Nutritional care of the older patient with fragility fracture is complex. Diagnostic difficulties, multi-morbidities and interdependencies and social complexities all contribute to the wicked problem of malnutrition. Whilst many settings have attempted to address malnutrition through highly specialised care, increasing evidence supports the role of systematised, interdisciplinary approaches across acute care, rehabilitation and secondary prevention settings. Consequently, this chapter is devoted to highlighting why a SIMPLE approach to malnutrition should underpin the nutritional care of the older patient with fragility fracture, regardless of setting or healthcare provider.

S Screen for nutrition risk

I Interdisciplinary assessment

M Make the diagnosis (es)

P Plan with the patient

L impLement interventions

E Evaluate ongoing care requirements

18.1. Background

Increasing numbers of fragility fractures in ageing populations represent a substantial and significant pressure on patients, carers, healthcare systems and societies around the world [1]. Frail older people with fragility fractures require comprehensive, orthogeriatric care [2]. Co-existing chronic diseases confound acute interventions and efforts to improve recovery in rehabilitation, and have a negative impact on patient outcomes, long-term survival and quality of life.

An interdisciplinary approach to the management of the presenting fracture and pre-existing co-morbidities will improve outcomes. Preventing future fractures and additional harmful diagnoses should also be a priority for treating teams in the acute, rehabilitation and secondary prevention settings [1]. Individualised care is a core component of orthogeriatric care. However, this must be underpinned by interdisciplinary actions and systems that support timely and appropriate delivery of care.

Nutrition-related diagnoses are key predictors of initial and secondary fragility fractures and are among the most harmful co-morbidities in older orthopaedic patients across acute, rehabilitation and community settings. Nutrition interventions are core components of primary and secondary fracture prevention and have been shown to improve outcomes in the acute and rehabilitation settings.

Many models of nutrition care focus on highly individualised assessments and interventions provided by dietitians or medical nutrition specialists [3]. The high prevalence of protein–energy malnutrition and other nutrition-related diagnoses is well described across many orthogeriatric settings, and there are strong associations between nutrition-related diagnoses and patient and healthcare outcomes. Despite this, in many orthopaedic settings timely access to specialist clinical nutrition care is limited or absent [4]. Increases in diagnosis and referral rates, patient complexity, healthcare costs and service demands, combined with reduced lengths of stay and unsustainable health expenditure growth, suggest that it will not be possible to provide all patients identified at risk of a nutrition-related diagnosis with individual access to specialist nutrition services [3]. This chapter therefore presents a call to action. Systematised, interdisciplinary nutrition care actions are urgently required across the pillars of acute care, rehabilitation and secondary fracture prevention [1].

18.2. SIMPLE or Specialised Nutrition Care?

Models in which interdisciplinary healthcare workers provide early, supportive nutrition care across the three pillars may be best placed to deliver high value nutrition support. Such models include the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE), the More-2-Eat program and a multidisciplinary, multimodal nutrition care model applied in hip fracture by Bell et al. [3, 5, 6]. These models suggest that patients are triaged into three groups: those not at risk and appropriate for standard care, those who are at risk or malnourished but do not require specialised nutrition care and those who are likely to benefit from a nutrition care specialist.

These models have focused on implementing nutrition care in the acute setting for patients with, or at risk of, protein–energy malnutrition. This has included the use of action reflection cycles to collect relevant data justifying change, then progressively developing, implementing, evaluating and iteratively improving chosen nutrition care activities [7, 8].

Figure 18.1 provides a SIMPLE illustration of how to support nutrition care of the older patient with fragility fracture. This is considerate of key nutrition care models internationally [3, 5, 9–11], and supports different members of orthogeriatric teams to contribute to systematised, interdisciplinary nutrition care for patients with, or at risk of a nutrition-related diagnosis, globally.

