised care plan combining resistance training and nutrition therapy commencing within 14 days post-surgery. Outcomes will be assessed by an individual masked to treatment allocation at six and 12 months. To determine differences between the groups at the primary end-point (six months), ANCOVA or logistic regression will be used with models adjusted according to potential confounders.

Discussion

The INTERACTIVE trial is among the first to combine nutrition and exercise therapy as an early intervention to address the serious consequence of rapid deconditioning and weight loss and subsequent ability to regain pre-morbid function in older patients post proximal femoral fracture. The results of this trial will guide the development of more effective rehabilitation programs, which may ultimately lead to reduced health care costs, and improvements in mobility, independence and quality of life for proximal femoral fracture sufferers.

Trial registration

Australian Clinical Trials Registry: ACTRN12607000017426.

Preoperative assessment of elderly cancer patients

The incidence of most types of cancers is age-dependent and progressive ageing is rapidly increasing the number of elderly people who need treatment for cancer. It is an ethical dilemma how aggressive one should be when it comes to treating cancer in the older population. Presumed fear of increased postoperative morbidity and mortality often results in delivery of sub-optimal cancer surgery. A careful evaluation of the general and organ-related conditions of the patients is absolutely necessary for planning the right treatment. Nevertheless, preoperative removal of risk factors and postoperative rehabilitation are as important as the use of the best techniques of anaesthesia and surgery to achieve good postoperative outcomes in these patients. In this review article we take into consideration physiology of the aged and tools available to assess surgical risks in elderly patients, in the aim of increasing awareness on optimising surgical management of elderly patients with cancer. MEDLINE and EMBASE.com (search terms: "elderly", "preoperative", "surgery"), bibliographies of articles retrieved and the authors' reference files have been used as data sources. Independent extraction has been performed by the authors using predefined criteria, including study quality indicators.

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.

Metabolism and catabolism in hip fracture patients: nutritional and anabolic intervention--a review

Patients suffering from hip fracture are known to be at risk of catabolism and protein-energy malnutrition. In this review we discuss the pathogenesis of hip fracture-related catabolism per- and postoperatively. We also describe the consequences of malnutrition after a hip fracture and summarize studies that have evaluated the effect of nutritional or anabolic treatment of these patients. There has been relatively little published on the effects of nutritional and anabolic pharmacological interventions for improvement of nutritional status and on the role of nutritional status in clinical outcomes. Even so, there have been 19 randomized studies in this field. 12 studies evaluated nutritional supplementation or protein supplementation. 6 found improved clinical outcome with fewer complications, faster recovery and shorter length of hospital stay, whereas the others reported no difference in clinical outcome. For pharmacological interventions, the outcomes have been even less clear. Supplementation studies in general appear to be underpowered or suffer logistic problems. Studies of higher scientific quality are needed, and enteral feeding, anabolic treatment and multimodal approaches need to be evaluated in greater depth.

Nutritional supplementation and resistance training in nutritionally at risk older adults following lower limb fracture: a randomized controlled trial

OBJECTIVE

To describe the independent and combined effects of oral nutrition supplementation and resistance training on health outcomes in nutritionally at risk older adults following lower limb fracture.

DESIGN

Randomized controlled trial with 12-week masked outcome assessment.

SETTING

Teaching hospital.

PARTICIPANTS

One hundred nutritionally at risk older adults hospitalized following a fall-related lower limb fracture.

INTERVENTION

Commenced seven days after injury. Consisted of daily multinutrient energy-dense oral supplement (6.3 kJ/mL) individually prescribed for six weeks (n = 25), tri-weekly resistance training for 12 weeks (n = 25), combined treatment (n = 24) or attention control plus usual care and general nutrition and exercise advice (n = 26).

MEASUREMENTS

Weight change, quadriceps strength, gait speed, quality of life and health care utilization at completion of the 12-week intervention.

