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

Abstract

BackgroundMalnutrition 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).MethodsOpen-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.ResultsOne 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; plogrank = .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.ConclusionsIntensive 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.

Hip Fracture Patients in Geriatric Rehabilitation Show Poor Nutritional Status, Dietary Intake and Muscle Health

“…Other studies in hip fracture patients found mean protein intakes ranging from 43 to 57 g [33][34][35]62], which are comparable to our findings (55 g). In these studies energy intakes were also low (mean intakes ranged from 1025 to 1304 kcal versus 1319 kcal in the current study) [33][34][35]62]. Since the intake of protein and energy were low (overall low intake of food), the intakes of many other nutrients were low as well.…”

“…Such low protein intake can further induce a decline of muscle and bone mass, a higher hip fracture risk and a poor nutritional status [26,61]. Other studies in hip fracture patients found mean protein intakes ranging from 43 to 57 g [33][34][35]62], which are comparable to our findings (55 g). In these studies energy intakes were also low (mean intakes ranged from 1025 to 1304 kcal versus 1319 kcal in the current study) [33][34][35]62].…”

“…The majority of the participants, 73%, were classified as either malnourished or at risk of malnutrition. In other studies that used the MNA to measure nutritional status in hip fracture patients, prevalence varied from 30 to 86% for malnourishment and risk of malnutrition together [20,23,[32][33][34][55][56][57]. Differences in prevalence may be explained by the inclusion of patients with dementia and delirium as we did in our study, because these patients have an increased risk of malnutrition [58][59][60].…”

“…Previous studies have shown that indeed energy, protein, vitamin D and calcium intakes can be low after a hip fracture [32][33][34][35]. However, these studies involve hospitalized patients and still little is known about inpatient geriatric rehabilitation.…”

JPEN Journal Club 39. Validating a Surrogate

“…The hypothesis of the investigators was that an improvement of the malnutrition would improve the clinical outcome. As was pointed out in the Netherlands statement, and has usually been observed in RCTs in which both nutrition and clinical outcomes have been assessed (including this trial), this has not typically been the case. Various methods of providing nutrition support (including oral supplements) commonly improve nutrition status (at least with regard to energy and protein intake, body weight, and nitrogen balance), but mortality and various morbidities are, in general, not similarly affected.…”