Mini Nutritional Assessment predicts gait status and mortality 6 months after hip fracture

Nutritional status as independent prognostic factor of outcome and mortality until five years after hip fracture: a comprehensive prospective study

We determined the prognostic value of nutritional status for outcome after hip fracture. Nutritional status was a strong independent prognostic factor for clinical outcome and 5-year mortality. Physical function showed incomplete recovery. Elderly care should focus on prevention already before hip fracture.

PURPOSE

To determine the prognostic value of nutritional status in hip fracture patients for multiple clinical and functional outcomes over 6 months, and for new fractures and survival over 5 years post-fracture.

METHODS

We included 152 well-characterized subjects (age 55+ years) with a hip fracture from a previously published randomized controlled trial. Nutritional status was appraised using the Mini Nutritional Assessment (MNA). Multivariable linear, logistic and Cox regression models were fitted, adjusted for age, sex, ASA score, group and additional prognostic covariates identified in backward regression models.

RESULTS

At baseline, impaired nutritional status was significantly associated with physical disability, depression, impaired cognition and lower quality of life. Prospective analyses showed that impaired baseline nutritional status was an independent prognostic factor for postoperative complications (OR 2.00, 95%CI 1.01-3.98, p = 0.047), discharge location from hospital (home vs. rehabilitation clinic, OR 0.41, 95%CI 0.18-0.98, p = 0.044), hospital readmission (OR 4.59, 95%CI 1.70-12.4, p = 0.003) and total length of hospital stay (HR of being discharged: 0.63, 96%CI 0.44-0.89, p = 0.008), as well as for 5-year mortality (HR 3.94, 95%CI 1.53-10.2, p = 0.005), but not for risk of new fractures (5y-HR 0.87, 95%CI 0.34-2.24, p = 0.769). Curves of physical disability over time showed that the three nutritional status categories followed almost parallel trajectories from baseline until 6 months after hip fracture, without complete recovery and even with further deterioration in malnourished subjects from 3 to 6 months post-fracture.

CONCLUSION

As baselline nutritional status is a strong independent prognostic factor for clinical outcome after hip fracture, affecting even five-year survival, elderly health care should focus on prevention and identification of at-risk individuals already before hip fracture.

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

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

GLIM criteria represent a more suitable tool to evaluate the nutritional status and predict postoperative motor functional recovery of older patients with hip fracture: A retrospective study

Early recognition of malnutrition is essential to improve the prognosis of older patients with hip fracture. The Nutritional Risk Screening 2002 (NRS-2002), the Short-Form Mini Nutritional Assessment (MNA-SF) and the Global Leadership Initiative on Malnutrition (GLIM) are widely used in malnutrition diagnosis. However, criteria for predicting postoperative hip joint motor function in older patients with hip fractures are still necessary. The objective of this study was to select the most appropriate criteria from the NRS-2002, the MNA-SF and the GLIM in predicting the postoperative hip joint motor function recovery 1 year after surgery. This retrospective observational study included 161 patients aged ≥ 65 years with hip fractures. The nutritional status of patients was determined by the NRS-2002, MNA-SF and GLIM. The Harris hip joint score (HHS), the primary outcome of this study, was used to evaluate hip joint motor function. HHS was classified as excellent (HHS > 75) or non-excellent outcomes (HHS ≤ 75). Logistic regression models for hip joint motor function recovery were constructed. Both the receiver operating characteristic curve and the decision curve analysis were used to select the most predictive criteria. The overall mean age of the 161 patients was 77.90 ± 8.17. As a result, NRS-2002 (OR:0.06, 95%CI [0.01, 0.17]), MNA-SF (OR:0.05, 95%CI [0.00, 0.23]) and GLIM (OR of moderate: 0.03, 95%CI [0.01, 0.11]; OR of severe: 0.02 [0.00, 0.07]) were predictive for recovery of hip joint motor function. Additionally, both the area under curve of the receiver operating characteristic curve (NRS-2002: 81.2 [73.8, 88.6], MNA-SF: 76.3 [68.5, 84.2], GLIM: 86.2 [79.6,92.8]) and the decision curve analysis showed the GLIM was better than others. Compared with NRS-2002 and MNA-SF, GLIM was a more suitable nutritional assessment criteria to predict the postoperative recovery of hip joint motor function for older patients with hip fracture 1 year after surgery.

SF-36 physical function and general health domains are independent predictors of acute hospital length of stay after hip fracture surgery

OBJECTIVE

The demographics and co-morbidities of individuals may impact healthcare consumption, but it is less understood how premorbid physical and mental function may influence these effects. The aim of this study is to determine patient's pre-fracture quality of life and mobility affect acute hospital burden in the management of hip fracture, using length of stay (LOS) as a proxy for healthcare resource.

MATERIALS AND METHODS

This is a retrospective study which investigated hip fracture patients who underwent surgery over the period of 2017-2020. Variables collected include LOS, age, gender, race, marital status, payer type, ASA score, time to surgery (TTS), type of surgery, fracture type, POD1 mobilization, discharge disposition, pre-fracture SF-36, EQ-5D and Parker mobility score (PMS) based on patient's recollection on admission. These variables were correlated with LOS using binary logistic regression on SAS.

RESULTS

There were 1045 patients, and mean age was 79.5 + 8.57 (range 60-105) years with an average LOS 13.64 + 10.0 days (range 2-114). On univariate analysis, PMS, EQ-5D and all domains of SF-36 except bodily pain (BP), emotional role and mental health were associated significantly with LOS. Amongst the QOL and PMS scores, only the domains of SF-36 Physical Function (PF) (OR = 0.993, p = 0.0068) and General Health perception (GH) (OR 0.992, p = 0.0230) remained significant on the multivariate model.

