Nutritional supplementation for hip fracture aftercare in older people
Abstract
Background
Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.
Objectives
To review the effects of nutritional interventions in older people recovering from hip fracture.
Search methods
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE, six other databases and reference lists. We contacted investigators and handsearched journals.
Selection criteria
Randomised and quasi‐randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.
Data collection and analysis
Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from trialists, and pooled data for primary outcomes.
Main results
Twenty‐one randomised trials involving 1727 participants were included. Overall trial quality was poor, specifically regarding allocation concealment, assessor blinding and intention‐to‐treat analysis, and limited availability of outcome data.
Eight trials evaluated oral multinutrient feeds: providing non‐protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (15/161 versus 17/176; relative risk (RR) 0.89, 95% confidence interval (CI) 0.47 to 1.68) but may reduce 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (14/66 versus 26/73; RR 0.52, 95% CI 0.32 to 0.84).
Four trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97) but the studies were heterogeneous regarding case mix. Nasogastric feeding was poorly tolerated. There was insufficient information for other outcomes.
Increasing protein intake in an oral feed was tested in four trials. There was no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.
Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or 1‐alpha‐hydroxycholecalciferol (an active form of vitamin D) respectively, produced no evidence of effect for either supplement.
One trial, evaluating dietetic assistants to help with feeding, showed a trend for a reduction in mortality (RR 0.57, 99% CI 0.29 to 1.11).
Authors' conclusions
Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. Adequately sized trials are required which overcome the methodological defects of the reviewed studies. In particular, the role of dietetic assistants requires further evaluation.
PICOs
Plain language summary
Nutritional supplementation for older people after hip fracture
Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture.
The 21 randomised controlled trials included in this review involved 1727 participants. Results from 19 trials are described here. The trials had methodological flaws that may affect the validity of their results. Eight trials examined the use of additional feeds providing non‐protein energy, protein, some vitamins and minerals. Pooled data from these trials found that there may be a reduction in 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications), but no effect on mortality.
Four trials examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non‐protein energy, protein, some vitamins and minerals. These trials provided very limited data but tube feeding, which was poorly tolerated, did not seem to make a difference to mortality.
Increasing protein intake in an oral feed was tested in four trials. Protein supplementation may have reduced the number of long term complications, but it did not seem to make a difference to mortality alone.
Two trials examining intravenous vitamin B1 and other water soluble vitamins, or a form of vitamin D, did not alter outcomes.
One trial, evaluating dietetic assistants to help improve nutritional intake found a trend for a reduction in mortality.
Some evidence exists for the effectiveness of oral protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. The role of dietetic assistants requires further evaluation. Trials are required which overcome the defects of the reviewed studies, particularly inadequate size and trial methods.
