Nutritional supplementation for hip fracture aftercare in older people

 

Abstract

Background

Older people with hip fractures are often malnourished at the time of fracture, and have poor food intake subsequently.

Objectives

To review the effects of nutritional interventions in older people recovering from hip fracture.

Search methods

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 3), MEDLINE and other major databases (to July 2008).

Selection criteria

Randomised and quasi-randomised controlled trials of nutritional interventions for people aged over 65 years with hip fracture.

Data collection and analysis

Both authors independently selected trials, extracted data and assessed trial quality. We pooled data for primary outcomes.

Main results

Twenty-four randomised trials involving 1940 participants were included. Outcome data were limited and many trials were methodologically flawed. Results from 23 trials are presented here.

Ten trials evaluated oral multinutrient feeds: providing non-protein energy, protein, some vitamins and minerals. Oral feeds had no statistically significant effect on mortality (16/244 versus 21/226; risk ratio (RR) 0.76, 95% confidence interval (CI) 0.42 to 1.37) or 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications) (46/126 versus 41/103; RR 0.76, 95% CI 0.55 to 1.04).

Four heterogenous trials examining nasogastric multinutrient feeding showed no evidence of an effect on mortality (RR 0.99, 95% CI 0.50 to 1.97). Nasogastric feeding was poorly tolerated.

One trial examining nasogastric tube feeding followed by oral feeds found no evidence for an effect on mortality or complications.

One trial of multinutrient intravenous feeding followed by oral supplements found a reduction in participants with complications (RR 0.21, 95% CI 0.10 to 0.46), but not in mortality (RR 0.11, 95% CI 0.01 to 2.00).

Four trials testing increasing protein intake in an oral feed found no evidence for an effect on mortality (RR 1.42, 95% CI 0.85 to 2.37). Protein supplementation may have reduced the number of long term medical complications.

Two trials, testing intravenous vitamin B1 and other water soluble vitamins, or oral 1-alpha-hydroxycholecalciferol (vitamin D) respectively, produced no evidence of effect.

One trial, evaluating dietetic assistants to help with feeding, showed no statistically significant effect on mortality (RR 0.57, 99% CI 0.29 to 1.11).

Authors' conclusions

Weak evidence exists for the effectiveness of protein and energy feeds. Adequately sized randomised trials with robust methodology are required. In particular, the role of dietetic assistants, and peripheral venous feeding require further evaluation.

 

Plain language summary

Nutritional supplementation for older people after hip fracture

Older people with hip fractures are often malnourished at the time of their fracture and many have poor food intake while in hospital. Malnutrition may hinder recovery after hip fracture. We reviewed the effects of nutritional interventions in older people recovering from hip fracture.

The 24 randomised controlled trials included in this review involved 1940 participants. The trials had methodological flaws that may affect the validity of their results. Ten trials examined the use of additional feeds by mouth providing non-protein energy, protein, some vitamins and minerals. Pooled data from these trials found that there may be a possibility of a reduction in 'unfavourable outcome' (combined outcome of mortality and survivors with medical complications), but no effect on mortality.

Four trials examined nasogastric tube feeding, where liquid food is delivered via a tube inserted into the nose and passed down into the stomach, with non-protein energy, protein, some vitamins and minerals. These trials provided very limited data but tube feeding, which was poorly tolerated, did not seem to make a difference to mortality.

One trial found nasogastric tube feeding followed by oral feeds did not seem to affect mortality or complications.

One trial examined giving feed into a vein initially, then by mouth. This did not seem to affect mortality but might reduce complications.

Increasing protein intake in an oral feed was tested in four trials. Protein supplementation may have reduced the number of long term complications, but it did not seem to make a difference to mortality alone.

Two trials examining intravenous vitamin B1 and other water soluble vitamins, or a form of vitamin D given orally, did not alter outcomes.

One unpublished study comparing ornithine alpha-ketoglutarate with an isonitrogenous peptide supplement found very weak evidence of a delay in the onset of complications but not their occurrence.

One trial, evaluating dietetic assistants to help improve nutritional intake found a trend for a reduction in mortality.

Some evidence exists for the effectiveness of protein and energy feeds, but overall the evidence for the effectiveness of nutritional supplementation remains weak. The role of dietetic assistants, and peripheral intravenous feeding require further evaluation. Trials are required which overcome the defects of the reviewed studies, particularly inadequate size and trial methods.