CONCLUSION

Our study showed that poor premorbid scores of SF36 PF and GH are independent factors associated with longer LOS in hip fracture patients after surgery, regardless of fracture type, age and ASA status. Hence, premorbid SF36 PF and GH can be used to identify patients that are at risk of prolonged hospital stay and employ targeted strategies to facilitate rehabilitation and discharge planning.

Malnutrition diagnosed by the Global Leadership Initiative on Malnutrition criteria as a predictor of gait ability in patients with hip fracture

AIM

Malnutrition is common in patients with hip fractures and is associated with poor clinical outcomes. The Global Leadership Initiative on Malnutrition (GLIM) and the European Society for Clinical Nutrition and Metabolism (ESPEN) criteria are widely used to diagnose malnutrition. However, the criteria regarding the prediction of gait ability in patients with hip fractures during the acute phase remain unclear. We aimed to determine whether GLIM or ESPEN criteria were more appropriate for predicting gait ability at discharge from an acute hospital.

METHODS

This retrospective observational study included hip fracture patients aged ≥ 65 years. Patients were classified as malnourished or non-malnourished according to the GLIM and ESPEN criteria at admission. The primary outcome was gait ability, which was evaluated using functional ambulation categories (FAC) at discharge. We categorized into those with (FAC score ≥ 3 points) and without (< 3 points) improved gait ability. Logistic regression analysis for FAC was performed to determine whether GLIM or ESPEN was predictive of gait ability at discharge.

RESULTS

Overall 157 patients were included; the median age was 84 years, and 75.3% were female. The prevalence of malnutrition was 73.9% and 25.5% according to the GLIM and ESPEN criteria, respectively. Logistic regression analysis showed that malnutrition evaluated using the GLIM criteria were predictive of lower FAC at discharge (odds ratio, 0.394; 95% CI, 0.164-0.946), while ESPEN criteria did not show statistically significant differences (odds ratio, 0.625; 95% CI, 0.292-1.335).

CONCLUSION

GLIM criteria are useful for predicting gait ability at discharge during acute hospitalization in patients with hip fractures.

Short- and long-term prognostic factors associated with functional recovery in elderly patients with hip fracture: A systematic review

This systematic review aimed to identify short- and long-term associated factors to functional recovery of elderly hip fracture patients after discharge. We identified 43 studies reporting 74 associated factors to functional recovery; most of them were biological, sociodemographic, or inherent factors to patients' baseline characteristics, including their pre-facture functional capacity.

PURPOSE

This systematic review aimed to identify short- and long-term associated factors to functional recovery of elderly hip fracture patients after hospital discharge. We assessed the use of the hip fracture core-set and key-performance indicators for secondary fracture reduction.

METHODS

A search was performed in seven electronic databases. Observational studies reporting predictors after usual care of elderly patients with hip fracture diagnoses receiving surgical or conservative treatment were included. Primary outcomes considered were part of the domains corresponding to functional capacity.

RESULTS

Of 3873 references identified, and after the screening and selection process, 43 studies were included. Sixty-one functional measures were identified for ten functional outcomes, including BADLs, IADLs, ambulation, and mobility. Biological characteristics such as age, sex, comorbidities, cognitive status, nutritional state, and biochemical parameters are significantly associated. Determinants such as contact and size of social network and those related to institutional care quality are relevant for functional recovery at six and 12 months. Age, pre-fracture function, cognitive status, and complications continue to be associated five years after discharge. We found 74 associated factors to functional recovery of elderly hip fracture patients. Ten of the studies reported rehabilitation programs as suggested in KPI 9; none used the complete hip fracture core-set.

CONCLUSION

Most of the associated factors for functional recovery of elderly hip fracture were biological, sociodemographic, or inherent factors to patients' baseline characteristics, including their pre-facture functional capacity. For the core-set and KPI's, we found an insufficient use and report. This study reports 61 different instruments to measure functional capacity.

REGISTRATION NUMBER

PROSPERO (CRD42020149563).

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of nutritional status before femoral neck fracture surgery on postoperative outcomes: a retrospective study

Background

Although nutritional status is crucial in gait recovery after femoral neck fracture surgery, the relationship between preoperative nutritional status and postoperative outcomes remains unknown. This study examined the effects of preoperative nutritional status on postoperative outcomes in patients undergoing femoral neck fracture surgery.

Methods

Data regarding the joints of 137 patients (29 men, 108 women) who underwent bipolar hemiarthroplasty for femoral neck fractures at our hospital from January 2015 to December 2019 were retrospectively examined. The Geriatric Nutritional Risk Index (GNRI), an index of nutritional status, was used to classify patients into two groups: a normal group (GNRI ≥92; n = 62) and an undernourished group (GNRI < 92; n = 75). The study endpoints included age at surgery, sex, Mini Mental State Examination (MMSE), American Society of Anesthesiologists Physical Status (ASA) classification, preoperative waiting period, intraoperative blood loss, surgery time, perioperative hemoglobin levels, blood transfusion rate, complication rate, 6-month mortality rate, transfer rate, percentage of patients unable to walk at discharge or transfer, and inability to walk 6 months postoperatively.

Results

The patients in the undernourished group was significantly older at surgery (p < 0.01) and had a lower perioperative hemoglobin levels (p < 0.01), a higher blood transfusion rate (p < 0.01), a lower MMSE (p < 0.01), a longer preoperative waiting period (p < 0.05), a higher transfer rate (p < 0.05), were more likely to be unable to walk 6 months postoperatively (p < 0.01), a higher complication rate (p < 0.05), and a higher 6-month mortality rate (p < 0.01) than the normal group. Patients in the undernourished group had worse rates of postoperative complications, transfer, mortality, and inability to walk 6-month after surgery than those in the normal group.

Conclusions

A poor nutritional status affects the gait function and systemic condition of patients undergoing femoral neck fracture surgery; therefore, early nutritional interventions may reduce mortality rates and shorten rehabilitation. These results suggest that the GNRI effectively predicts postoperative complications, mortality, and gait function.

