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Vulnerable patients with a fractured neck of femur:nutritional status and support in hospital M. Nematy,* M. Hickson,* A.E. Brynes,* C.H.S. Ruxton  & G.S. Frost* *Nutrition and Dietetic Research Group, Imperial College London, Hammersmith Hospitals Trust, London W12 0HS, UK;  Schoolof Biosciences, University of Westminster, London W1W 6UW, UK 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 nutri- tional support, which was provided to this group during their stay in Tel.: 020 8383 3048/014 8368 9384fax: 020 8383 3379 Twenty-five consecutive people admitted to an ortho- paedic ward with a fractured NOF at Charing Cross Hospital, London hospital, elderly, fractured neck offemur, hospital malnutrition, were recruited. Anthropometric measures, biochemical indices, nutritional status, nutritional support.
3 days dietary intake and dietetic referral rates were collected.
Patients had a significantly lower body mass index (BMI) compared with the mean BMI for sex and age in an elderly UKpopulation (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 inweek 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 referredto a dietitian and were given nutritional supplements. Nutritionalassessment revealed that their nutritional status worsened duringstay.
This group of patients with fractured NOF is likely to be malnourished on admission and to show a rapid deterioration inits nutrition status during admission. Energy needs were not met inup to 50% of patients. These results reinforce the need to screen,supplement and monitor fractured NOF patients.
currently accounting for 16% of the population with an estimated rise to 20% by 2021 (Office of Elderly people, aged over 65 years, are the fastest national statistics, 2000). Falls are more common growing section of the population in the UK, in older age groups; one study estimated that 50% Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 of people over 80 years fall, compared with only nutritional supplements are used in most hospitals 30% of people over 65 years (Vellas et al., 1992).
but their effectiveness varies (Milne et al., 2005), Malnutrition has been suggested to increase the probably because of reasons of palatability, prac- risk of falls (Lumbers et al., 2003); to increase ticality and also the influence of poor appetite.
recovery time and to account for a proportion of This observational study was conducted to disability and death in the elderly (Hayes et al., evaluate the nutritional status of a group of elderly 1996). The incidence of malnutrition in hospital- patients admitted to an orthopaedic ward with a ized over-80s is high (Corish & Kennedy, 2000).
fractured NOF and their nutritional support dur- Therefore elderly orthopaedic in-patients are at particular risk of a suboptimal nutritional status.
This high risk of malnutrition in hospitalized elderly is supported by a previous study, whichsuggested the nutritional intake of elderly female patients recovering from a fractured neck of femur(NOF) is often inadequate (Older et al., 1980). We This was a prospective study and local ethics have previously presented insufficient energy in- committee approval was obtained (RREC 3439/ take in patients with fractured NOF in abstract 2003). Patients who could read the information sheet and acknowledged that they understand the Clearly, early identification and treatment of study gave written informed consent, and relatives undernourished patients with fractured NOF who gave assent prior to enrolment for those with are at risk of poor nutritional status are essential impaired vision. The inclusion criteria were male (Beck & Ovesen, 1998). However, in practice it is and female patients aged 65 years and over, with a very difficult to re-feed sick and elderly patients.
fractured NOF resulting from a fall, who were Oral supplements are predominantly suitable for admitted to the orthopaedic wards at Charing elderly people compared with nasogastric or ent- eral feeds, as they are not invasive and are easy to use. However, there may be problems with the • Those unable to give informed consent and who motivation and capability of older people to take did not have relatives who could give assent.
oral supplements and therefore, supplements may • NOF fracture following pathological conditions not be consumed in sufficient amounts. One study or road traffic accidents as these patients may have showed that even if supplements are prescribed, had associated complications that exaggerated or staff may forget to give them to patients or, if they complicated the assessment of nutritional status.
are given, they may not be consumed (Peak et al., • Those who were admitted for elective surgery 1998). A recent study identified patients who were not meeting their estimated energy requirements, • Patients who were enrolled in another concur- then used supplements to achieve this goal.
However, the energy intake (EI) only increased to The study was performed in accordance with the a median of 67% of estimated requirements, sug- gesting that insufficient supplements were con-sumed (Miller et al., 2005a).
