nutricia · prevalence • approximately 65,000 hip fractures each year in the uk1,2 • at any one...

$: Nutricia · Prevalence • Approximately 65,000 hip fractures each year in the UK1,2 • At any one time over 4,000 hospital beds are occupied by patients with hip fractures in the$
Nutrition and Fractured Neck of Femur (NOF)

Nutricia

Outline • Introduction to fractured neck of femur (NOF)

• Definition

• Prevalence

• Cost and impact on NHS

• Causes and risk factors

• Impact and complications

• Malnutrition in fractured NOF

• Definition and screening

• Prevalence

• Link between NOF fractures and malnutrition

• Causes of malnutrition in this group

• Consequences of malnutrition on this group

• Nutritional requirements of patients with fractured NOF

• Nutritional management of patients with fractured NOF

• Case study

1 Introduction

Definition

1. NHS 2016 http://www.nhs.uk/Conditions/Hip-fracture/Pages/Introduction.aspx [06.12.16] 2. Brunner LC, et al. Am Fam Physician. 2003; 67(3):537-543. Available from: http://www.aafp.org/afp/2003/0201/p537.html [06.12.16]

• Fractured neck of femur (NOF) = hip fracture

• Refers to “cracks or breaks in the top of the thigh bone (femur)

close to the hip joint.”1

Prevalence

• Approximately 65,000 hip fractures each year in the UK1,2

• At any one time over 4,000 hospital beds are occupied by

patients with hip fractures in the UK1

• Peak number of hip fractures occurred at 75-79 years of age for

both sexes3

• Approximately 75% of hip fractures occur in women3

• The most common serious injury and most common reason for

emergency surgery in older people2

1. RCP 2015. http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf [06.12.16] 2. RCP 2016. http://web1.crownaudit.org/Report2016/NHFD2016Report.pdf [06.12.16] 3. IOF 2015. https://www.iofbonehealth.org/facts-statistics [06.12.16]

Cost and impact on NHS

Average length of

stay across UK is 21 days.1

Annual cost approx £1-2 billion = 1-2 % of NHS budget1,2

Major public health issue

due to increasing

ageing population2,3

Co-morbidites

prevalent in NOF fracture

patients2

1. RCP 2016. http://web1.crownaudit.org/Report2016/NHFD2016Report.pdf [06.12.16] 2. NICE 2014. https://www.nice.org.uk/guidance/CG124/chapter/Introduction [06.12.16] 3. Parliament 2015. https://www.parliament.uk/business/publications/research/key-issues-parliament-2015/social-change/ageing-population/ [06.12.16]

Falls are common in older people1,2

More likely to happen when e.g. slippery floor, dim lighting, carpet not

secured properly, when reaching for item, going down stairs, rushing

to toilet.3

Cause

This is because older people are more likely to

experience :1,2

• Muscle weakness

• Balance problems

• Osteoporosis

• Impaired vision

• Confusion

• Long term health condition e.g. heart disease, dementia,

hypotension dizziness

1. NHS 2016. http://www.nhs.uk/Conditions/Hip-fracture/Pages/Introduction.aspx[06.12.16] 2. CDC 2016. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html[06.12.16] 3. NHS 2015. http://www.nhs.uk/conditions/Falls/Pages/Introduction.aspx ] [06.12.16]

Risk factors1-6

1. NHS 2016. http://www.nhs.uk/Conditions/Hip-fracture/Pages/Introduction.aspx [06.12.16] 2. NHS 2016. http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx [06.12.16] 3. IOF 2015. https://www.iofbonehealth.org/facts-statistics [06.12.16] 4. Zhanglin Cui et al. J Med Eco 2015; 18(1):1-43

5. CDC 2016. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html [06.12.16] 6. Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014 7. Anatomy Zone 2016. https://www.nof.org/patients/what-is-osteoporosis/ [20.12.16] 8. National Osteoporosis Foundation 2016. https://www.nof.org/patients/what-is-osteoporosis/ [20.12.16]

Osteoporosis

• Age- bone resorption rate increases with age

• Gender

• BMI

• Smoking/drinking

• Inactive

• Poor diet

•

Muscle weakness

• Inactive

• Inadequate diet

• Disease

• Poor appetite

7

8

2 Malnutrition in NOF fracture

Definition of Malnutrition

‘A state of nutrition in which a deficiency or excess of energy, protein and

other nutrients causes measurable adverse effects on tissue/body form,

function and clinical outcome’.

• Malnutrition can refer to both undernutrition and overnutrition.

• This presentation focuses solely on undernutrition.