Cutoff Value for a Nutritional Indicator Related to Gait Independence in Elderly Fracture Patients: A Preliminary Study

OBJECTIVE

Previous studies have reported the relationship between nutritional status and gait independence in elderly fracture patients. However, the degree to which nutritional indicators are related to gait independence is unclear. The purpose of this study is to calculate a cutoff value for a nutritional indicator related to gait independence in patients with hip and vertebral compression fractures.

METHOD

This study included 69 patients (33 hip fracture, 36 vertebral compression fracture) who underwent rehabilitation at a convalescent rehabilitation ward. The relationships between nutritional indexes (Mini-Nutritional Assessment-Short Form [MNAⓇ-SF] and skeletal muscle mass index [SMI] ) at admission and gait independence at discharge were analyzed using logistic regression. In addition, receiver operating characteristic analysis was performed to calculate a cutoff value that predicts gait independence.

RESULTS

Among the nutritional indicators used in this study, only MNAⓇ-SF was significantly able to predict gait independence at discharge, and this association was maintained, even after adjustment for confounders. The calculated MNAⓇ-SF cutoff values were 5.5 (sensitivity 100%, specificity 46.3%) and 7.5 points (sensitivity 67.9%, specificity 78.0%).

CONCLUSION

This study suggests that MNAⓇ-SF may be an index for predicting gait independence in patients with hip or vertebral compression fractures in the convalescent rehabilitation ward. The cutoff values calculated in this study were simple and useful index for physical therapists to interpret the results of MNAⓇ-SF.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

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.

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

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

Outcome of surgery in neck of femur fracture patients with poor pre-fracture mobility

BACKGROUND

Hip fractures are common with a UK incidence of over 70,000 cases and total healthcare costs of over £2 billion per year. Mortality rates of 10% at 30 days and up to 30% at 1-year have been reported. We wanted to assess the outcome of hip fracture surgery in patients with reduced pre-fracture mobility as this has not been exclusively studied previously.

METHODS

We retrospectively reviewed 168 hip fracture patients with reduced pre-fracture mobility (wheelchair bound, bed bound, walking with 2 aids or a frame) who underwent hip fracture surgery at our institution between 2008 and 2013 using case notes, discharge letters, outpatient clinic letters and laboratory test results. Measured outcomes included 30-day renal, cardiac and respiratory morbidity as well as 30-day and 1-year mortality.

RESULTS

Our study comprised 27% males and 73% females with a mean age of 82 years. The 30-day chest infection, acute renal failure and acute coronary syndrome rates were 26%, 7.7% and 4% respectively. In those patients who were either wheelchair or bed bound, 30-day and 1-year mortality rates were 11.8% and 52% respectively whereas in those who could mobilise with the help of 2 aids or frame, 30-day and 1-year mortality rates were 4.34% and 39.70% respectively.

CONCLUSION

Our study highlighted increased 30-day and 1-year morbidity and mortality rates following hip fracture surgery with notable high rates of respiratory and renal complications in patients with reduced pre-fracture mobility. We would recommend pre- and postoperative optimisation with orthogeriatric review, chest physiotherapy and intravenous fluid hydration to reduce complication rates and improve morbidity and mortality.

Risk of malnutrition in orthopedic trauma patients with surgical site infections is associated with increased morbidity and mortality - a 3-year follow-up study

BACKGROUND

Malnutrition is a worldwide problem which can result in prolonged hospitalization from complications such as poor wound healing and increased morbidity. There is increasing evidence of the effect of risk of malnutrition (ROM) on outcomes in orthopedic surgical patients. However, there is little data on the effect of nutritional status on clinical outcomes in orthopedic trauma patients with surgical site infections (SSI). Therefore, our aim was to investigate how malnutrition risk affects clinical outcomes in a prospective cohort of orthopedic trauma patients with SSI.

METHODS

The study included 345 patients who underwent surgery due to SSI at a level 1 trauma center. All patients were evaluated on their nutritional status as assessed by the Nutritional Risk Screening in 2014/15 and 2017/18. 238 (69.0%) datasets were available for the follow-up analysis. Twenty patients (8.4%) had died, resulting in 218 patients. Outcomes investigated included comorbidities, medication intake, destination of discharge, degree of mobility, support for procuring food, mortality risk and quality of life.

RESULTS

32.8% were at risk of malnutrition (ROM) at EXAM1. Female patients had a higher ROM than males (p < 0.05). Patients with ROM had more comorbidities (p < 0.001), an increased need for medication intake (p < 0.001), a decreased level of mobility (p < 0.001) and increased need of support in procuring food (p < 0.001). The destination of discharge was independent of the nutritional status (p = 0.641). Twenty (8.4%) of the available 238 patients had died during follow-up time period, resulting in a 6.2-times higher risk of mortality in patients with ROM. EQ-5D revealed that mobility, self-supply and usual activities of daily living were increased in well-nourished patients (p < 0.001).

CONCLUSION

ROM in orthopedic trauma patients with SSI is associated with an increased number of comorbidities and need for medication intake, a decrease in mobility and a higher dependency for food acquisition. Patients at ROM exhibited a 6.2-times higher mortality rate than well-nourished patients. EQ-5D evaluation showed better mobility, self-supply, and activity of daily living in well-nourished patients. We therefore strongly recommend supplementing patients with ROM with a specific diet during and after discharge from the hospital in order to reduce postoperative complications and long-term mortality.

Independent factors associated with long-term functional outcomes in patients with a proximal femoral fracture: A systematic review

INTRODUCTION

The current understanding of prognostic factors of functional recovery after a proximal femoral fracture is limited, and enhancements could improve the prognostic accuracy and target subgroups for additional care strategies. This systematic review aims to identify all studied factors with an independent prognostic value for the long-term functional recovery of patients with a proximal femoral fracture.