One study has shown that, even with additional feeding support, older patients did not eat enough Nutritional and medical data were collected from to achieve an adequate weight gain or nutritional patients, charts, medical notes, nurses‘ files, care status (Hickson et al., 2004). Possibly this failure staff, dietitians, occupational therapists, physio- to respond to feeding support is due to suppressed therapists and the medical team. Parameters cor- appetite; no matter how much assistance and encouragement is given, if the appetite is poor, anthropometrics [mid-arm circumference (MAC), intake is unlikely to improve. At present, height or demi-span, weight and body mass index Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 Nutritional status in fractured neck of femur patients (BMI)] biochemical indices (albumin, total pro- of infection, period of fasting and the need for tein, C-reactive protein and haemoglobin) and help with eating and drinking). In combination, dietary intake were recorded. At the first visit it these factors enable patients to be categorized as was established which type of accommodation the either high risk of malnutrition, moderate risk, patient had been admitted from (own home, sheltered housing, residential home and nursinghome), whether they lived alone, their alcohol consumption and smoking status, their mobilitybefore admission, whether they were taking Mid-arm circumference was assessed on admis- medication or any food supplement, their previous sion to the orthopaedic ward using standard pro- history of falls and their general medical history.
tocols (Jensen et al., 1981; Gibson, 1993), by one Subjects were followed-up, until discharged researcher. After their operation, patients were from hospital, to identify: malnutrition risk during weighed using a chair scale (Weighcare, Marsden, stay, referral to a dietitian, prescribed drugs UK). The demi-span was measured to estimate including antibiotics, Waterlow score change, standing height in order to compute BMI (Bassey, pressure sores occurrence, dietary supplement use, physiotherapy mobility assessment, malnu-trition risk on discharge, and date and destination The Elderly Mobility Scale (EMS) was seriallyperformed in patients with fractured NOF by physiotherapists. This is a valid tool with good Dietary intake was recorded over 3 days during inter-rater reliability that could be readily applied week 2 after the operation, using unweighed during daily clinical work for measurement of food records completed at ward level. Nurses mobility of hospitalized elderly people (Prosser & were given instructions on how to complete the Canby, 1997). This scale scores between 0 (corre- records and these were checked daily by the sponding to complete dependence) to 20 (corre- researcher. Where possible food charts were sponding to complete independence). The EMS is verified with the patient to make sure of based on scoring seven actions including, (i) lying to sitting, (ii) sitting to lying, (iii) sit to stand, brought in by relatives. Mean daily energy and (iv) stand, (v) gait, (vi) timed walk (6 m) and nutrient intake was calculated from the food records using the Dietplan5 computerized foodtables (Forestfield Software Ltd, West Sussex, UK). Estimation of the total energy requirementof patients at the time of their food record was The data were analysed using SPSS 12.0 for Win- calculated by estimating basal metabolic rate dows. All data were checked for normality and (BMR) (Schofield, 1985), adding a stress factor presented as mean and standard error of the of 20% (to account for the increased energy mean. An independent 2-tailed t-test was per- requirements because of surgical correction of formed to compare the nutritional parameters’ the fractured NOF) and adding another 10–25% variables between patients and National Diet and (based on the level of mobility in the ward) to Nutritional Survey findings (Finch et al., 1998).
allow for rehabilitation, physical activity and Paired t-tests were used to compare EI and energy diet-induced thermogenesis. Malnutrition risk requirements in each malnutrition risk group.
was also recorded from the hospital’s own Analyses of variance with Bonferonni corrections screening tool (Peak et al., 2000). This tool is for multiple testing were used to compare EIs and based on changes in dietary intake, weight and energy deficits between the three malnutrition risk other risk factors (pressure sore status, presence Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 consent. Demographics of patients, their past medical history, mobility data, residence at time ofadmission and discharge, whether they lived alone and length of stay in hospital are shown in Table 1.
Thirty-six patients were approached to take part. Of Mean age was 85.3 ± 1.5 years, supporting previ- these 25 were recruited and all completed the study.
ous studies which show an increased risk of NOF A further eight patients were confused and unable to fracture in the over 80s. The most common secon- give informed consent and three refused to give to an orthopaedic ward at Charing CrossHospital, London *Nutrition risk was established using the local risk assessment tool, which incorporates dietaryintake, recent weight loss and other factors affecting intake or requirements.
 Elderly mobility scale runs from 0 to 20 with 20 corresponding to complete independence,anthropometric data shown are related to admission.
MAC, muscle arm circumference; BMI, body mass index; COPD, chronic obstructive pulmonarydisease.
Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 Nutritional status in fractured neck of femur patients Table 2 Profile of BMI categories used to diagnose malnu- females, who lived alone in their own home and trition in patients with fracture neck of femur admitted to anorthopaedic ward (n ¼ 25) were able to walk without an aid before the frac-ture. On discharge from hospital this picture altered dramatically with only 44% of subjects able Pain killers were used commonly during the first week post-surgery. Antibiotics (cefuroxime, ceftazidime, chloramphenicol, gentamicin and nitrofurantoin) were prescribed for related com- plications (urinary tract infections, conjunctivitis *Suggested cut-off for people older than 75 years.
 Commonly used cut-off in many prevalence studies.
àWHO definition.
Table 1 shows the anthropometric profile of sub- malnutrition risk assessment tool. The results for jects. Compared with nationally representative biochemical indices, food intake during week 2, data from the UK National Diet and Nutritional referral rates to the dietitian and the number of Survey (Finch et al., 1998). Our patient group had deaths in hospital are also given. Malnutrition risk a significantly lower BMI (21.97 ± 1.06 versus was high at admission with 56% (14 of 25) of 26.73 ± 0.03 kg m)2, P < 0.005). BMI is not the patients either at moderate or high risk and this best indicator of malnutrition risk, however it can picture worsened during the stay to 68% (17 of 25).
offer a guide when used in combination with other The food intake data collected in the second week factors. There is no consensus in the literature as revealed that mean daily EI was 59% of estimated yet regarding the most appropriate cut-off point energy requirements (4219 ± 319 kJ day)1 versus for malnutrition risk in older people. However, increasing evidence suggests that the BMI range The biochemistry showed a picture of an acute associated with the lowest risk of mortality is phase response following the fracture and surgery higher than previously thought in the over 75s with C-reactive protein (CRP) rising and albumin (Beck & Ovesen, 1998; Stevens, 2000) . For this and total protein falling. Haemoglobin levels also reason, we examined our data with respect to three possible cut-off points and this analysis is shown The screening tool used in this study recom- mends that all high-risk patients are referred to • 18.5 kg m)2, the WHO definition of the lower the dietitian whereas moderate-risk patients are limit for normal weight (World Health Organisa- put on a nutrition care plan which incorporates nurse-led interventions (such as giving ‘build-up’ • 20 kg m)2, the usual value used throughout the drinks and encouraging intake at meal times).
literature to recognize malnourished elderly; No data were collected on whether appropriate • 24 kg m)2, suggested as the most appropriate care plans were instigated for moderate-risk cut-off to identify the elderly at-risk patient (Beck patients in our study. However, referrals to the dietitian were recorded showing that four of 11 The data show wide differences in the incidence (36%) high-risk patients were not referred. Of of ‘malnutrition’ depending on the cut-off used.
the seven patients referred to the dietitian (allwere from the high risk group), all were given astandard high-energy diet during week 2–4 (extra snacks and fortified choices on the menu).
Table 3 describes the nutritional assessment of In addition to this, four were prescribed supple- mented drinks and one was given a nasogastric Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 Table 3 Changes in the malnutrition risk, biochemical indices and energy intakes of fractured neck of femur patients during ahospital stay *Assessed using the Hammersmith Hospital Nutrition Screening Tool (O’Flynn et al., 2005).
nutritionally at risk group (n ¼ 17) andthe not at risk group (n ¼ 8) of patients BMI, body mass index; MAC, muscle arm circumference; CRP, C-reactive protein. Values pre-sented here are mean ± SEM.
feed. Of all 25 patients, five were prescribed irontablets by their doctor.
Comparison between the at risk group (n ¼ 17) and the not at risk group (n ¼ 8) revealed that theformer demonstrated a significantly lower mean weight, BMI, MAC and higher CRP on admissionand a significant lower EI during week 2 of stay Figure 1 shows energy deficit and differences in EI between the three risk groups. EI fell across thegroups with the lowest intakes seen in the ‘high risk’ group (P ¼ 0.05 between the ‘not at risk’ and‘high risk’ groups). Paired t-tests showed that EI in each risk group was significantly less than esti- mated energy requirements, but there were no significant differences between the energy deficits Figure 1 Energy deficit (MJ day)1) in each malnutrition group of patients with fractured neck of femur. Solid bar, mean Within 9 months of entry to the study nine energy intake; stripped bar, estimated energy requirement patients had died. Seven of these were from the (EER); mean energy intake in not at risk versus high risk +,P ¼ 0.05. Energy intake in each group was significantly less ‘high risk’ group, one from the ‘moderate risk’ than EER *,P < 0.005, P ¼ 0.001 and P ¼ 0.02 versus EER group and one was from the ‘not at risk’ group.
Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 Nutritional status in fractured neck of femur patients from surgery for a fractured NOF. This would serve to lower estimated energy requirements in The mean length of stay in this group of emer- gency surgical patients was 36.2 ± 4.7 days. This Although we aimed to collect malnutrition is significantly longer than the 5 days average for status on discharge for this cohort it proved surgical patients admitted to this hospital. The extremely difficult. Patients were moved around mean score of 8.4 on the EMS on discharge sug- the hospital and often transferred out to rehabil- gests that patients were highly dependent on itation centres with little or no warning. Thus, our mobility aids and devices and would require data for this period are not reliable enough to ongoing physiotherapy and occupational therapy, present. Nevertheless the data presented here represent convincing evidence that a more activeand aggressive approach to nutritional support inthis patient group is justified. Our data do show that independence is compromised after hip frac- This study confirms that hip fracture patients are ture and this may further affect patients’ abilities an elderly and particularly frail group and that the to eat and drink, or shop and cook, once dis- event of a hip fracture alters dramatically the prognosis and level of independence of the indi- It should also be noted that our study group is vidual. We have also shown that the nutritional not truly representative of the usual geriatric status of such patients can deteriorate dramatic- patient population as we were unable to recruit ally during the first 1–2 weeks of their hospital cognitively impaired patients. Such patients are stay, due in part to a severely reduced food intake, more likely to be malnourished and have a greater as shown by the food intake data. Even with a well- risk of deteriorating nutritional status.
established and monitored screening tool in place Furthermore, evidence shows that following a a third of the patients in this study who merited period of restricted intake and weight loss, older dietetic referral were not referred. It is not known adults are less likely to compensate by eating more whether the mortality figures in our study were and regaining weight. Roberts et al. (1994) dem- influenced by this failure to address malnutrition, onstrated that young men quickly regained weight although other studies have clearly demonstrated by eating more whereas old men did not adapt and that the risk of mortality increases when nutri- continued to restrict their EI, further exacerbating tional status is poor (Kagansky et al., 2005).
weight loss. Every effort was made to record all the Energy needs were not met in up to 50% of food and drinks which patients consumed how- patients. The energy requirements for these pa- ever there might be a few instances of under- tients to maintain weight were estimated by taking reporting. All the patients in our study ate less into account additional energy needs postopera- than their estimated requirements, thus even the tively and current activity levels. Although 36% of patients with the best recovery may continue to lose weight once discharged. This would contrib- (BMI < 20 kg m)2), we did not adjust their energy ute to longer-term mortality and loss of inde- requirements to include a factor for gaining weight. This was because of the difficulty in The mechanisms controlling appetite and this meeting requirements to simply maintain weight.
lack of adaptation to poor intake observed with Attempting to gain weight at this stage may be ageing have yet to be fully elucidated but, in this considered unrealistic. In addition, bed rest im- patient group, the reasons for the poor food intake pacts on energy expenditure and, thus energy are likely to be linked to both physiological and requirements. (Miller et al., 2005b) reported that pathological factors. Patients often have a lower resting metabolic rate was lower in the late post- food intake because of pain, nausea, confusion, operative period (day 10–42) compared with the immobility and drug side-effects, at a time when early postoperative period in patients recovering they have increased energy requirements. Factors Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 relating to hospital food provision will also play a some of the patients in rehabilitation centres may role, such as lack of choice, unfamiliar foods and also have returned home given time. A similar low mealtimes, unpleasant environmental factors, eat- rate of recovery to independence was shown by ing alone and lack of assistance. Possibly physio- Delmi et al. (1990) who reported 50–60% of patients logical factors associated with appetite suppression returning to their own home. These data suggest also play an important role. Hickson et al. (2004) that the major trauma of a hip fracture and subse- highlighted the difficulties of improving the intake quent surgical repair may hasten the end of a per- of acutely ill elderly patients during a hospital stay.
