Post-fracture Nutritional Care

Transcription

1 International Osteoporosis Foundation Webinar, January 15th 2019 Post-fracture Nutritional Care Prof René Rizzoli M.D. Division of Bone Diseases Geneva University Hospitals and Faculty of Medicine Geneva, Switzerland

2 Disclosure Speaker Bureau or Member of Scientific Advisory Board for Danone, Effryx, Nestlé, ObsEva, Pfizer, Radius Health, Sandoz, TEVA/Theramex

3 Objectives To identify fractured patients at risk of malnutrition To evaluate malnutrition severity in various types of fractures To review the various nutritional interventions (dietary, supplements) To review the outcomes of dietary/supplements intervention in fracture patients (rehabilitation, length of stay (LoS), mortality, fracture healing, refracture rates, etc.) To remind the role of Fracture Liaison Services (FLS) in improving nutritional management and reducing secondary fracture risk

4 Pathogenesis of Osteoporotic Fracture Sarcopenia (-> Falls) Sway Walking Muscle Strength Neuro-muscular Impairment Osteoporosis Bone Mass Geometry Microstructure Material level properties Mechanical Overload Mechanical Incompetence Malnutritio n Fracture Fracture Repair Rehabilitation -> To Restore Independence -> To Reduce Disabilities Prevention Subsequent Fracture Adapted from Rizzoli, Best Pract Res Clin Endocrinol Metab 2014

5 Wallace & Frankenfeld JACN 2017

6 Durosier-Izart et al AJCN 2017

7 Malnutrition is Associated with Functional Limitations Kiesswetter et al., J Nutr Health Ageing 2013

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9 SeS: Septic Surgery Ihle et al Int J Care Injured 2017

10 SeS: Septic Surgery Ihle et al Int J Care Injured 2017

11 Koren-Hakim et al Clin Nutr 2016

12 Malafarina et al Nutrients 2018

13 Functional Independence Measure (13 motor and 5 cognitive items) Inoue et al Clin Nutr 2017

14 Miu et al Ann Rehabil Med 2017

15 N=322, 83 Yrs, 71 % W, 54 % Delirium > 24 h, 43 % Malnutrition, 28 % Residential Aged Care Facilities Malnutrition: Subjective Global Assessment Detsky et al JPEN 1987 Bell et al ANZ J Surg 2016

16 Koren-Hakim et al Clin Nutr 2012

17 Malafarina et al Nutrients 2018

18 50 nmol /l or 20 ng/ml, hip fracture 57% of the Studies Sprague et al J Orthop Trauma 2016

19 Severe 25(OH)D deficiency: 25(OH)D < 30 nmol/l Bischoff-Ferrari et al Bone 2008

20 Nutritional Support after Hip Fracture: Outcomes 1. Rate of Medical Complications 2. Length of Stay 3. Clinical/Biochemical Signs of Malnutrition 4. Rehabilitation (ADL, Walking, Function, Disability) 5. Mortality Rate 6. BMD 7. Fracture Healing 8. Quality of Life 9. Destination at Discharge 10. Refracture Risk

21 IGF-I FN BMD Median LoS: - 33% Schurch et al Ann Int Med 1998

22 20 g/d casein or Whey or Whey + AA 81 Yrs Chevalley et al Clin Nutr 2010

23 Effects of Nutritional Supplements on Clinical Outcomes after Hip Fracture (Controlled Trials) (1) Author Year Delmi 1990 Tkatch 1992 Schürch 1998 Espaulella 2000 Bruce 2003 Houwings 2003 N Mean Age Yrs Yrs Yrs Yrs Yrs Yrs Duration (Months) Supplements 1 Prot 20 g/d 254 kcal Outcome Complications: 16 vs 37% (6 Mo) Median LoS: - 40% Mortality: 24 vs 37% (6 Mo) 1.3 Prot 20 g/d Complications & deaths: 52 vs 80% (7 Mo) Median LoS: - 32% 6 Prot 20 g/d LoS (Rehab.): - 33% FN BMD: 2.4% (12 Mo) IGF-I: 51% (6 Mo) 2 Prot 20 g/d Complications: 55 vs 70% (inhospital and at 6 Mo) 1 Prot 17.6 g/d 352 kcal/d 1 Prot 40 g/d 500 kcal/d No body weight nor clinical outcomes Pressure ulcers grade II: - 9%

24 Effects of Nutritional Supplements on Clinical Outcomes after Hip Fracture (Controlled Trials) (2) Author Year Sullivan 2004 Tidemark 2004 Neumann 2004 Duncan 2006 Hommel 2007 Tengstrand 2007 Gunnarsson 2009 Botella- Carretero 2010 N Mean Age Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Duration (Months) Supplements kcal/d nasogatric, orally Outcome No complications nor mortality 12 Prot 20 g/d ADL (6 Mo) 1 Prot 30 vs 17.8 g/d 4 Dieticians kcal: 350/d No in Functional Independence Measure nor LoS Mortality: 13 vs 23% (4 Mo) kcal/d Pressure ulcers: 9 vs 18.6% 6 Prot 20 g/d BMD (12 Mo) kcal/kg nasogastric Pressure ulcers: 18 vs 36% 0.33 Prot 40 g/d Complications: - 7.5%