MATERIALS AND METHODS

Observational studies with multivariate analyses on prognostic factors of long-term functional outcome after proximal femoral fractures were obtained through an electronic search performed on November 9, 2018.

RESULTS

In the 31 included articles, thirteen prognostic factors were studied by at least two independent studies and an additional ten by only one study. Age, comorbidity, functionality and cognition were factors for which the majority of studies indicated a significant effect. The majority of studies which included sex as a factor found no significant effect. The level of evidence for the remaining factors was deemed too low to be conclusive on their relevance for long-term functional outcome.

CONCLUSION

The identified factors showed overlap with prognostic factors of short-term functional outcomes and mortality. The validity and applicability of prognostic models based on these factors may be of interest for future research.

Preoperative prognostic nutritional index predicts postoperative delirium in elderly patients after hip fracture surgery

BACKGROUND

Postoperative delirium (POD) is a very common complication in elderly patients after hip fracture surgery, which has poorly understood pathophysiology. This study aimed to investigate potential risk factors for POD.

METHODS

Elderly patients (aged ≥65 years) scheduled to undergo selective surgery in our hospital were consecutively recruited. Patient characteristics, preoperative laboratory tests and prognostic nutritional index (PNI) levels were compared between patients with or without POD. The risk factors for POD were evaluated by univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PNI and age for POD.

RESULTS

Fifty-seven of the 163 enrolled patient had suffered POD within postoperative day 7 with an incidence of 35.0%. Multivariate logistic analyses revealed that an advanced age (cut-off value: 71.5 years, sensitivity: 48.1%, specificity: 75.4%, odds ratio (OR): 3.24, 95% CI: 1.16-8.69, P = 0.026) and lower PNI level (cut-off value: 47.45, sensitivity: 86.0%, specificity: 51.9%, OR: 2.88, 95% CI: 1.25-6.64, P = 0.012) were two independent predictive factors associated with POD. According to the ROC curve analysis, preoperative PNI level was a predictor for POD with an area under the curve of 0.686 (95% CI: 0.604-0.767, P < 0.001).

CONCLUSIONS

Advanced age and lower preoperative PNI level were significantly associated with POD in elderly patients after hip fracture surgery.

Malnutrition among elderly patients with severe aortic stenosis

BACKGROUND

Most patients with aortic stenosis (AS) are elderly. To achieve favorable outcomes after interventional treatments, careful management including adequate nutritional support is required. However, there has been a lack of knowledge about the prevalence of malnutrition and factors related to it.

AIMS

To explore the prevalence of malnutrition and its related factors in patients with severe AS.

METHODS

This was a single-institution, cross-sectional study. A total of 300 consecutive older patients (mean age, 83.8 ± 0.5 years) with AS were prospectively enrolled. Nutritional status was evaluated with the Mini Nutritional Assessment-Short Form (MNA-SF). Cardiac, kidney, physical, cognitive functions, instrumental activities of daily living (IADL) as measured with the Frenchay Activities Index (FAI), medical history, and comorbidities were evaluated as potentially related factors. Multiple logistic regression analysis was performed to identify factors that were significantly associated with the MNA-SF.

RESULTS

The mean (SD) score of the MNA-SF was 10.9 (2.5). 34 patients (11.3%) and 127 patients (42.3%) met the criteria for malnutrition and at risk of malnutrition, respectively. On multiple logistic regression analysis, female sex (OR 3.455, 95% CI 1.045-11.42, P = 0.042), NYHA class (OR 3.625, 95% CI 1.627-8.074, P = 0.002), left ventricular ejection fraction (/10%) (OR 0.961, 95% CI 0.932-0.991, P = 0.010), and FAI score (/10 points) (OR 0.911, 95% CI 0.864-0.961, P < 0.001) were significantly related to malnutrition.

CONCLUSIONS

The prevalence of malnutrition was high among older persons with severe AS, and female sex, poor cardiac function, and lower IADL were independently related to it.

Efficacy of Nutritional Intervention in Elderly After Hip Fracture: A Multicenter Randomized Controlled Trial

Background

Malnutrition after hip fracture is associated with increased rehabilitation time, complications, and mortality. We assessed the effect of intensive 3 month nutritional intervention in elderly after hip fracture on length of stay (LOS).

Methods

Open-label, randomized controlled trial. Exclusion criteria: age < 55 years, bone disease, life expectancy < 1 year, bedridden, using oral nutritional supplements (ONS) before hospitalization, and cognitive impairment. Intervention: weekly dietetic consultation, energy-protein–enriched diet, and ONS (400 mL per day) for 3 months. Control: usual nutritional care. Primary outcome: total LOS in hospital and rehabilitation clinic, including readmissions over 6 months (Cox regression adjusted for confounders); hazard ratio (HR) < 1.0 reflects longer LOS in the intervention group. Secondary outcomes: nutritional and functional status, cognition, quality of life, postoperative complications (6 months); subsequent fractures and all-cause mortality (1 and 5 years). Effect modification by baseline nutritional status was also tested.

Results

One hundred fifty-two patients were randomized (73 intervention, 79 control). Median total LOS was 34.0 days (range 4–185 days) in the intervention group versus control 35.5 days (3–183 days; p_logrank = .80; adjusted hazard ratio (adjHR): 0.98; 95% CI: 0.68–1.41). Hospital LOS: 12.0 days (4–56 days) versus 11.0 days (3–115 days; p = .19; adjHR: 0.75; 95% CI: 0.53–1.06) and LOS in rehabilitation clinics: 19.5 days (0–174 days) versus 18.5 days (0–168 days; p = .82; adjHR: 1.04; 95% CI: 0.73–1.48). The intervention improved nutritional intake/status at 3, but not at 6 months, and did not affect any other outcome. No difference in intervention effect between malnourished and well-nourished patients was found.

Conclusions

Intensive nutritional intervention after hip fracture improved nutritional intake and status, but not LOS or clinical outcomes. Paradigms underlying nutritional intervention in elderly after hip fracture may have to be reconsidered.