RESULTS

At 12 weeks, all groups lost weight: nutrition -6.2% (-8.4, -4.0); resistance training -6.3% (-8.3, -4.3); nutrition and resistance training -4.7% (-7.4, -2.0); attention control -5.2% (-9.0, -1.5). Those receiving resistance training alone lost more weight than those receiving the combined treatment (P= 0.029). Significant weight loss was prevented if supplement was consumed for at least 35 days. Groups were no different at 12 weeks for any other outcome.

CONCLUSION

Frail, undernourished older adults with a fall-related lower limb fracture experience clinically significant weight loss that is unable to be reversed with oral nutritional supplements. Those receiving a programme of resistance training without concurrent nutrition support are at increased risk of weight loss compared with those who receive a combined nutrition and resistance training intervention. In this high-risk patient group it is possible to prevent further decline in nutritional status using oral nutritional supplements if strategies are implemented to ensure prescription is adequate to meet energy requirements and levels of adherence are high.

A personalized snack-based intervention for hip fracture patients: development, feasibility and acceptability

INTRODUCTION

Undernutrition is common in older people admitted to hospital with hip fracture. Oral supplementation with sip feeds may be provided but compliance is a major problem.

OBJECTIVE

To develop a personalized snack-based intervention for practical implementation in hip fracture patients and to assess feasibility, adherence, acceptability and cost.

PARTICIPANTS AND METHODS

Twenty-three older hip fracture patients with a mean age (SD) 84.1 (6.3) were provided with three between-meal snacks daily for 4 weeks following surgery. Dietary counselling, assessment of acceptability and feasibility were undertaken and costs of intervention calculated.

RESULTS

Sixteen of the 23 participants recruited completed the study. Mean estimated energy derived from the snacks provided 26% of daily energy requirements. Monitoring adherence proved problematic and stocktakes highlighted discrepancies. Although several participants reported that they did not usually eat between meals, overall the intervention was acceptable to participants. The cost of implementation was 21.29 UK pounds per participant per week.

CONCLUSIONS

Although it proved feasible, practical difficulties were encountered with implementation and adherence due to timing. A more appropriate time to deliver such an intervention may be after the acute phase is over and patients are back home. The costs compared favourably with the alternative of providing sip feeds.

Vulnerable patients with a fractured neck of femur: nutritional status and support in hospital

BACKGROUND AND AIM

Malnutrition has serious consequences for recovery and increases the risk of complications in hospital patients. Fractured neck of femur (NOF) patients may be particularly at risk because of their old age and frail state of health. We conducted an observational study to evaluate the nutritional state and the nutritional support, which was provided to this group during their stay in hospital.

METHODS

Twenty-five consecutive people admitted to an orthopaedic ward with a fractured NOF at Charing Cross Hospital, London were recruited. Anthropometric measures, biochemical indices, 3 days dietary intake and dietetic referral rates were collected.

RESULTS

Patients had a significantly lower body mass index (BMI) compared with the mean BMI for sex and age in an elderly UK population (21.97 +/- 1.06 versus 26.73 +/- 0.03 kg m(-2); P < 0.005). They took just 58.6% of their energy requirements in hospital (4219 +/- 319 versus 7199 +/- 202 kJ mean(-1) daily intake over 3 days in week 2). Using the hospitals own nutritional risk assessment tool 56% of patients were found to be at risk of malnutrition on admission, which increased to 68% after 2-3 weeks. Of these 64% were referred to a dietitian and were given nutritional supplements. Nutritional assessment revealed that their nutritional status worsened during stay.

CONCLUSIONS

This group of patients with fractured NOF is likely to be malnourished on admission and to show a rapid deterioration in its nutrition status during admission. Energy needs were not met in up to 50% of patients. These results reinforce the need to screen, supplement and monitor fractured NOF patients.

Lower limb fracture, cognitive impairment and risk of subsequent malnutrition: a prospective evaluation of dietary energy and protein intake on an orthopaedic ward

OBJECTIVE

To report the dietary energy and protein intake of undernourished older adults (with and without cognitive impairment) admitted to hospital following a lower limb fracture and to determine whether dietary intakes met estimated requirements.

