Nutricia. Nutrition and Fractured Neck of Femur (NOF)

Transcription

1 Nutricia Nutrition and Fractured Neck of Femur (NOF)

2 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

3 1 Introduction

4 Definition 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 NHS [ ] 2. Brunner LC, et al. Am Fam Physician. 2003; 67(3): Available from: [ ]

5 Prevalence Approximately 65,000 hip fractures each year in the UK 1,2 At any one time over 4,000 hospital beds are occupied by patients with hip fractures in the UK 1 Peak number of hip fractures occurred at years of age for both sexes 3 Approximately 75% of hip fractures occur in women 3 The most common serious injury and most common reason for emergency surgery in older people 2 1. RCP [ ] 2. RCP [ ] 3. IOF [ ]

6 Average length of stay across UK is 21 days. 1 Annual cost approx 1-2 billion = 1-2 % of NHS budget 1,2 Cost and impact on NHS Comorbidites prevalent in NOF fracture patients 2 Major public health issue due to increasing ageing population 2,3 1. RCP [ ] 2. NICE [ ] 3. Parliament [ ]

7 Cause Falls are common in older people 1,2 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 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 NHS CDC NHS ] [ ]

8 7 Risk factors 1-6 Osteoporosis Age- bone resorption rate increases with age Gender BMI Smoking/drinking Inactive Poor diet Muscle weakness Inactive Inadequate diet Disease Poor appetite 8 1. NHS [ ] 2. NHS [ ] 3. IOF [ ] 4. Zhanglin Cui et al. J Med Eco 2015; 18(1): CDC [ ] 6. Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, Anatomy Zone [ ] 8. National Osteoporosis Foundation [ ]

9 2 Malnutrition in NOF fracture

10 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 [ ]

11 Malnutrition Universal Screening Tool (MUST) Takes into account: BMI Unplanned weight loss in in past 3-6 months Illness and nutritional intake Source: BAPEN [ ]

12 Prevalence of Malnutrition in NOF fractures Likely to be malnourished on admission (~60%) 1-5 Significantly lower BMI compared to UK mean for sex and age 4 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 1. Li HJ et al. J Adv Nur 2013; 69(8): Olofsson B et al. J Clin Nur 2007; 16(11): Bonjour JP et al. Bone 1996; 18(3S): 139S-144S 4. Nematy M et al. JHND 2006; 19(3): Hanger HC et al. NZ Med J 1999; 112(1084):88-90

13 Malnutrition and Hip fracture link Malnutrition may increase risk of hip fracture by: 1,2 Reducing muscle strength Diminishing protective layer of soft tissue padding Accelerating the loss of bone mineral density at proximal femur 1. Paillaud E et al. Br J Nutr 2000; 83(2): Bonjour JP et al. Bone 1996; 18(3S): 139S-144S

14 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

15 Causes of Malnutrition in Older adults 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 Source: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014

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

17 Other consequences of Malnutrition Effect Impaired psycho-social function Consequences 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 And many more Source: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014

18 Poorer clinical outcomes Malnutrition Morbidity Wound healing Infections Complications Convalescence Mortality Treatment Length of stay in hospital GP visits Hospital admissions and readmissions QOL and COST Source: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014

19 3 Nutritional Requirements in Fractured Neck of Femur

20 Increased Energy Requirements 1. Increased energy metabolism Hypermetabolic (3 months post surgery) 1 2. Low BMI upon admission Likely to be malnourished upon admission Reduced dietary intake Likely to show rapid deterioration during admission 5 1. Paillaud E et al. Br J Nutr 2000; 83(2): Li HJ et al. J Adv Nur 2013; 69(8): Olofsson B et al. J Clin Nur 2007; 16(11): Bonjour JP et al. Bone 1996; 18(3S): 139S-144S 5. Nematy M et al. JHND 2006; 19(3): Hanger HC et al. NZ Med J 1999; 112(1084):88-90

21 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 state 2,3 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 rates 4 Low protein intake increases hip fracture risk 5 1. Paillaud E et al. Br J Nutr 2000; 83(2): Nematy M et al. JHND 2006; 19(3): Delmi M et al. Lancet 1990; 335(8696): Bonjour JP et al. Bone 1996; 18(3S): 139S-144S 5. Wu AM et al. Sci Rep 2015; (16)5:9151

22 Increased Protein Requirements Insufficient dietary protein compromises bone quality 1 and may decrease bone strength 2 and structure 3 4. Normalising protein intake improves outcomes Reduced post fracture bone loss, enhanced muscle strength and improved medical complications and length of inpatient stay 4 Significantly reduced both complications and length of hospital stay 1 Reduced length of hospital stay, as well as lower rates of complications and death 5 1. Bonjour JP et al. Bone 1996; 18(3S): 139S-144S 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): Bonjour JP. 2011; 81(2-3): Tkatch L et al. J Am Coll Nutr 1992; 11(5):519-25

23 Protein Revision of Protein Requirements by the ESPEN Expert Group Protein intake for optimal muscle function with ageing: g protein/kg body weight/ day for healthy older adults 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: g/d (healthy) g/d (acute or chronic illness) Source: Deutz N, et al. Clin Nutr. 2014;33:

24 Increased Micronutrient Requirements Micronutrient intake is likely to be compromised in individuals who have a diet deficient in energy and protein 1 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 micronutrients 1 1. FAO. [ ] 2. Gandy J. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014.