Relationship between nutritional status and improved ADL in individuals with cervical spinal cord injury in a convalescent rehabilitation ward

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate the relationship of nutritional status with improvement of activities of daily living in individuals with cervical spinal cord injury.

SETTING

A convalescent rehabilitation ward at the Toyama Prefectural Rehabilitation Hospital and Support Center for Children with Disabilities in Japan.

METHODS

This retrospective analysis investigated adults (age ≥20 years) with cervical spinal cord injury who were consecutively admitted to a convalescent rehabilitation ward between 2006 and 2015. Data of 154 patients were analyzed. Nutritional status was evaluated using the Subjective Global Assessment (SGA; 3 groups: well-nourished, suspected of being malnourished or moderately malnourished, severely malnourished) and body mass index (BMI; 3 groups: underweight, standard, and overweight and obese). The main outcome was functional independence measure (FIM) efficiency. Multiple regression analysis was performed to investigate the relationship of SGA and BMI to FIM efficiency.

RESULTS

FIM efficiency was significantly higher in the well-nourished group based on the SGA than in the two groups with malnutrition (P = .007: 0.32 vs. 0.26 vs. 0.10). Multivariate regression analysis revealed that FIM efficiency was similar in the underweight and standard group, but was significantly higher in the overweight and obese group (P = .006: 0.20 vs. 0.21 vs. 0.31).

CONCLUSIONS

SGA and BMI on admission may be independently associated with FIM efficiency in patients with cervical spinal cord injury.

Nutritional Status and Functional Outcomes in Older Adults Admitted to Geriatric Rehabilitations: The SAFARI Study

Objective: Evidence about the role of nutritional status (NS) on functional outcomes (FO) after rehabilitation in older adults is scarce. Our aim was to analyze the association between NS and FO in older adults admitted to geriatric rehabilitation units. Methods: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) multicenter study enrolled patients aged ≥65 years admitted to geriatric rehabilitation units in Italy and Spain. FO were absolute and relative functional gain (AFG-RFG) in Barthel Index (BI) at 1 and 3 months after admission. The association between NS (Mini Nutritional Assessment-Short Form) and FO was explored using linear regression and mixed models, adjusted for potential confounders. Analyses were then stratified for diagnosis at admission. Results: We included 415 patients (mean age 81.4 years [SD: 7.7]; 67% female; 9.4% malnourished [MN], 42.7% at risk of malnutrition [RM], and 48% well nourished [WN]). Admission diagnoses were hip fracture (39.5%), elective orthopedic surgery (EOS) (29.5%), and stroke (31%). In an adjusted linear mixed model, MN and RM participants had lower BI compared to WN (MN: β: -8.47, p = 0.023; RM: β: -5.22, p = 0.031), and differences between groups remained stable over time. After stratification for admission diagnosis, only MN patients admitted after EOS had worse FO, both at 30 days (AFG: β adjusted: -13.54, p < 0.001; RFG: β: -32, p < 0.001) and 3 months (AFG: β adjusted: -17.79, p < 0.001; RFG: β: -26.77, p = 0.002). Conclusions: In our sample, poor NS is associated with worse BI in older adults admitted to geriatric rehabilitation units; in patients undergoing EOS, MN is associated with worse FO. Our results documented for the first time the importance of assessing nutritional status before EOS.

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.

ESPEN guideline on clinical nutrition and hydration in geriatrics

BACKGROUND

Malnutrition and dehydration are widespread in older people, and obesity is an increasing problem. In clinical practice, it is often unclear which strategies are suitable and effective in counteracting these key health threats.

AIM

To provide evidence-based recommendations for clinical nutrition and hydration in older persons in order to prevent and/or treat malnutrition and dehydration. Further, to address whether weight-reducing interventions are appropriate for overweight or obese older persons.

METHODS

This guideline was developed according to the standard operating procedure for ESPEN guidelines and consensus papers. A systematic literature search for systematic reviews and primary studies was performed based on 33 clinical questions in PICO format. Existing evidence was graded according to the SIGN grading system. Recommendations were developed and agreed in a multistage consensus process.

RESULTS

We provide eighty-two evidence-based recommendations for nutritional care in older persons, covering four main topics: Basic questions and general principles, recommendations for older persons with malnutrition or at risk of malnutrition, recommendations for older patients with specific diseases, and recommendations to prevent, identify and treat dehydration. Overall, we recommend that all older persons shall routinely be screened for malnutrition in order to identify an existing risk early. Oral nutrition can be supported by nursing interventions, education, nutritional counseling, food modification and oral nutritional supplements. Enteral nutrition should be initiated if oral, and parenteral if enteral nutrition is insufficient or impossible and the general prognosis is altogether favorable. Dietary restrictions should generally be avoided, and weight-reducing diets shall only be considered in obese older persons with weight-related health problems and combined with physical exercise. All older persons should be considered to be at risk of low-intake dehydration and encouraged to consume adequate amounts of drinks. Generally, interventions shall be individualized, comprehensive and part of a multimodal and multidisciplinary team approach.

CONCLUSION

A range of effective interventions is available to support adequate nutrition and hydration in older persons in order to maintain or improve nutritional status and improve clinical course and quality of life. These interventions should be implemented in clinical practice and routinely used.