Fig. 18.1

Nutritional care of the older patient with fragility fracture

Specific strategies have not been identified, so that local teams can tailor the approach across a variety of nutrition-related diagnoses, frameworks and contexts. Systematised and interdisciplinary care nutrition actions are encouraged, but local processes should still inform referral for specialist nutrition advice when this is likely to add value. Conversely, if referral is unlikely to add value, for example when ongoing specialist intervention is unlikely to add benefit or improve what matters to the patient, supportive nutrition care should be the priority [12, 13].

The underlying themes along the bottom of the model highlight that successful and sustained nutrition care requires the engagement of local patients and teams using a knowledge translation approach; a ‘cut and paste’ approach to process changes will not yield the same outcomes [7, 11, 14].

18.3. Screening for Nutrition Risk (SIMPLE)

Nutritional risk increases substantially with age, multimorbidity and fragility fracture, and screening and/or assessment should be routine across orthopaedic settings. A two-step approach, with ‘first pass’ nutrition screening, followed by a detailed assessment by a qualified health professional, is often applied as an efficient approach to making a nutrition-related diagnosis [15]. In high-risk settings, such as acute hip fracture units (with a high proportion of patients at malnutrition risk), the poor sensitivity of common screening tools and the need for prompt nutrition care, support proceeding straight to detailed assessment and intervention [15]. Nutrition screening to identify patients at risk of a nutrition deficiency, excess or imbalance state should be quick and easy and designed to be administered by diverse people with limited or no training [16].

18.4. Interdisciplinary Assessment (SIMPLE)

Where patients are identified at nutrition risk, appropriately trained interdisciplinary team members should undertake further nutrition assessment. The lack of distinction between screening and assessment measures, the diversity of nutrition-related diagnoses and factors contributing to their development and the presence of confounding co-morbid conditions have resulted in the absence of any gold standards for nutrition screening or diagnosis [17–19]. Not surprisingly, a range of nutrition screening and assessment tools have been applied or recommended in orthogeriatric settings; Table 18.1 applies an ABCDEF anagram to highlight nutrition assessment measures, screening tools and malnutrition diagnostic criteria commonly reported, observed, applied or recommended for use in orthogeriatric settings [4, 10, 15–38] (Table 18.1). Local treating teams should select measures, tools and diagnostic criteria that have proven concurrent and predictive validity in the population in which they are to be applied, and that are feasible for local implementation [19, 21, 39, 40].

Table 18.1

Nutrition assessment measures, screening tools and malnutrition diagnostic criteria commonly applied or recommended for use in orthogeriatric settings

The ease of retrospective access and cut-off measures have led to the continued practice of using single-point nutrition outcomes measures, such as BMI or albumin, in clinical and research settings [17, 22]. Single measures may be appropriate for some specific nutrition-related diagnoses, for example some vitamin deficiency states. However, applying single measures for the definition of protein–energy malnutrition should probably be avoided. Protein–energy malnutrition has traditionally been assumed to apply to ‘stick thin’ patients with low BMIs. However, there is now a clear imperative to screen for malnutrition in overweight and obese as well as underweight older people [41]. Protein–energy malnutrition is evident across BMI ranges and the risks of increased morbidity and mortality associated with rapid loss of muscle mass are now becoming recognised across under-, overweight and obese BMI categories [42, 43]. Serum albumin and other markers of visceral protein status are also not reliable as a standalone malnutrition markers in acutely unwell orthogeriatric populations [18, 44]. Inflammation is today considered the major reason for reduced serum levels of visceral proteins, and inflammation due to disease or ageing is well recognised as a contributor to the development of malnutrition [44]. Inflammation is also a predictor of sepsis, longer hospital stay and readmission and mortality, so it is not surprising that studies report associations between low visceral proteins and poor patient and healthcare outcomes.

Differences in study designs, populations, evidence-based outcomes, guidelines and consensus recommendations preclude making specific macro- or micronutrient recommendations. Consequently, local teams should consider latest evidence and relevant national or international recommendations for macro- and micronutrients. As a start point, ageing-related inefficiencies in absorption and utilisation suggest considering an energy intake target of 30 kcal/kg bodyweight daily in older patients, and at least 1 g/kg protein with individual adjustment for nutritional status, physical activity level, disease status and tolerance [45, 46].