DESIGN

An observational study of a sequential sample.

SETTING

The orthopaedic ward of a South Australian metropolitan teaching hospital.

SUBJECTS

Sixty-eight patients aged > or =70 years screened as undernourished and admitted to hospital following lower limb fracture (50% cognitively impaired) provided 3 to 5 days of dietary data. MAJOR OUTCOME METHODS: Dietary energy and protein intake.

METHODS

Dietary assessment using plate waste methodology and snack record charts commenced within 6 days postinjury and continued for up to five consecutive days or until discharge. Estimated resting energy requirements were calculated and adjusted for activity equivalent to bed rest and physiological stress. Protein requirements were calculated as 1 g/kg/day. Cognition was assessed using the Short Portable Mental Status Questionnaire.

RESULTS

Cognitively impaired participants and those without cognitive impairment consumed, mean (95% CI) respectively, 3661 kJ/day (3201, 4121) versus 4208 kJ/day (3798, 4619) and 38 g (33, 44) versus 47 g (41, 52) protein/day. Cognitively impaired participants consumed mean (95% CI) 48% (43, 53) of estimated total energy expenditure and 78% (69, 87) of estimated protein requirements.

CONCLUSIONS

Orthopaedic fracture patients at greatest nutritional risk, including those with cognitive impairment, do not achieve estimated energy or protein requirements from diet alone. Effective methods of achieving requirements in this vulnerable group are needed before improvements in outcomes will be observed.

Lack of meal intake compensation following nutritional supplements in hospitalised elderly women

Undernutrition contributes to poor clinical outcomes in hospitalised elderly patients but the potential impact of oral nutritional supplements may be reduced by suppressing subsequent food intake. We investigated this possibility in elderly female patients recovering mainly from hip fracture by studying the effect of oral supplements on subsequent food intake during an ad libitum buffet luncheon meal. We tested the effect in seven women by giving the supplement 90 min before the meal and compared energy and macronutrient intake with a control water pre-load condition. A similar study was carried out in another seven women with the supplement or water drink given 30 min beforehand. Both self-rated appetite and energy intake were low in these women. The nutritional supplement did not alter ratings of hunger, fullness or prospective consumption or subsequent energy and macronutrient consumption whether given 90 or 30 min before the meal. There were significant independent correlations between the lack of adequate compensation of energy intake at meals and chronic undernutrition (as assessed by skinfold thickness) and energy intake during the control meal. We conclude that elderly women during the recovery phase after major fractures have low appetites and energy intakes and markedly impaired adjustment of energy intake following liquid oral nutritional supplements. The reasons for this are unknown but are related to anorexia and undernutrition. The consumption of liquid oral supplements given up to 30 min before a meal does not suppress subsequent energy intake from meals.

Value of body mass index in the detection of severe malnutrition: influence of the pathology and changes in anthropometric parameters

BACKGROUND & AIMS

We have estimated the prevalence of severe malnutrition in groups of patients hospitalized for different medical causes and assessed the sensitivity of BMI in the diagnosis of severe malnutrition.

DESIGN

A prospective study enrolled 1052 patients: 396 patients with liver cirrhosis including 165 non-ascitic patients (NAP), 124 patients with mild ascites (MAP), 107 patients with tense ascites (TAP), 251 patients after cardiac surgery (SCP), 81 patients with cardiac diseases (MCP), 85 patients with stroke (SP), 36 patients with degenerative neurological diseases (DNP), 68 patients after surgery of a hip fracture (HFP), 91 patients with palliative care for cancer (CP) and 44 elderly patients with medical affections (EP). BMI, mid-arm muscular circumference (MAMC) and triceps skinfold thickness (TST) were measured within 48 h after admission. Patients with MAMC and TST below the 5th percentile of a reference population when aged < or = 74 or the 10th percentile when aged > or = 75 were defined as severely malnourished. Sensitivity of BMI < 20 to detect malnutrition was assessed.