Nutritional Status and Nutritional Treatment Are Related to Outcomes and Mortality in Older Adults with Hip Fracture

Malnutrition is very prevalent in geriatric patients with hip fracture. Nevertheless, its importance is not fully recognized. The objective of this paper is to review the impact of malnutrition and of nutritional treatment upon outcomes and mortality in older people with hip fracture. We searched the PubMed database for studies evaluating nutritional aspects in people aged 70 years and over with hip fracture. The total number of studies included in the review was 44, which analyzed 26,281 subjects (73.5% women, 83.6 ± 7.2 years old). Older people with hip fracture presented an inadequate nutrient intake for their requirements, which caused deterioration in their already compromised nutritional status. The prevalence of malnutrition was approximately 18.7% using the Mini-Nutritional Assessment (MNA) (large or short form) as a diagnostic tool, but the prevalence was greater (45.7%) if different criteria were used (such as Body Mass Index (BMI), weight loss, or albumin concentration). Low scores in anthropometric indices were associated with a higher prevalence of complications during hospitalization and with a worse functional recovery. Despite improvements in the treatment of geriatric patients with hip fracture, mortality was still unacceptably high (30% within 1 year and up to 40% within 3 years). Malnutrition was associated with an increase in mortality. Nutritional intervention was cost effective and was associated with an improvement in nutritional status and a greater functional recovery. To conclude, in older people, the prevention of malnutrition and an early nutritional intervention can improve recovery following a hip fracture.

Predictive factors of hospital stay, mortality and functional recovery after surgery for hip fracture in elderly patients

OBJECTIVES

Due to its high prevalence and serious consequences it is very important to be well aware of factors that might be related to medical complications, mortality, hospital stay and functional recovery in elderly patients with hip fracture.

MATERIAL AND METHODS

A prospective study of a group of 130 patients aged over 75 years admitted for osteoporotic hip fracture. Their medical records, physical and cognitive status prior to the fall, fracture type and surgical treatment, medical complications and functional and social evolution after hospitalization were evaluated.

RESULTS

Patients with greater physical disability, more severe cognitive impairment and those who lived in a nursing home before the fracture had worse functional recovery after surgery. Treatment with intravenous iron to reduce transfusions reduced hospital stay and improved walking ability. Infections and heart failure were the most frequent medical complications and were related to a longer hospital stay. The prescription of nutritional supplements for the patients with real indication improved their physical recovery after the hip fracture CONCLUSIONS: Evaluation of physical, cognitive and social status prior to hip fracture should be the basis of an individual treatment plan because of its great prognostic value. Multidisciplinary teams with continuous monitoring of medical problems should prevent and treat complications as soon as possible. Intravenous iron and specific nutritional supplements can improve functional recovery six months after hip fracture.

Effectiveness of nutritional supplementation on sarcopenia and recovery in hip fracture patients. A multi-centre randomized trial

BACKGROUND AND OBJECTIVES

Functional deterioration and reduced mobility in elderly patients with a hip fracture are associated with a loss of both muscle mass and function (sarcopenia). The aim of this study was to assess whether oral nutritional supplementation (ONS) improves muscle mass and nutritional markers (BMI, proteins) in elderly patients with hip fracture.

METHODS

Patients aged 65 years and over with hip fractures admitted to either of two rehabilitation facilities were included. Patients with diabetes, with Barthel index scores <40 prior to the fracture or with pathological fractures were excluded. A random-numbers generator was used to randomly allocate patients to the intervention group (IG) or the control group (CG). Those in the IG received a standard diet plus ONS in the form of two bottles a day of β-hydroxy-β-methylbutyrate (HMB), while those in the CG received a standard diet only. The intervention was not blinded. In order to assess changes in body mass index (BMI), anthropometric parameters were recorded at both admission and discharge. Patients' functional situation was evaluated using the Barthel index (BI) and the Functional Ambulation Categories (FAC) score. Muscle mass was assessed using bioelectrical impedance analysis, which allowed us to calculate appendicular lean mass (aLM). The outcome variable was the difference between aLM upon discharge, minus aLM upon admission (Δ-aLM).

RESULTS

Of the 107 randomised patients (IG n55, CG n52), 49 finished the study in the IG and 43 in the CG. BMI and aLM were stable in IG patients, whilst these parametres decreased in the CG. A significant difference was observed between the two groups (p<0.001, and p=0.020 respectively). The predictive factors for Δ-aLM were ONS (p=0.006), FAC prior to fracture (p<0.001) and BI prior to fracture (p=0.007). The concentration of proteins (p=0.007) and vitamin D (p.001) had increased more in the IG than in the CG.

CONCLUSION

A diet enriched in HMB improves muscle mass, prevents the onset of sarcopenia and is associated with functional improvement in elderly patients with hip fractures. Orally administered nutritional supplements can help to prevent the onset of sarcopenic obesity.

TRIAL REGISTRATION

www.clinicaltrials.gov identifier: NCT01404195, registered 22 July 2011, HYPERPROT-GER Study.

Comparison of the Mini-Nutritional Assessment short and long form and serum albumin as prognostic indicators of hip fracture outcomes

INTRODUCTION

Malnutrition is common among older hip fracture patients and associated with adverse outcomes. We examined Mini Nutritional Assessment short (MNA-SF) and long form (MNA-LF) and serum albumin as prognostic indicators of mobility, living arrangements and mortality after hip fracture.

METHODS

Population-based prospective data were collected on 594 hip fracture patients aged 65 and over. MNA-SF, MNA-LF and serum albumin were assessed on admission. Outcomes were poorer mobility; transfer to more assisted living accommodation and mortality one month, four months and one year post fracture. Logistic regression analyses for mobility and living arrangements with odds ratios (OR) and Cox proportional hazards model for mortality with hazard ratios (HR) and 95% confidence intervals (CI) were used, adjusted for age, gender, ASA grade and fracture type.

RESULTS

All measures predicted mortality at all time-points. Risk of malnutrition and malnutrition measured by MNA-LF predicted mobility and living arrangements within four months of hip fracture. At one year, risk of malnutrition predicted mobility and malnutrition predicted living arrangements, when measured by MNA-LF. Malnutrition, but not risk thereof, measured by MNA-SF predicted living arrangements at all time-points. None of the measures predicted one-month mobility.