Dehydration should also be closely monitored as this can be causative for fracture incidence and a substantial and significant contributor to subsequent harm [47]. Unless a clinical comorbidity requires a different approach consensus daily recommendations suggest 1.6 L for women and 2.0 L for men with normal physical activity in a moderate climate [46, 48].

In summary, in many settings, a positive nutrition risk screen simply informs a referral for a thorough assessment and diagnosis by an appropriately trained nutrition care specialist, prior to commencing nutrition care interventions. A SIMPLE alternative is recommended; orthogeriatric teams need to action opportunities for systematised nutrition care from the point of risk identification. These may consider opportunities for timely nutrition diagnoses, goal setting, interventions and evaluation processes.

18.5. Make the Diagnosis/(es) (SIMPLE)

A broad array of nutrition-related diagnoses are observed across orthogeriatric settings and can result from deficiency, excess or imbalance states that lead to adverse effects on body form, function, clinical outcomes, healthcare systems and community costs (Table 18.2) [34].

Table 18.2

Common nutrition-related diagnoses observed or reported within and across global orthogeriatric settings—with ICD-10 Diagnostic Code [34]

Cachexia, sarcopaenia, frailty and osteoporosis are of particular interest, given their prevalence trajectories and likely impact on outcomes globally. Concurrent diagnoses, for example of obesity and malnutrition, are also worthy of special attention. The most outstanding single diagnosis in terms of reported prevalence, incidence and harm imposed on patient and healthcare systems is protein–energy malnutrition. In many settings globally, the skeleton continues to hide in the hospital closet; undervalued, under-recognised, and consequently, undertreated [49, 50].

Protein–energy malnutrition (malnutrition) is an ICD-coded condition that can be treated using medical nutrition therapy [34]. Its prevalence varies across orthogeriatric settings, reflecting differences in screening and diagnostic tools, as well as real differences in the populations observed. Estimates suggest that less than 1 in 3 non-complex elective orthogeriatric inpatients are at risk of malnutrition, whilst up to two-thirds of hip fracture patients will have a diagnosis of protein–energy malnutrition by the time they are discharged from acute or rehabilitation care settings [36, 50]. Although differences in design and tools again make comparisons difficult, the reported prevalence appears higher in studies from low- and middle-income counties than in high-income countries [51, 52].

Protein–energy malnutrition is recognised as the most costly comorbidity in hip fracture, the one most likely to increase length of stay and a strong independent predictor of post discharge mortality [53, 54]. Table 18.3 highlights associations between protein–energy malnutrition and outcomes observed across orthopaedic specified studies and those including older, multimorbid populations including those with fragility fractures [18, 54–63].

Table 18.3

Association between protein-energy malnutrition and outcomes in orthogeriatric settings

Recent updates to key orthogeriatric evidence-based recommendations, guidelines and registry datasets suggest positive, albeit belated, recognition of the need for timely identification, treatment and monitoring of nutrition care across the acute, rehabilitation and secondary prevention orthogeriatric settings globally.

A thorough assessment will also identify the aetiology, or root cause, of the nutrition-related diagnosis or diagnoses being assessed [9]. A comprehensive list of all potential aetiologies observed in orthogeriatric settings is beyond the remit of this chapter, however, Table 18.4 provides some potential starting points for consideration [17, 37, 50].