Source: BAPEN 2016. http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition [06.12.16]

Malnutrition Universal Screening Tool (MUST)

Takes into account:

• BMI

• Unplanned weight loss

in in past 3-6 months

• Illness and nutritional

intake

Source: BAPEN 2011. http://www.bapen.org.uk/pdfs/must/must_full.pdf [06.12.16]

Likely to be malnourished on

admission (~60%)1-5

Significantly lower BMI compared to UK

mean for sex and age4

Energy needs not met in up to 50% of patients in hospital 4

56% patients at risk of malnutrition on

admission, increased to 68% after 2-3

weeks in hospital 4

Prevalence of Malnutrition in NOF fractures

1. Li HJ et al. J Adv Nur 2013; 69(8):1691-703

2. Olofsson B et al. J Clin Nur 2007; 16(11):2027-38

3. Bonjour JP et al. Bone 1996; 18(3S): 139S-144S

4. Nematy M et al. JHND 2006; 19(3): 209-218

5. Hanger HC et al. NZ Med J 1999; 112(1084):88-90

Malnutrition and Hip fracture link

Malnutrition may increase risk of hip fracture by:1,2

1. Paillaud E et al. Br J Nutr 2000; 83(2):97-103 2. Bonjour JP et al. Bone 1996; 18(3S): 139S-144S

Reducing muscle strength

Diminishing protective layer of soft tissue padding

Accelerating the loss of bone mineral density at proximal femur

Malnutrition and Hip fracture link

And having a hip fracture is likely to make malnutrition

worse or induce it.

Malnutrition may occur during recovery from surgery as a

result of:

• Hypermetabolic state (3 months post surgery)

• Underlying issues affecting food intake

(poor appetite, dementia etc.)

Source: Paillaud E et al. Br J Nutr 2000; 83(2):97-103

Causes of Malnutrition in Older adults

Source: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014

Lack of interest in food- poor appetite caused by medications, depression,

illness, taste changes,

Availability of food - rely on others for shopping, cooking, feeding

Mental health – depression, loneliness, bereavement, confusion

Finances – limited budget, food can be seen as something to save on

Oral problems – poor fitting dentures, gum disease, poor oral hygiene

Swallowing problems- frightened of choking, embarrassed, pureed food,

thickened drinks

Mealtime experience – Unprotected mealtimes, poorly served food, portion

sizes, lack of choice

Assistance with food – reduced manual dexterity, poor hand to mouth

coordination, ability to unwrap and use cutlery

Effect Consequences

Weight loss (fat and muscle) Muscle wasting, poor mobility, increased risk of falls and chest infection

Reduced muscle strength and

fatigue

Inactivity, reduced ability to work, shop, cook and self care.

Poor muscle function may result in falls, and in poor cough pressure –

delaying expectoration and recovery from chest infection.

Reduced immune function

Impaired ability to fight infection

Impaired wound healing and

synthesis of new protein

Increased wound-related complications, such as infections

Impaired recovery from illness

and surgery

Longer recovery time

Consequences of Malnutrition


Effect Consequences

Impaired psycho-social

function

Even when uncomplicated by disease, malnutrition causes apathy, depression,

introversion, self-neglect, loss of libido and deterioration in social interactions