RESULTS

The prevalence of severe malnutrition was the highest in TAP (39.1%) HFP (25.6%) and MAP (24.3%) and the lowest in SCP (4%), SP (4.8%), DNP (5.7%) and MCP (7.4%) (P < 10(-4)). In multivariate analysis, low TST was associated with female gender (P < 10(-4)) mild and tense ascites (P = 0.038, P = 0.0004), low MAMC with male gender (P < 10(-4)), low BMI with female gender (P = 0.0082), hip fracture (P = 0.0407) and cancer (P = 0.0059). The sensitivity of BMI to detect severe malnutrition was the highest in HFP, CP and EP (100%, 80% and 100% respectively) and the lowest in TAP, MCP and SP (40%, 33.3% and 50% respectively). After exclusion of TAP, sensitivity of BMI to detect malnutrition correlated significantly with the coefficient of correlation between MAMC and TST observed in each group (r = 0.821, P = 0.0066).

CONCLUSION

Ascitic cirrhotic patients and elderly patients after surgery of hip fracture had the highest prevalence of severe malnutrition. BMI had the highest sensitivity when both TST and MAMC were damaged to the same extent. BMI < 20 has a high sensitivity in the diagnosis of severe malnutrition in elderly and cancer patients but not in cirrhotic patients with tense ascites, cardiovascular and neurological patients.

Is dietary counselling effective in increasing dietary calcium, protein and energy intake in patients with osteoporotic fractures? A randomized controlled clinical trial

To determine the feasibility of increasing the calcium, protein and calorie intake of osteoporotic fracture patients by repeated dietary counselling delivered by a dietitian, a randomized controlled trial was conducted. Among 189 patients presenting with osteoporotic fractures to an Orthopaedics and Traumatology Department of a large regional hospital, 98 patients were randomized to the intervention group and 91 were randomized to the control group (with usual care). Intervention group received three sessions of dietary counselling with tailored made recommendations over a period of 4 months, while the control group only received dietary assessment and pamphlets on the prevention of osteoporosis. Almost all subjects in both intervention and control groups had calcium intake below the recommended level of 1000 mg at baseline. Half and 60% of subjects in both groups had total energy and protein intake below recommended levels respectively. The mean weights of control and intervention groups at baseline were 51.5 and 50.9 kg respectively, while the body mass index (BMI) were 22.6 (kg m(-2)) and 22.6 (kg m(-2)) respectively. After dietary intervention, significant increase of intake was seen in calcium intake (P = 0.0095 by t-test) in the intervention group. No significant increase was seen in protein or calorie intake. No significant change was observed in the body weight or BMI although there was a positive trend in the intervention group for all these parameters. We concluded that there was general malnutrition in Chinese elderly who presented with osteoporotic fractures. Dietary calcium could be increased by repeated professional dietary counselling. Future studies with longer duration and more objective clinical outcomes will be helpful to further demonstrate the long-term effects of dietary intervention on osteoporosis and other chronic diseases.

[Malnutrition in hospitalized patients: prevalence and economic impact]

BACKGROUND AND OBJECTIVE

Malnutrition constitutes a serious problem of public health. We intended to know the prevalence of undernourishment in our hospital, as well as to assess the expenses generated by its presence.

PATIENTS AND METHOD

A study of cohorts was designed to evaluate the nutritional state of randomly selected patients admitted to a third level hospital. We carried out a protocol of nutritional evaluation and quantified the associated costs including drugs, diet, and hospital stay according to diagnosis-related groups.

RESULTS

In agreement with anthropometry and the index of corporal mass, the prevalence of malnutrition was 0.3% and 13.4%, respectively. When analyzing the biochemical markers, the prevalence rose to 65.7%. Patients with malnutrition at the time of admission underwent a 59.9% deterioration of their nutritional state. An increase of costs was observed in relation to the length of hospital stay (68.04% compared with normo-nourished patients). Costs related to consumption of medicines, especially antibiotics, were also higher, as well as costs related to nutritional support.

CONCLUSIONS

Malnutrition is a phenomenon frequently observed in a hospital setting. Malnutrition associated costs are significant.