Table 18.4

Commonly observed determinants of nutrition-related diagnoses across orthogeriatric settings

Efforts to identify a primary aetiology for a nutrition-related diagnosis in older, multimorbid inpatients are difficult, and perhaps over-simplistic [64]. For example, protein–energy malnutrition may be attributable to wasting, cachexia or a combination of these [30]. This is further confounded by the complex relationships and substantial overlap in variables applied for the purposes of screening and diagnosing protein–energy malnutrition, wasting, cachexia, sarcopaenia, frailty, osteoporosis and other nutrition-related diagnoses [65]. It is therefore unsurprising that malnutrition is considered a ‘wicked’ problem [66, 67] (Table 18.5). A pragmatic approach would consider whether administration of nutritional intervention is likely to improve outcomes; if so then the aetiology is likely to include a nutritional component and locally tailored nutrition interventions should be provided.

Table 18.5

Why malnutrition should be considered a wicked problem

Once diagnoses and aetiologies have been articulated, these should be documented in the appropriate care record. Proper documentation is critical to providing quality standard care, communication with other professions and recording diagnosis that can have effects on other medical diagnosis or treatment [68]. Documentation also supports service planning and review processes, and in many settings also influences resource allocation.

Multidisciplinary clinicians should ensure that patients are aware of positive nutrition risk screens. Open and honest discussion about consequent nutrition-related diagnoses and a shared decision-making approach to treatment (and no treatment) options should be considered within a sensitive approach that allows patients or carers to control the amount of information they receive [46, 69].

A ‘truth-telling’ approach to informing patients of a diagnosis of malnutrition, for example may initially appear confronting. However, studies suggest that patients’ wish to understand a harmful diagnosis such as malnutrition far outweighs concerns over potential disbenefits of receiving this advice [69]. Recognition of a problem is a primary first step towards positive change, and awareness of nutrition status may positively influence treatment adherence or patient experiences.

18.6. Plan with the Patient (SIMPLE)

Wicked problems do not have magic bullets for care [70]. Multi-modal, interdisciplinary interventions should be considered to treat nutrition diagnoses, aetiologies or related conditions at both the individual and systems levels [9, 31, 38, 46, 71, 72]. Nutrition interventions planned at the individual level should consider a shared decision-making approach, including informed consent. This should be applied to establish nutrition treatment goals and intervention strategies and to establish monitoring and reassessment processes to identify whether interventions are effective and consistent with patient goals and healthcare system deliverables [3, 9, 46, 73, 74]. Whilst these care processes are presented in linear fashion, this is not how care will or should be delivered in many real-world settings. Orthogeriatric teams should also engage patients in co-design approaches to improve systems, processes, resources, environmental and governance structures that facilitate delivery of nutrition care across the three pillars of care [1, 75, 76].

To the best of our knowledge, no specific literature has focused its attention on the need for shared decision-making or co-design in orthogeriatics. Nevertheless, increasing evidence suggests the importance of these components in the nutritional care of frail and older patients. Patients should be encouraged to become more active in goal setting and developing strategies for ongoing care; these should ideally be patient-driven and support patients and/or carers to make ‘informed choices’ about treatment options [77]. This is especially important in the absence of a ‘one strategy fits all’ approach to nutrition care. Building behaviour change through setting small realistic goals, encouraging self-monitoring, providing positive feedback and health coaching are also potential opportunities that could implemented by interdisciplinary healthcare workers across orthopaedic settings [77]. Perhaps most importantly, goals and strategies should be individualised to consider the patients’ stage of change, health literacy, cognition and cultural needs [77]. Involving family and other significant support people, particularly those who are primary meal providers, in nutrition education strategies may positively influence behaviour change [77].

Who is best placed to facilitate appropriate goal-setting with patients varies across settings; how, when and where this takes occurs is also highly contextual. As an example, in a palliative situation, the patient should be offered whatever he or she likes to eat and drink orally, in the amount he or she likes to consume, regardless of nutrition status. This approach is mostly described by the term comfort feeding [78]. In this situation, meeting a patient’s nutritional requirements is obviously irrelevant, and nutrition treatment goals and strategies should focus on their comfort [79]. In contrast, the appropriateness of reinserting an enteral feeding tube, after its removal by a malnourished, acutely delirious hip fracture patient, is far more complex and would require attention to clinical judgement and shared decision-making [80, 81].