Impaired temperature

regulation

Hypothermia

Impaired ability to

regulate salts and fluids

Predisposes to over-hydration, or dehydration

Other consequences of Malnutrition

And many more


Poorer clinical outcomes

↑ Morbidity

↓ Wound healing

↑ Infections

↑ Complications

↓ Convalescence

↑ Mortality

↑ Treatment

↑ Length of stay in hospital

↑ GP visits

↑ Hospital admissions

and readmissions

Malnutrition

↓ QOL and ↑ COST


3

Nutritional Requirements in Fractured Neck

of Femur

Increased Energy Requirements

1. Paillaud E et al. Br J Nutr 2000; 83(2):97-103

2. Li HJ et al. J Adv Nur 2013; 69(8):1691-703

3. Olofsson B et al. J Clin Nur 2007; 16(11):2027-38



6. Hanger HC et al. NZ Med J 1999; 112(1084):88-90

1. Increased energy metabolism

Hypermetabolic (3 months post surgery)1

2. Low BMI upon admission

Likely to be malnourished upon admission2-6

3. Reduced dietary intake

Likely to show rapid deterioration during admission5

Increased Protein Requirements

1. Hypermetabolic (3 months post surgery)1

Increased protein requirements

2. Hip fracture patients are commonly admitted in energy AND

protein malnourished state2,3

Important to meet protein requirements

3. Low protein intake predicts worse outcomes in hip fractures pts

Patients with a low protein status take longer to heal, and have

higher complication and mortality rates4

Low protein intake increases hip fracture risk5

1. Paillaud E et al. Br J Nutr 2000; 83(2):97-103


3. Delmi M et al. Lancet 1990; 335(8696):1013-6


5. Wu AM et al. Sci Rep 2015; (16)5:9151

Increased Protein Requirements


2. Heaney RP et al. Am J Clin Nutr 2008; 87(5): 1567S-1570S

3. Darling AL et al. J Clin Nutr 2009; 90(6): 1674-92

4. Bonjour JP. 2011; 81(2-3): 134-42

5. Tkatch L et al. J Am Coll Nutr 1992; 11(5):519-25

Insufficient dietary protein compromises bone quality1 and may

decrease bone strength2 and structure3

4. Normalising protein intake improves outcomes

Reduced post fracture bone loss, enhanced muscle strength and

improved medical complications and length of inpatient stay4

Significantly reduced both complications and length of hospital

stay1

Reduced length of hospital stay, as well as lower rates of

complications and death5

Protein

Revision of Protein Requirements by the ESPEN Expert Group

• Protein intake for optimal muscle function with ageing:

− 1.0-1.2 g protein/kg body weight/ day for healthy older adults

− 1.2-1.5 g protein/g body weight/ day may be indicated for

certain older adults who have acute or chronic illnesses

− Even higher intake for individuals with severe illness or injury

• For a female 50+ years (50kg) the ESPEN recommendation for

protein is:

− 50-60 g/d (healthy)

− 60-75 g/d (acute or chronic illness)

Source: Deutz N, et al. Clin Nutr. 2014;33: 929-36

Increased Micronutrient Requirements

• Micronutrient intake is likely to be compromised in individuals who

have a diet deficient in energy and protein1

• Micronutrients are important for:

‒ Regulation of numerous body processes

− Optimal use of macronutrients (protein, fat and carbohydrate)

• Any form of nutritional support should consider the provision of

adequate micronutrients1

1. FAO. http://www.fao.org/docrep/x8200e/x8200e04.htm [06.12.16]

2. Gandy J. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014.

Nutritional Management in Fractured Neck

of Femur

4

ONS

Food fortification

Dietary advice

Nutrition support options

ONS

Food fortification

Dietary advice

Dietary advice

Highlight importance of adequate

nutrition for:

Ideas:

• Bone healing

• Recovery from surgery

• Reversing malnutrition

• Maintaining or gaining weight (may

decrease risk of hip fracture2)

• Increasing muscle mass and strength

• Increasing body fat for padding

• Puddings daily (e.g sticky toffee

pudding, rice pudding, cake and

custard, full fat yogurt)

• Snacks daily (e.g cheese and

crackers, hot chocolate and

biscuits) 1. Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014 2. Wu AM et al. Sci Rep 2015; (16)5:9151

Food fortification

ONS

Food fortification

Dietary advice

Fortify meals with high energy and protein foods e.g.

butter, cream, milk powder, cheese

• Add butter to mashed potato

• Cook vegetables in creamy, cheesy

sauce • Add cheese to meals

• Add cream to soup

• Fortify milk with milk powder

• Fortify porridge with cream or milk

powder


1. Hanger HC et al. NZ Med J 1999; 112(1084):88-90 2. Hubbard G et al. Clin Nutr Supp 2009;4(2):41-41

Oral Nutritional Supplements

ONS

Food fortification

Dietary advice

• High energy and protein, low

volume, complete in

micronutrients

• Helps to meet energy and protein

requirements and so aids in

achieving better outcomes

• 91% compliance in energy

dense (>2kcal/ml) ONS as

opposed to mean compliance

of up to 78%2

• ONS come in a variety of flavours

and styles to suit all tastes.

High protein ONS

Significant reduction

Complications

Hospital readmissions

Significant increase

Patient independence

Mean ADL score

Significant Improvement

Handgrip strength

Nutritional intake and

weight

Source: Cawood AL et al. Ageing Res Rev 2012;11(2): 278-96

Managing Adult Malnutrition in the Community

• Developed by a multi-professional

team and endorsed by 10 key

organisations, it is a pathway and

guideline to assist in community

identification and management of

malnutrition

• It uses the ‘MUST’ to place individuals

into risk categories and has

suggested management plans based

on low, medium and high risk ‘MUST’

scores

• This includes the use of prescription

ONS in medium and high risk patients

in the community

• It also includes guidance on

prescribing, monitoring and stopping

ONS

• Available from

www.malnutritionpathway.co.uk

http://www.malnutritionpathway.co.uk/

5

Case Study

Case Study

• 78 year old female admitted to Hospital

• Presenting condition:

− BMI 17.4

− Inpatient referral to Dietitian for low BMI and poor intake (less than

half of all meals)

− MHx: osteopenia (diagnosed 20 years ago)

− Medications: senna

− SHx: lives with husband who she helps to care for.