CONCLUSIONS

All measures were strong indicators of short- and long-term mortality after hip fracture. MNA-LF was superior in predicting mobility and living arrangements, particularly at four months. All measures were relatively poor in predicting short-term outcomes of mobility and living arrangements.

Association Between Preoperative Malnutrition and Postoperative Delirium After Hip Fracture Surgery in Older Adults

OBJECTIVES

To determine whether poor nutritional status can predict postoperative delirium in elderly adults undergoing hip fracture surgery.

DESIGN

Prospective observational cohort study.

SETTING

Italian orthogeriatric unit.

PARTICIPANTS

Individuals aged 70 and older (mean age 84.0 ± 6.6, 74.5% female) consecutively admitted for surgical repair of a proximal femur fracture between September 2012 and April 2016 (N = 415).

MEASUREMENTS

Participants underwent a comprehensive geriatric assessment including nutritional status, which was evaluated using the Mini Nutritional Assessment Short Form (MNA-SF). The MNA-SF-based three-class stratification was tested using multivariable logistic regression to assess its role in predicting postoperative delirium (outcome).

RESULTS

Seventy-eight malnourished individuals (MNA-SF score 0-7), 185 at risk of malnutrition (MNA-SF score 8-11), and 152 who were well nourished (MNA-SF score 12-14) were compared. On average, individuals with poor nutritional status were more disabled and more cognitively impaired than those who were well nourished and those at risk of malnutrition. Moreover, those who were malnourished were more likely to have postoperative delirium. Multivariate regression analysis adjusted for age, sex, comorbidity, functional impairment, preoperative cognitive status, and American Society of Anesthesiologists score showed that those who were at risk of malnutrition (odds ratio (OR) = 2.42, 95% confidence interval (CI) = 1.29-4.53) and those who were overtly malnourished (OR = 2.98, 95% CI = 1.43-6.19) were more likely to develop postoperative delirium.

CONCLUSION

This is the first study in a Western population showing that risk of malnutrition and overt malnutrition, as assessed using the MNA-SF, are independent predictors of postoperative delirium. Accordingly, nutritional status should be assessed in individuals with hip fracture before surgery to determine risk of developing delirium.

Addressing Disease-Related Malnutrition in Healthcare: A Latin American Perspective

Alarmingly high rates of disease-related malnutrition have persisted in hospitals of both emerging and industrialized nations over the past 2 decades, despite marked advances in medical care over this same interval. In Latin American hospitals, the numbers are particularly striking; disease-related malnutrition has been reported in nearly 50% of adult patients in Argentina, Brazil, Chile, Costa Rica, Cuba, Dominican Republic, Ecuador, Mexico, Panama, Paraguay, Peru, Puerto Rico, Venezuela, and Uruguay. The tolls of disease-related malnutrition are high in both human and financial terms-increased infectious complications, higher incidence of pressure ulcers, longer hospital stays, more frequent readmissions, greater costs of care, and increased risk of death. In an effort to draw attention to malnutrition in Latin American healthcare, a feedM.E. Latin American Study Group was formed to extend the reach and support the educational efforts of the feedM.E. Global Study Group. In this article, the feedM.E. Latin American Study Group shows that malnutrition incurs excessive costs to the healthcare systems, and the study group also presents evidence of how appropriate nutrition care can improve patients' clinical outcomes and lower healthcare costs. To achieve the benefits of nutrition for health throughout Latin America, the article presents feedM.E.'s simple and effective Nutrition Care Pathway in English and Spanish as a way to facilitate its use.

Mini Nutritional Assessment and Mortality after Hip Fracture Surgery in the Elderly

BACKGROUND

Hip fracture surgery in elderly patients is associated with a poor postoperative outcome and a high mortality. Malnutrition is a frequent problem in elderly patients and may be associated with mortality after hip fracture surgery. The Mini Nutritional Assessment (MNA) is a valuable tool to identify malnourished patients and those at risk for malnutrition.

OBJECTIVE

To evaluate the association between the preoperative MNA score and mortality after surgery for hip fractures in elderly patients.

METHODS

Patients with a hip fracture and an indication for surgery were included in our study. This study was part of a randomized trial on the effect of taurine on postoperative outcome in elderly hip fracture patients. The MNA was assessed on admission before surgery. Length of stay, postoperative complications and mortality were documented. The association of the MNA score on postoperative outcome and mortality was analyzed using Cox regression analysis.

RESULTS

The one-year survival rate in 226 elderly hip fracture patients was 79%. In-hospital mortality rates and 1-year mortality were 27% and 46% in malnourished patients, 12% and 26% in patients at risk for malnutrition and 7% and 17% in well-nourished patients as assessed by MNA.

CONCLUSION

Preoperative malnutrition measured by the MNA is associated with mortality in elderly hip fracture patients.

Factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture

PURPOSE

To examine factors associated with changes in mobility and living arrangements in a comprehensive geriatric outpatient assessment after hip fracture.

METHOD

Population-based prospective data on 887 consecutive hip fracture patients aged 65 years and older. The domains of the geriatric assessment were the independent and changes in mobility level and living arrangements 4 months postoperatively the outcome variables.

RESULTS

Of the survivors, 499 (73%) attended the assessment. The mobility level had declined in 39% of the attendees and 38% of them had moved to more supported living arrangements 4 months after the hip fracture. In the age-adjusted univariate logistic regression analyses, almost all the domains of the comprehensive geriatric assessment were significantly associated with both outcomes. In the forward stepwise multivariate analysis, disability in activities of daily living, poor performance in Timed Up and Go and comorbidity as measured by the American Society of Anesthesiologists scores remained significantly associated with the outcomes.

CONCLUSIONS

While comorbidity and disability in activities of daily living and mobility are the major indicators of poor outcomes of mobility and living arrangements after hip fracture, all the domains in the comprehensive geriatric assessment deserve attention during hip fracture care and rehabilitation.