25 Effects of Nutritional Supplements on Clinical Outcomes after Hip Fracture (Controlled Trials) (3) Author Year Fabian 2011 Hoekstra 2011 Myint 2013 Li 2013 Anbar 2014 Bell 2014 Flodin 2015 N Mean Age Yrs Yrs Yrs Yrs Yrs Yrs Yrs Duration (Months) Supplements Outcome 0.6 Prot + 16% LoS: - 11% > 0.25 Prot + 16% Lower decrease EQ-5D (3 Mo) 1 Prot g/d Maintained BMI Infections. - 52% LoS: - 13% 12 Diet counselling Better ADL & walking capacity 0.3 Prot g/d Kcal Complications: 27 vs 64% 1 Prot g/d Discharged to community dwelling: + 100% 6 Prot 40 g/d 600 kcal/d No in lean mass nor EQ- 5D

26 Effects of Nutritional Supplements on Clinical Outcomes after Hip Fracture (Controlled Trials) (4) Author Year Ekinci 2016 Niitsu 2016 Malafarina 2017 Wyers 2018 Invernizzi 2019 N Mean Age Yrs Yrs Yrs Yrs Yrs Duration (Months) Supplements 1 Prot 36 g/d HMB 3 g/d 0.5 Whey prot 32.2 g/d 1.5 Prot 40 g/d HMB 3.1 g/d 3 Prot 40 g/d 500 kcal/d Outcome Shorter wound healing period Mobility: 81 vs 27% (1 Mo) Higher muscle strength Higher lower limbs muscle strength Better Barthel index Maintained BW and alm No in LoS nor in clinical outcomes 2 EAA 4 g/d No in functional outcomes (grip strength,tug)

27 Ourcome Trials (n) Oral Nutritional Supplements (n) Controls (n) Odds Ratio 95% CI Complications Wound infection Respiratory infection Urinary infection Mortality Liu et al Clin Interv Aging 2015

28 Outcome Mortality (1-12 months follow-up) Complications (pressure sore, infections) Unfavourable outcome (deaths & complications) Trials (n) Relative Risk with Oral Nutritional Supplements 95 % CI GI side effects Avenell et al Cochrane Database of Systematic Reviews 2016

29 Strength Contact Dayer et al JBMR 2006

30 Yoneme et al Nutrition 2015

31 Two clinical studies found a positive effect of vitamin D supplementation and calcium, of increased bone mineral density or respectively increased fracture callus area at the fracture site. One study found indirect evidence that vitamin D and calcium promoted fracture healing. Conclusion: Despite these results, and the presumed beneficial effect of vitamin D supplementation in deficient patients, clinical studies that address the effects of vitamin D deficiency or supplementation on fracture healing are scarce and remain inconclusive. We conclude that vitamin D has a role in fracture healing, but the available data are too inconsistent to elucidate how and in what manner. Gorter et al Bone 2014

32 Alterations of Protein Use in Older Persons inadequate intake of protein (e.g. anorexia of aging) reduced ability to use available protein (e.g., insulin resistance, splanchnic extraction etc. ) greater need for protein (e.g., inflammatory disease) loss of functionality muscle, bone, immune system Recommended: 0.8 g/kg BW (RDA) -> g/kg BW Bauer et al JAMDA 2013

33 Anabolic resistance Cuthbertson et al., FASEB J., 2005

34 Timing of Protein Ingestion and Exercise to Optimize Muscle Protein Synthesis Paddon-Jones et al AJCN 2015

35 Trombetti et al Eur J Clin Nutr 2013

36 Milte et al J Rehabil Med 2016

37 One fracture leads to another A prior fracture at any skeletal site doubles future fracture risk 2 nd fracture often happens within 6-8 months

38 CAPTURE THE FRACTURE A global flagship programme by the International Osteoporosis Foundation (IOF) Launched in 2012 Mission: facilitating the implementation of FLS to prevent secondary fractures

39 Running an FLS? Join the Capture the Fracture Programme Why join? Showcase your achievements Learn from the BPF to improve your service Get international recognition with a Gold, Silver, or Bronze star Be part of a global invitiative to prevent secondary fractures Who can participate? Coordinator-based models of care All type of facilities At any stage in development Any size worldwide

40 THANK YOU

41 Q & A

42 On behalf of IOF and CTF SteerCo, we thank you for your participation in this webinar If you have any additional questions or comments please