Mrs Smith

Case Study

• Anthropometry

― Weight: 46kg

― Height: 162.5cm

― BMI: 17.4 kg/m2

― Wt Hx:

o 51kg 6 months ago (9.8% weight loss in 3-6 months)

o reports gradual weight loss with age

o decreased appetite for many years

• Biochemistry

― raised CRP

― Low serum 25(OH)D

Case Study

• Clinical

− Must score = ≥ 3

Requirements for maintenance

(based on 20% AF + 10% SF)

=1,350 kcal, 69g protein (1.5g/kg/day)

Requirements for weight gain (+500 kcal)

=1,850 kcal, 69g protein

1. Henry CJ. Basal metabolic rate studies in humans: measurement and development of new equations. Public Health Nutr 2005;8:1133-1152. (Activity factor: 20%, Stress factor: 10%)

2. Deutz NEP et al. Protein intake and exercise for optimal muscle function with ageing: Recommendations from the ESPEN Expert Group. Clin Nutr 2014;33:929-936 (1.2-1.5g/kg/day )

3. Todorovic VE and Micklewright A (Eds). A pocket guide to clinical nutrition. 4th ed. British Dietetic Association, 2011.30-35ml/kg/day

Energy: 1,350-1,8501

Protein: 69g2

Estimated

Requirements

Fluid: = 1600 ml3

• Dietary (diet history)

Meal Food Consumed Energy (kcal) Protein (g)

Breakfast

¼ bowl porridge with milk 1 slice bread with butter + jam ½ cup orange juice Tea with milk and 1 sugar

60 146 29 40

2.5 2.1 0.4 0.8

Lunch ¼ tuna and mayonnaise sandwich ½ pot fruit yoghurt ½ cup orange juice

98 68 29

5.0 2.5 0.4

Dinner Small bowl of tomato soup 1 slice of bread with butter ½ serve custard

66 107 59

1.2 2.0 1.6

Snacks 2 biscuits Tea with milk and 1 sugar

140 40

1.9 0.8

Total 881 21.3

Case Study

Nutritional diagnosis

Inadequate energy and protein intake

Related to:

• Poor appetite

• Increased energy needs

As evidenced by:

• BMI: 17.4 kg/m2

• 9.8% weight loss 6/12

• current intake = 65% estimated energy requirement (470 kcal deficit) and 30% estimated protein requirement (48g deficit)

Case Study

Nutritional intervention:

1. Educate patient on the importance of good nutrition for overcoming surgery and preventing further weight loss

2. Change to HEHP diet with fortified snacks and determine diet preferences to tailor food service provision

3. Initiate Fortisip Compact Protein BD (600kcal, 36g protein)

4. Discuss with nursing staff the importance of encouraging oral intake and assisting with feeding

5. Commence food chart

6. Weekly body weights

7. Review

Nutritional supplementation

• Oral nutritional supplements (ONS) are a convenient and easy way of taking a concentrated source of both macro- and micro-nutrients

• ONS are available either in liquid or semi-solid form

• Sip feeds served ice-cold are often more palatable and soothing if the patient’s mouth is sore and help if the patient is nauseous

• Sip feeds are available as milk style, juice-style and yogurt tasting drinks in a variety of flavours

• Yogurt based sip feeds often appeal to those with taste changes

• Sip feeds can also be heated, frozen or incorporated into recipes

• High protein supplements can be particularly useful in patients with increased protein and micronutrient requirements during wound healing.

Summary

Many hip fracture patients present with malnutrition, and continue to deteriorate after surgery (despite increased nutritional requirements).

Malnutrition and hip fractures are linked: malnutrition can increase risk of

falls (weakness, less padding, osteoporosis) while hip fractures can increase risk of malnutrition (increased needs, hospital environment, underlying issues).

Adequate energy, protein and micronutrients are important in both prevention and recovery of hip fractures. This can be achieved with dietary advice, HEHP diet and high protein ONS.