18.7. ImpLement Interventions (SIMPLE)

18.7.2. Interventions to Influence Nutrient Intake

Numerous studies demonstrate that patients with hip fracture, and older adults in the acute and rehabilitation settings more generally, commonly fail to meet rudimentary recommendations for macronutrient, micronutrient and fluid intakes. In many cases, multiple nutrition-related diagnoses co-exist, for example in malnourished patients with co-diagnoses of obesity and pressure injuries; in such cases, clinical care processes are best supported by dietitians or medical nutrition specialists, where available [42].

In most cases, the underlying treatment strategies for patients with undernutrition revolve around the deficient nutrient or nutrients, whether protein and/or energy, fluids or micronutrients. Ensuring adequate provision and intake of fluids and micronutrients may not be an insurmountable challenge in acute, rehabilitation and secondary prevention settings with appropriate application of intravenous therapy and pharmaceutical support. Nonetheless, dehydration is still commonly observed, vitamin D and other micronutrient deficiencies often remain untreated and a high proportion of post-fracture patients fail to receive adequate bone protection medication. However, the most difficult challenge is the increased protein requirements of acutely unwell, older, multimorbid patients. Many intervention studies demonstrate persistent inadequate intakes with concomitant harm, even after intervention.

There is no single intervention that will guarantee delivery of protein and energy intake adequacy across acute, rehabilitation, community or residential care home settings. Multimodal approaches that engage patients and treating teams in the identification of locally relevant, multimodal strategies seem more likely to yield improved intakes, patient and healthcare outcomes and patient-reported experiences.

Table 18.6 lists systematised and/or interdisciplinary strategies that are considered to positively influence macronutrient, micronutrient and/or fluid intake across orthogeriatric settings [6, 9, 17, 22, 38, 46, 71, 72, 89]. Specific strategies for nutrition care should be considered by local teams after considering relevant evidence-based recommendations and tailoring interventions to the local context and patient needs.

Table 18.6

Systematised and/or interdisciplinary strategies to influence food and nutrition intake

18.8. Evaluating Ongoing Care Requirements (SIMPLE)

Patients with or at risk of a nutrition-related diagnosis will routinely require nutrition monitoring or re-assessment strategies. Processes for re-screening should also be considered for those not currently at risk. What needs to be monitored, how often, and by whom will depend on many factors, perhaps most notably the nutrition diagnosis in question, and resource constraints. This makes it challenging to provide definitive recommendations for clinical handover across the care pathway.

Local treating teams need to work with patients to identify the best opportunities for ongoing nutritional monitoring and evaluation. Discussions may consider the availability of access to specialist nutrition outpatient or community services and the potential benefits, costs and opportunity costs of these. Other alternatives for consideration could include general practitioners, nurse practitioners, mHealth programs, group programs or self-monitoring.

Finally, clinical audits of care delivery positively influence patient and healthcare outcomes. Table 18.7 provides a summative recap of potential opportunities for systematised, interdisciplinary nutrition care approaches across acute care, rehabilitation and secondary prevention orthogeriatric settings, and how these may be evaluated [3].

Table 18.7

Evaluating nutritional care of the older patient with fragility fracture

18.9. Recommended Further Reading

• Bell JJ et al (2018) Rationale and developmental methodology for the SIMPLE approach: a Systematised, Interdisciplinary Malnutrition Pathway for impLementation and Evaluation in hospitals. Nutr Diet 75(2):226–234
• King PC et al (2019) “I wouldn’t ever want it”: a qualitative evaluation of patient and caregiver perceptions toward enteral tube feeding in hip fracture inpatients. J Parenter Enteral Nutr 43(4):526–533
• Volkert D et al (2019) ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr 38(1):10–47

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This chapter is a component of Part 5: Cross-cutting Issues.

For an explanation of the grouping of chapters in this book, please see Chapter 1: ‘The multidisciplinary approach to fragility fractures around the world—an overview’.