Additional support at mealtimes was given to Nutrition assessment of our patients suggested patients in this study, yet no significant changes in that their nutritional status was poor prior to weight or nutritional status were seen. A similar admission to hospital. Quite how prevalent mal- finding was seen in the study of Delmi et al. (1990).
nutrition was in this patient group depends on the Daily oral supplements were given to 27 elderly classification of malnutrition risk used. We have patients with fractured NOF for 32 days but, despite clearly shown that different BMI cut-off points adequate energy provision, nutritional require- dramatically alter the number of potentially mal- ments were not met during the hospital stay.
Appetite may be the limiting factor, perhaps (<18.5 kg m)2) gives the lowest incidence of exacerbated by the dulling of taste and smell which malnutrition risk, but the data for this cut-off point were derived mainly from young healthy A range of neural and endocrine factors control adults. The usual value of <20 kg m)2 provides an appetite. Appetite reduction during ageing is incidence of malnutrition risk of 36%, comparable possibly related to gastric distension (Sturm et al., with many published studies (McWhirter & Pen- 2004) and changes in gut hormone release (Cum- nington, 1994; Corish & Kennedy, 2000). The no- mings et al., 2001; Le Roux & Bloom, 2005). There vel value of 24 kg m)2 suggests that 72% of the is an intriguing possibility that regulatory appetite patients are at risk of malnutrition (Stevens, 2000).
peptides may be changed by acute illness resulting The range of 23.5–24.9 kg m)2 was the BMI cate- in a depressed appetite (Nematy et al., 2005).
gory with the lowest hazard ratio among those Much work is still needed to understand appetite >75 years, with the lowest mortality relating to the regulation in general but particularly in this high end of this BMI range (Stevens, 2000). Thus, if the data of Stevens (2000) can be confirmed, the Our other findings reflect those of other studies. A prevalence of malnutrition in our patient group systematic review has reported that the mean age of was extremely high. It is also similar to the inci- hip fracture patients is usually over 80 years (Av- dence found with the nutrition screening tool, enell & Handoll, 2003). A study on 114 hip fracture where 56% of patients were at risk on admission.
patients showed 49% had a history of hypertension Further work is needed to reach a consensus on (Van et al., 1998) comparable with our finding of the ‘normal’ BMI range, which is most appropriate 60%. It is not known if patients who had fractured NOF secondary to fall underwent orthostatic The main weakness of this study is the small hypotension or transient ischaemic attacks. Tinetti sample size and the lack of data from the end of et al. (1986) who studied fall risk index for elderly the hospital stay. Further work is required to patients based on number of chronic disabilities verify these findings and additional research is reported that a postural drop in blood pressure was needed to investigate ways to treat the nutritional correlated with falls. Several studies have demon- deficits in this patient group. Perhaps the most strated an association between malnutrition and an promising new information will come from work increased risk of complications (Sullivan et al., investigating appetite control during ageing, dis- 1990) and extended length of stay (Paillaud et al., 2000), which support our finding of 36.2 days. Our The main implication of this work is to highlight study found 44% returned their own home, but the importance of early nutritional assessment in Ó The British Dietetic Association Ltd 2006 J Hum Nutr Dietet, 19, pp. 209–218 Nutritional status in fractured neck of femur patients this patient group and the urgent need for timely Bassey, EJ. (1986) Demi-span as a measure of skeletal size.
intervention. Dietitians working with fractured NOF patients should seek to ensure that all Beck, A.M. & Ovesen, L. (1998) At which body mass index and degree of weight loss should hospitalized elderly patients are screened early after admission and patients be considered at nutritional risk? Clin. Nutr. 17, given appropriate nutritional support. It may be more effective and time-saving to instigate a policy Corish, C.A. & Kennedy, N.P. (2000) Protein-energy requiring supplementation in all NOF in-patients undernutrition in hospital in-patients. Br. J. Nutr. 83, over 80 years during the first 2 weeks of their Cummings, D.E., Purnell, J.Q., Frayo, R.S., Schmidova, K., Wisse, B.E. & Weigle, D.S. (2001) A preprandial rise inplasma ghrelin levels suggests a role in meal initiation in Delmi, M., Rapin, C.H., Bengoa, J.M., Delmas, P.D., Vasey, Patients with a fractured NOF were likely to be H. & Bonjour, J.P. (1990) Dietary supplementation in malnourished on admission and showed a rapid elderly patients with fractured neck of the femur. Lan-cet. 335, 1013–1016.
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