Several Cochrane Reviews examine surgical techniques to repair hip fractures, and alongside these are reviews of other aspects of the management of people who have broken a hip. For instance, an updated review from November 2016 looks at nutritional supplements in the aftercare of older people who have had a hip fracture, and one of the authors, Toby Smith from the University of East Anglia in the UK, tells us more in this podcast.
John: Several Cochrane Reviews examine surgical techniques to repair hip fractures, and alongside these are reviews of other aspects of the management of people who have broken a hip. For instance, an updated review from November 2016 looks at nutritional supplements in the aftercare of older people who have had a hip fracture, and one of the authors, Toby Smith from the University of East Anglia in the UK, tells us more in this Evidence Pod.
Toby: Older people who break their hip are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder their recovery and we’ve found that nutritional interventions might help.
This is an update of a Cochrane review first published in 2000, and last updated in 2010. We now have 41 randomised trials, involving nearly 3900 people. Overall we felt that the quality of the evidence was moderate, with some evidence being of very low quality, particularly those studies with relatively small sample sizes and low event rates.
Eighteen studies examined the use of multinutrient oral feeds that provided energy from sources other than protein, as well as protein, some vitamins and minerals. There was low-quality evidence that these multinutrient oral feeds don’t reduce mortality but they may reduce the number of people with complications such as pressure sores, infection, venous thrombosis, pulmonary embolism, or confusion. There was very low-quality evidence that the feeds may reduce unfavourable outcomes (death or complications) and that they did not increase vomiting and diarrhoea.
Four studies examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach. These feeds included non-protein energy, protein, some vitamins and minerals. The studies provided very low-quality evidence that tube feeding, which was poorly tolerated by patients, did not seem to make a difference to mortality or complications. One study provided very low-quality evidence that nasogastric tube feeding followed by oral feeds might not affect mortality or complications.
One study provided very low-quality evidence that giving feed into a vein initially and then by mouth may not affect mortality but may reduce complications. However, we were surprised that this intervention was being used in people who seemed to be able to take nutrition orally.
Finally, increasing protein intake in an oral feed was tested in four studies, which provided low-quality evidence of no clear effect on mortality or complications and very low-quality evidence for a reduction in unfavourable outcomes.
In summary, this latest version of our review shows that there is low-quality evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 months after hip fracture, but that they have no clear effect on mortality. There is very low-quality evidence that oral supplements may reduce 'unfavourable outcome' (death or complications) without increasing the incidence of vomiting and diarrhoea. This evidence base needs to be improved through adequately sized randomised trials with robust methodology, to develop better understanding on the use of nutritional supplements for older people following a hip fracture.
John: If you would like to learn out more about the findings of this review, and watch for any future updates should the additional trials be done, you can find it online at Cochrane library.com with a simple search for ‘nutrition and hip fracture’.