IMPLICATIONS FOR REHABILITATION

In almost half of the patients the mobility level and living arrangements had deteriorated 4 months after the hip fracture, suggesting an urgent need for more effective postoperative rehabilitation. Almost all the domains of the comprehensive geriatric assessment were associated with poor outcomes and require equal attention during the acute and postacute phases of hip fracture care and in the course of rehabilitation. A geriatric outpatient assessment a few months after the hip fracture provides a check-point for the outcomes and an opportunity to target interventions at different domains of the comprehensive assessment.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

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.

Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management

Malnutrition and sarcopenia often occur in rehabilitation settings. The prevalence of malnutrition and sarcopenia in older patients undergoing rehabilitation is 49-67 % and 40-46.5 %, respectively. Malnutrition and sarcopenia are associated with poorer rehabilitation outcome and physical function. Therefore, a combination of both rehabilitation and nutrition care management may improve outcome in disabled elderly with malnutrition and sarcopenia. The concept of rehabilitation nutrition as a combination of both rehabilitation and nutrition care management and the International Classification of Functioning, Disability and Health guidelines are used to evaluate nutrition status and to maximize functionality in the elderly and other people with disability. Assessment of the multifactorial causes of primary and secondary sarcopenia is important because rehabilitation nutrition for sarcopenia differs depending on its etiology. Treatment of age-related sarcopenia should include resistance training and dietary supplements of amino acids. Therapy for activity-related sarcopenia includes reduced bed rest time and early mobilization and physical activity. Treatment for disease-related sarcopenia requires therapies for advanced organ failure, inflammatory disease, malignancy, or endocrine disease, while therapy for nutrition-related sarcopenia involves appropriate nutrition management to increase muscle mass. Because primary and secondary sarcopenia often coexist in people with disability, the concept of rehabilitation nutrition is useful for their treatment. Stroke, hip fracture, and hospital-associated deconditioning are major causes of disability, and inpatients of rehabilitation facilities often have malnutrition and sarcopenia. We review the concept of rehabilitation nutrition, the rehabilitation nutrition options for stroke, hip fracture, hospital-associated deconditioning, sarcopenic dysphagia, and then evaluate the amount of research interest in rehabilitation nutrition.

Secondary confounders of osteoporotic hip fractures in patients admitted to a geriatric acute care department

BACKGROUND

With respect to the pathogenesis of osteoporosis, primary and secondary forms of the disease can be distinguished. It has been recognized that the incidence of primary and secondary osteoporosis differs in women and men.

OBJECTIVE

The aim of the present study was to assess the incidence and gender distribution of factors contributing to osteoporosis in older hip fracture patients.

METHODS

In this cross-sectional study 404 patients with hip fractures and controls referred to an acute geriatric care department over a period of 15 months were included. The medical history was recorded and blood samples were analyzed for routine laboratory parameters.

RESULTS

A total of 249 patients with hip fractures and 155 matched controls were studied. The Tinetti test and the Barthel index were found to show highly significant differences in both groups mainly because of the postoperative state of patients with fractures. Vitamin D deficiency was found in 94.1% of male fracture patients and 94.6% of female fracture patients. On average 2.4 secondary contributors of osteoporosis were present in male fracture patients versus 2.9 in male controls and 2.3 in female fracture patients versus 2.3 in female controls. For most parameters no significant gender differences of possible secondary contributors to osteoporosis were found. Secondary osteoporosis was diagnosed in all male fracture patients and in 56.2% of all female fracture patients.

CONCLUSION

Based on the findings of this study it is recommended that hip fracture patients should be assessed for secondary contributors of osteoporosis. Although the overall distribution of secondary contributors was similar in women and men, the prevalence of secondary osteoporosis was higher in men.

Exercise, nutrition and managing hip fracture in older persons

PURPOSE OF REVIEW

Lifestyle factors play a role in both the genesis and recovery from fragility fracture. The purpose of this review is to summarize recent evidence for exercise and nutrition in the management of hip fracture.

RECENT FINDINGS

Recent randomized controlled trials of exercise have primarily consisted of isolated resistance training or multimodal home-based programs. More robust, long-term, or supervised training is generally associated with greater clinical benefits, including muscle strength, mobility, and function. Recent nutritional interventions have included multinutrient supplements, nutritional counseling and support, and vitamin D/calcium supplementation. Isolated nutritional interventions have not consistently shown significant impact on long-term outcomes after hip fracture, although improvements in body weight, biochemical indices, complication rates, and mobility have been reported. Overall, there is marked heterogeneity in the robustness of responses seen to hip fracture treatment studies. Few large, long-term, multicomponent interventions with clinically relevant outcomes of functional independence, need for residential care, mortality, and quality of life have been reported.

SUMMARY

Evidence-based approaches to hip fracture should include comprehensive risk-factor assessment and treatment for sarcopenia/dynapenia, balance impairment, undernutrition of protein, energy, vitamin D and calcium, depression, cognitive impairment, sensory impairment, social isolation, and comorbid illness with exercise, nutrition and other modalities.

Maximising functional recovery following hip fracture in frail seniors

This review discusses factors affecting recovery following hip fracture in frail older people as well as interventions associated with improved functional recovery. Prefracture function, cognitive status, co-morbidities, depression, nutrition and social support impact recovery and may interact to affect post-fracture outcome. There is mounting evidence that exercise is beneficial following hip fracture with higher-intensity/duration programmes showing more promising outcomes. Pharmacologic management for osteoporosis has benefits in preventing further fractures, and interest is growing in pharmacologic treatments for post-fracture loss of muscle mass and strength. A growing body of evidence suggests that sub-populations - those with cognitive impairment, residing in nursing homes or males - also benefit from rehabilitation after hip fracture. Optimal post-fracture care may entail the use of multiple interventions; however, more work is needed to determine optimal exercise components, duration and intensity as well as exploring the impact of multimodal interventions that combine exercise, pharmacology, nutrition and other interventions.