References

Anatomy Zone 2016. Muscles of the Thigh Part 2- Medical compartment- Anatomy Tutorial video available at: https://www.nof.org/patients/what-is-osteoporosis/ [20.12.16] BAPEN 2011. Malnutrition Universal Screening Tool. Available from: http://www.bapen.org.uk/pdfs/must/must_full.pdf [06.12.16] BAPEN 2016. Introduction to Malnutrition. http://www.bapen.org.uk/malnutrition-undernutrition/introduction-to-malnutrition [06.12.16] Bonjour JP. Protein intake and bone health. Int J Vitam Nutr Res 2011; 81(2-3):134-42 Bonjour JP, Schurch MA, Rizzoli R. Nutritional aspects of hip fractures. Bone. 1996; 18(3):139S-144S Brunner LC, et al. Hip fractures in adults. Am Fam Physician. 2003; 67(3):537-543. Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012; 11(2):278-96 Centers for Disease Control and Prevention 2016. Home and Recreational Safety. Available from: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html [06.12.16] Darling AL et al. Dietary protein and bone health: a systematic review and meta analysis. J Clin Nutr 2009; 90(6):1674-92 Delmi M et al. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990;335(8696):1013-6 Deutz NE et al. Protein intake and exercise for optimal muscle function with ageing: recommendations from the ESPEN Expert Group. Clin Nutr. 2014; 33:929-36 Hanger HC, Smart EJ, Merrilees MJ, Frampton CM. The prevalence of malnutrition in elderly hip fracture patients. NZ Med J. 1999; 112(1084):88-90 Food and Agriculture Organisation of the United Nations. Nutritional Status and Vulnerability. Available from: FAO.http://www.fao.org/docrep/x8200e/x8200e04.htm [06.12.16] Gandy J, Ed. Manual of Dietetic Practice. 5th ed. Oxford: Wiley Blackwell Publishing, 2014. Hubbard G, Holdoway A, Stratton RJ. P038 A pilot study investigating compliance and efficacy of a novel, low volume, energy dense (2.5 kcal/ml) multi-nutrient supplement in malnourished community patients. Clin Nutr. 2009; 4(2):41

International Osteoporosis Foundation 2015. Facts and Statistics. Available from: https://www.iofbonehealth.org/facts-statistics [06.12.16] Li HJ et al. Functional recovery of older people with hip fracture: does malnutrition make a difference? J Adv Nur 2013; 69(8):1691-703 Malnutrition Pathway. Managing Adult Malnutrition in the community. Available from: http://malnutritionpathway.co.uk/downloads/Managing_Malnutrition.pdf [06.12.16] National Osteoporosis Foundation 2016. What is Osteoporosis and What Causes It? Available at: https://www.nof.org/patients/what-is-osteoporosis/ [20.12.16] Nematy M, Hickson M, Brynes AE et al. Vulnerable patients with a fractured neck of femur: nutritional status and support in hospital. JHND 2006; 19(3):209-218 NHS 2016. Hip fracture. Available from: http://www.nhs.uk/Conditions/Hip-fracture/Pages/Introduction.aspx [06.12.16] NHS 2015. Falls. Available from: http://www.nhs.uk/conditions/Falls/Pages/Introduction.aspx [06.12.16] NHS 2016. Osteoporosis. Available from: http://www.nhs.uk/conditions/Osteoporosis/Pages/Introduction.aspx [06.12.16] NICE 2014. Clinical guideline [CG124] Available from: https://www.nice.org.uk/guidance/CG124/chapter/Introduction [06.12.16] Olofsson B et al. Malnutrition in hip fracture patients: an intervention study. J Clin Nurs 2007; 16(11):2027-38 Paillaud E et al. Nutritional status and energy expenditure in elderly patients with recent hip fracture during a 2-month follow-up. Br J Nutr 2000; 83(2):97-103 Parliament 2015. Political challenges relating to an aging population: Key issues for the 2015 Parliament https://www.parliament.uk/business/publications/research/key-issues-parliament-2015/social-change/ageing-population/ [06.12.16] Royal College of Physicians 2016. National Hip Fracture database 2016. Available from: http://web1.crownaudit.org/Report2016/NHFD2016Report.pdf [06.12.16] Royal College of Physicians 2015. National Hip Fracture database 2015. Availabe from: http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf [06.12.16]

Tkatch L et al. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr 1992; 11(5): 519-25

Wu AM et al. The relationship between dietary protein consumption and risk of fracture: a subgroup and dose-response meta-analysis of prospective cohort studies. Sci Rep 2015; (16)5:9151

Thank you

nutricia · prevalence • approximately 65,000 hip fractures each year in the uk1,2 • at any one...

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