 

摘要

背景

老年人在髖部骨折後照護的營養補給

有髖部骨折的老年人經常在骨折時營養不良，爾後也常攝取營養不足。

目標

研究在髖骨骨折的老年人恢復過程中營養治療介入的效果。

搜尋策略

我們搜尋了the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (2008年9月)，the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008年, Issue 3), MEDLINE 以及其他主要的資料庫(直到2008年7月)。

選擇標準

研究以營養治療超過65歲以上患有股骨骨折的老年人之隨機及半隨機對照試驗。

資料收集與分析

兩位作者獨立地選擇試驗、擷取數據並評估試驗品質。我們從主要的試驗結果來收集數據。

主要結論

24個隨機試驗包括了共1940位參與者。我們所得到的結果數據有限且許多試驗的方法皆有漏洞。 在這裡我們放入了從23個試驗所收集到的結果。 共有十個試驗評估了經口進食多重營養食物：提供了非蛋白質能量、蛋白質、些許維生素和礦物質。 由口進食並不會對降低致死率(16/244 versus 21/226; risk ratio (RR) 0.76, 95% confidence interval (CI) 0.42 to 1.37)或不良結果(包括致死及留有併發症的存活者) (46/126 versus 41/103; RR 0.76, 95% CI 0.55 to 1.04)有統計上的顯著療效。 四個研究經鼻胃管餵食多重營養品的異質性的試驗顯示無顯著證據對降低致死率有療效(RR 0.99, 95% CI 0.50 to 1.97)。 經鼻胃管餵食非常令人難以忍受。 一個在經口進食後改由經鼻胃管餵食的試驗發現在致死率及併發症上並無顯著效果。 一個在經口進食後改由靜脈輸入營養補充液方法的試驗顯示參與者的併發症 (RR 0.21, 95% CI 0.10 to 0.46)有減少的情形，但對致死率(RR 0.11, 95% CI 0.01 to 2.00)仍無影響。 四個試驗研究了經由口進食的患者增加蛋白質攝取之後，對於降低致死率(RR 1.42, 95% CI 0.85 to 2.37)並無任何效果。 蛋白質補充也許會降低患有長期併發症的個案數。 兩項試驗研究分別替患者靜脈注射維生素B1及其他維生素輸液、或口服1alphahydroxycholecalciferol (維生素D)，並不會產生任何的療效。 一項研究由助理協助餵食患者的試驗，顯示統計上並無對降低致死率有顯著的療效 (RR 0.57, 99% CI 0.29 to 1.11)。

作者結論

在餵食蛋白質及能量後能夠產生療效的證據其實不多。適當大小的隨機試驗及健全的試驗方法是必須的。特別是針對協助餵食的助理的角色及周邊靜脈輸液的方法還需要進一步的評估。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

給予髖骨骨折後的老年人營養補給：老年人在股骨骨折時經常是處於營養不良的狀態，有許多人在住院時亦飲食攝取不佳。營養不良常會延長髖骨骨折復原的時間。我們回顧了老年人從髖骨骨折復原時使用營養法的療效。本篇文獻回顧納入了24個研究包括了總共1940位參與者。這個試驗在試驗方法上的偏誤可能有會影響結果效力。十個試驗研究了額外由口進食非蛋白質能量、一些維生素及礦物質的使用。從這些試驗收集到的數據發現這些方式可能可以降低不良結果的發生(包括致死及留有併發症的存活者)，但是對於單純致死率並沒有影響。四個試驗研究了經由鼻胃管餵食非蛋白質能量、一些維生素及礦物質，也就是將液態食物經由一條管子由患者的鼻腔一直進入到胃部。這些試驗提供了非常有限的數據，但是以難以令人忍受的鼻胃管來說，其在降低致死率上並沒有任何影響。一個試驗發現在經口餵食後使用鼻胃管餵食並不會降低致死率也不會減少併發症的發生率。一個試驗研究了先從靜脈輸液給與營養之後改為經口進食，這麼做並不會對降低致死率有影響但卻會減少併發症的發生。有四個試驗研究了在經口進食的患者身上增加蛋白質的攝取。補充蛋白質也許可以降低長期併發症的個案數，但是單就致死率而言是沒有任何影響的。兩個試驗研究了由靜脈輸入維生素B1、和其他維生素輸液，或是口服一種形式的維生素D，但都沒有發現結果有任何改變。一個未公開的研究比較了ornithine alphaketoglutarat與一種 isonitrogenous的胜月太補充液後，發現對於延緩併發症的發生有微弱的效果，但是無法避免併發症的發生。一個試驗比較了有助理餵食病患來改善營攝取的確有助於降低致死率。有些證據證明增加蛋白質及能量攝取的確有它的療效，但是整體而言目前證明營養治療效果的證據依然很弱。而餵食助理所扮演的角色及周邊靜脈輸液的使用仍然需要更進一步的評估。我們需要其它能夠超越本篇文獻回顧研究中缺點的試驗(尤其是不適當的研究大小及研究方法)。