The relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome

doi:10.1016/j.clnu.2012.03.010

Clinical Nutrition

Volume 31, Issue 6, December 2012, Pages 917-921

https://doi.org/10.1016/j.clnu.2012.03.010 Get rights and content

Summary

Background & aims

Malnutrition is common in hip fracture elderly patients. The purpose of this study was to examine the relationship between the Mini Nutrition Assessment Short Form (MNA-SF) and cognitive, functional status, comorbidity and outcome of operated patients.

Methods

Clinical data, MNA, functioning, cognition were prospectively determined. Retrospectively, the Charlson Comorbidity Index (CCI) and Cumulative Illness Rating Scale for Geriatrics (CIRS-G) were applied.

Results

The study consisted of 95 well-nourished (WN), 95 at risk of malnutrition (ARM) and 25 malnourished (MN) patients. More WN patients were independent vs. partially or fully dependent; more WN patients were cognitively normal vs. cognitively impaired (p < 0.001). CIRS-G was higher in MN vs. WN patients and CCI was higher in MN and ARM vs. WN patients (p < 0.001). During a 6 month period, 100 patients were readmitted, with less readmissions in the WN group (p = 0.024). During a 36 month follow-up, 79 patients died. The mortality rate was lower in the WN group (p = 0.01). Stepwise regression analysis found that the only independent variables for mortality were CCI and functioning (p < 0.01).

Conclusions

Patients with higher cognitive and functional status were in superior nutritional condition. Poor nutritional status was associated with higher comorbidity indices, mortality and readmissions. However, we found that only comorbidity and low functioning can predict long-term mortality.

Introduction

The worldwide increase in hip fractures among the elderly poses a major challenge to the health care system and society.¹ Hip fracture in older adults is associated with increased mortality, disability and dependence on others.1, 2, 3, 4 The fracture may mark the end of a person's independent life, with reports that only 50–60% of patients return to their own home.2, 5, 6

Aging is associated with physical, mental, social and environmental changes which may contribute to the risk of malnutrition.⁷ Up to 58% of patients with a hip fracture have been found to be malnourished on admission or will develop serious nutritional deficits while hospitalized compared with only 2% of those living at home.1, 3, 8, 9, 10 Malnourishment may be aggravated by pre-operative semi-starvation due to pre-operative fasting, long delays pre-surgery, moderate to severe pain, nausea and vomiting.⁸ Malnutrition combined with the catabolic response to surgery, leads to muscle wasting and has been found to be associated with impairment in post-operative rehabilitation,1, 8 post-operative complications, poorer clinical outcomes, increased length of stay5, 7, 9 and mortality.2, 10, 11

Some studies involving oral supplements given to orthopedic patients, have attained positive effects as to activities of daily living (ADLs), health-related quality of life, reduction in post-operative complications, shorter hospitalization,⁷ reduced six months post-operative mortality8, 9 and improvement in the Mini Nutritional Assessment (MNA) score,¹² while other studies did not demonstrate any specific effects. Clearly, early identification and treatment of undernourished patients with a hip fracture is essential.¹¹

Although large numbers of hip fracture elderly patients are functionally and cognitively impaired pre-fracture, little is known about the relationship between their nutritional and functional status and outcome. The aim of the current study was to examine the relationship between the nutritional status assessed by the MNA short-form (MNA-SF) and cognitive, functional status, comorbidity, readmissions and long term mortality of hip fracture operated elderly patients.

Section snippets

Study design

This cohort study took place in the Ortho-geriatric unit of the Department of Geriatrics, Beilinson Hospital, Rabin Medical Center, Israel. Included in the study were all patients ≥65 years old who were operated on for hip fracture between 11/2007–10/2009 and hospitalized in the Ortho-geriatric unit. Excluded were patients with terminal illnesses (end stage malignancy, severe chronic lung disease or heart failure) and multi-trauma cases such as vehicular accidents. The study was reviewed and

Results

A total of 251 patients were admitted between 11/2007–10/2009 to the Ortho-geriatric unit. Two hundred fifteen operated patients were included in the study (36 mainly non-operated patients were excluded), of whom 154 (71.6%) were women. Mean age was 83.5 ± 6.09 years, ranging from 66 to 104 years. One hundred twenty six (58.6%), 78 (36.3%) and 11 (5.1%) patients had undergone surgical repair of pertrochanteric, sub-capital and sub-trochanteric fractures, respectively. One hundred twenty-five

Discussion

In the present study, we found that elderly patients admitted with a hip fracture, have a higher rate of malnutrition or are at risk of malnutrition. Many of these patients are partially or fully-dependent and cognitively impaired. In addition, they have higher comorbidity scores, readmissions and mortality rates.