25 4 Nutritional Management in Fractured Neck of Femur

26 Nutrition support options ONS Food fortification Dietary advice

27 Dietary advice ONS Highlight importance of adequate nutrition for: Maintaining or gaining weight (may decrease risk of hip fracture 2 ) Recovery from surgery Reversing malnutrition Food fortification Dietary advice Bone healing Increasing muscle mass and strength Increasing body fat for padding Ideas: Puddings daily (e.g sticky toffee pudding, rice pudding, cake and custard, full fat yogurt) 1. Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, Wu AM et al. Sci Rep 2015; (16)5:9151 Snacks daily (e.g cheese and crackers, hot chocolate and biscuits)

28 Food fortification ONS Fortify meals with high energy and protein foods e.g. butter, cream, milk powder, cheese Add butter to mashed potato Food fortification Dietary advice 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 Source: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014

29 Oral Nutritional Supplements ONS come in a variety of flavours and styles to suit all tastes. ONS Food fortification Dietary advice High energy and protein, low volume, complete in micronutrients 91% compliance in energy dense (>2kcal/ml) ONS as opposed to mean compliance of up to 78% 2 Helps to meet energy and protein requirements and so aids in achieving better outcomes 1. Hanger HC et al. NZ Med J 1999; 112(1084): Hubbard G et al. Clin Nutr Supp 2009;4(2):41-41

30 High protein ONS Significant reduction Significant increase Significant Improvement Complications Patient independence Handgrip strength Hospital readmissions Mean ADL score Nutritional intake and weight Source: Cawood AL et al. Ageing Res Rev 2012;11(2):

31 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

32 5 Case Study

33 Case Study Mrs Smith 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.

34 Case Study Anthropometry Weight: 46kg Height: 162.5cm BMI: 17.4 kg/m 2 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

35 Case Study Clinical Must score = 3 Requirements for maintenance (based on 20% AF + 10% SF) =1,350 kcal, 69g protein (1.5g/kg/day) Estimated Requirements Energy: 1,350-1,850 1 Protein: 69g 2 Fluid: = 1600 ml 3 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: (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: ( g/kg/day ) 3. Todorovic VE and Micklewright A (Eds). A pocket guide to clinical nutrition. 4 th ed. British Dietetic Association, ml/kg/day

36 Dietary (diet history) Meal Food Consumed Energy (kcal) Protein (g) Breakfast Lunch Dinner ¼ bowl porridge with milk 1 slice bread with butter + jam ½ cup orange juice Tea with milk and 1 sugar ¼ tuna and mayonnaise sandwich ½ pot fruit yoghurt ½ cup orange juice Small bowl of tomato soup 1 slice of bread with butter ½ serve custard Snacks 2 biscuits Tea with milk and 1 sugar Total

37 Case Study Nutritional diagnosis Inadequate energy and protein intake Related to: Poor appetite Increased energy needs As evidenced by: BMI: 17.4 kg/m 2 9.8% weight loss 6/12 current intake = 65% estimated energy requirement (470 kcal deficit) and 30% estimated protein requirement (48g deficit)

38 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

39 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.

40 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.

41 References Anatomy Zone Muscles of the Thigh Part 2- Medical compartment- Anatomy Tutorial video available at: [ ] BAPEN Malnutrition Universal Screening Tool. Available from: [ ] BAPEN Introduction to Malnutrition. [ ] Bonjour JP. Protein intake and bone health. Int J Vitam Nutr Res 2011; 81(2-3): 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): 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): Centers for Disease Control and Prevention Home and Recreational Safety. Available from: [ ] Darling AL et al. Dietary protein and bone health: a systematic review and meta analysis. J Clin Nutr 2009; 90(6): Delmi M et al. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990;335(8696): Deutz NE et al. Protein intake and exercise for optimal muscle function with ageing: recommendations from the ESPEN Expert Group. Clin Nutr. 2014; 33: 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. [ ] Gandy J, Ed. Manual of Dietetic Practice. 5 th ed. Oxford: Wiley Blackwell Publishing, 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) multinutrient supplement in malnourished community patients. Clin Nutr. 2009; 4(2):41

42 International Osteoporosis Foundation Facts and Statistics. Available from: [ ] Li HJ et al. Functional recovery of older people with hip fracture: does malnutrition make a difference? J Adv Nur 2013; 69(8): Malnutrition Pathway. Managing Adult Malnutrition in the community. Available from: [ ] National Osteoporosis Foundation What is Osteoporosis and What Causes It? Available at: [ ] 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): NHS Hip fracture. Available from: [ ] NHS Falls. Available from: [ ] NHS Osteoporosis. Available from: [ ] NICE Clinical guideline [CG124] Available from: [ ] Olofsson B et al. Malnutrition in hip fracture patients: an intervention study. J Clin Nurs 2007; 16(11): 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): Parliament Political challenges relating to an aging population: Key issues for the 2015 Parliament [ ] Royal College of Physicians National Hip Fracture database Available from: [ ] Royal College of Physicians National Hip Fracture database Availabe from: [ ] 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): 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

43 Thank you