Studies on hip fracture patients : effects of nutrition and rehabilitation

Hip fracture in the elderly is a serious condition associated with increased mortality. Survivors experience an increase in morbidity and disability that affect their independence and quality of life; the outcome for patients with dementia is particularly poor. Many hip fracture patients have signs of malnutrition already on admission and this patient group has been shown to have a lower body mass index (BMI) than aged-matched controls. A catabolic state develops following hip fracture, characterized by loss of bone mineral density (BMD) and muscle mass. The combination of generalized loss of muscle mass, muscle strength and/or physical performance is known as sarcopenia, which impacts functionality and health- related quality of life. This thesis has three major aims: 1) to study the possible association between BMI, a potentially modifiable factor, and one-year mortality, as well as the ability to return to independent living following hip fracture; 2) to evaluate the effect of nutritional supplementation on bone mineral density (BMD), body composition, muscle strength and health-related quality of life (HRQoL) following hip fracture; and 3) to investigate factors of importance for preservation of ambulatory function and activities of daily living (ADL) following hip fracture in patients with cognitive impairment.

Study I: A prospective study of 843 elderly patients with hip fracture, without severe cognitive impairment, who came from an independent living situation at the time of admission. The results show that overweight was associated with increased one-year survival and a greater likelihood of independent living one year post-fracture.

Study II: A randomized controlled study in which 79 patients with hip fracture were randomized to one of three treatment groups. Six months of postoperative treatment with protein and energy-rich supplementation combined with orally administered bisphosphonate, calcium and vitamin D were shown to have a small additive effect on bone mineral density compared with bisphosphonate and calcium alone.

Study III: A randomized controlled study of the same population as in study II. Postoperative treatment with protein and energy-rich supplementation did not prevent loss of lean mass following hip fracture. However, trends toward improved handgrip strength and HRQoL were observed following nutritional supplementation.

Study IV: A prospective study of 246 patients with femoral neck fracture and cognitive impairment, but ambulant prior to fracture. In addition to ambulatory and ADL function prior to fracture, the results showed that discharge to rehabilitation facilities was associated with preserved ambulatory function and ADL skills at the 4-and 12 month follow-ups.

List of scientific papers

I. Lena Flodin, Agnes Laurin, Johan Lökk, Tommy Cederholm, Margareta Hedström. Overweight in elderly hip fracture patients is associated with increased 1-year survival and discharge to independent living: a prospective study of 843 patients. [Manuscript]

II. Lena Flodin, Maria Sääf, Tommy Cederholm, Amer Al-Ani, Paul Ackermann, Eva Samnegård, Nils Dalén, Margareta Hedström. Additive effects of nutritional supplementation, together with bisphosphonates, on bone mineral density after hip fracture: a 12-month randomized controlled study. Clinical Interventions in Aging 2014, 9: 1043-1050.
https://doi.org/10.2147/CIA.S63987

III. Lena Flodin, Tommy Cederholm, Maria Sääf, Wilhelmina Ekström, Amer Al-Ani, Margareta Hedström. Effects of protein-rich nutritional supplementation and bisphosphonates on body composition, handgrip strength and health-related quality of life after hip fracture: a 12-month randomized controlled study. [Submitted]

IV. Amer Al-Ani, Lena Flodin, Anita Söderqvist, Paul Ackermann, Eva Samnegård, Nils Dalen, Maria Sääf, Tommy Cederholm, Margareta Hedström. Does rehabilitation matter in patients with femoral neck fracture and cognitive impairment? A prospective study of 246 patients. Archives of Physical Medicine and Rehabilitation 2010, 91(1): 51-57.
https://doi.org/10.1016/j.apmr.2009.09.005