Nutritional supplementation for hip fracture aftercare in older people

Abstract

Fractures of the hip are an important cause of later ill health and mortality in older people. People with hip fractures are often malnourished at the time of fracture, and have poor food intake in hospital. This review assesses the effects of nutritional interventions in older people recovering from hip fracture. We searched the Cochrane Musculoskeletal Injuries Group Specialised Register, the Cochrane Central Register of Controlled Trials (The Cochrane Library issue 3, 2004), MEDLINE (1966 to October week 1 2004), Nutrition Abstracts and Reviews, EMBASE, BIOSIS, CINAHL, HEALTHSTAR, the National Research Register and reference lists. We contacted investigators and handsearched four nutrition journals. Randomised and quasi-randomised trials of nutritional interventions for mainly older people (aged over 65 years) with hip fracture. Both authors independently selected trials, extracted data and assessed trial quality. We sought additional information from all trialists, and pooled data for primary outcomes. Eighteen randomised trials involving 1306 participants were included. Overall trial quality was poor; specifically in terms of allocation concealment, assessor blinding and intention-to-treat analysis. This, and the limited availability of outcome data, mean that the following results must be interpreted with caution. Eight trials evaluated oral multinutrient feeds: these provided 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 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. There was insufficient information for other outcomes. The specific effect of protein given in an oral feed was tested in three trials. There was no evidence for an effect on mortality (RR 1.38, 95% CI 0.82 to 2.34). Protein supplementation may have reduced the number of long term complications and days spent in rehabilitation wards. Two trials, testing intravenous thiamin (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 vitamin supplement. While some evidence exists for the effectiveness of oral protein and energy feeds, overall the evidence for the effectiveness of nutritional supplementation remains weak. Future trials are required which overcome the defects of the reviewed studies, particularly inadequate size, methodology and outcome assessment.