Previous studies have revealed similar rates of undernourished and at risk of malnutrition hip fracture patients upon admission, 32.5% and 56%, respectively.1, 11 Recently, Hoekstra

Conclusions

Elderly patients admitted with a hip fracture have a high rate of malnutrition and risk of malnutrition. Patients with higher cognitive and functional status are in a superior nutritional condition. Poor nutritional status assessed by the MNA is associated with higher comorbidity indices, mortality and readmissions. However, only comorbidity and low functioning can predict long-term mortality.

Funding

None.

Author agreement

All authors have made substantial contributions and gave final approval of the conceptions, drafting and final version.

Author contributions

TK-H a principal investigator conceived the study, participated in its design, collection and analysis of data, interpretation of results and writing the manuscript

AW was involved in the study design and interpretation of the results

AH participated in the study implementation

IO participated in collection and analysis of data

BG contributed to the study design and implementation, participated in collection of data

SF was involved in the study design and implementation

MS was involved in the study

Conflict of interest

None known.

Acknowledgments

All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. The manuscript, including related data, figures and tables has not been previously published and that the manuscript is not under consideration elsewhere. I.e. collection of data,

References (32)

K. Norman et al.
Prognostic impact of disease-related malnutrition
Clin Nutr
(2008)
M.F. Folstein et al.
“Mini-Mental State”. A practical method for grading the cognitive state of patients for the clinician
J Psychiatr Res
(1975)
J. Kondrup et al.
Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002
Clin Nutr
(2003)
M.D. Miller et al.
Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale
Psychiatry Res
(1992)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
J.C. Hoekstra et al.
Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study
Clin Nutr
(2011)
Y. Guigoz et al.
Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment
Clin Geriatr Med
(2002)
S. Chevalier et al.
The physical functional capacity of frail elderly persons undergoing ambulatory rehabilitation is related to their nutritional status
J Nutr Health Aging
(2008)
M. Pirlich et al.
The German hospital malnutrition study
Clin Nutr
(2006)
H.M. Kruizenga et al.
Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ)
Eur J Intern Med
(2006)

E. Paillaud et al.

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

Br J Nutr

(2000)

A. Avenell et al.

Nutritional supplementation for hip fracture aftercare in older people (Review)

Cochrane Database Syst Rev

(2010)

T.T. Huang et al.

A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling

J Clin Nurs

(2005)

J. Espaulella et al.

Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial

Age Ageing

(2000)

M. Lumbers et al.

Nutritional status in elderly female hip fracture patients: comparison with an age-matched home living group attending day centers

Br J Nutr

(2001)

A. Avenell et al.

Nutritional supplementation for hip fracture aftercare in older people

Cochrane Database Syst Rev

(2006)

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Malnutrition and cognitive impairment are associated with poor functional recovery in older adults following hip-fracture surgery. This study examined the combined effects of cognitive impairment and nutritional trajectories on postoperative functional recovery for older adults following hip-fracture surgery.
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Better nutritional status over time for older adults following hip fracture can protect against adverse influences of cognitive impairment on ADLs during postoperative recovery. Participants with malnutrition and cognitive impairment had the poorest ADLs. These findings suggest interventions tailored to improving nutritional status may improve recovery for older adults following hip-fracture surgery.
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Original articleThe relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome

Summary

Background & aims

Methods

Results

Conclusions

Introduction

Section snippets

Study design

Results

Discussion

Conclusions

Funding

Author agreement

Author contributions

Conflict of interest

Acknowledgments

Clin Nutr

J Psychiatr Res

Clin Nutr

Psychiatry Res

J Chronic Dis

Clin Nutr

Clin Geriatr Med

J Nutr Health Aging

Clin Nutr

Eur J Intern Med

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

Br J Nutr

Nutritional supplementation for hip fracture aftercare in older people (Review)

Cochrane Database Syst Rev

A randomized clinical trial of the effectiveness of a discharge planning intervention in hospitalized elders with hip fracture due to falling

J Clin Nurs

Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial

Age Ageing

Nutritional status in elderly female hip fracture patients: comparison with an age-matched home living group attending day centers

Br J Nutr

Nutritional supplementation for hip fracture aftercare in older people

Cochrane Database Syst Rev

Original article
The relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome