Nutrition Screening and Assessment in Hip Fracture

  • Jack Bell
Living reference work entry


Protein-energy malnutrition is prevalent in one in two patients admitted with a hip fracture; commonly observed inadequate postoperative protein/energy intake leads to further incident inpatient malnutrition. This condition is reported as the most costly comorbidity in hip fracture. The complex, multimorbid population limits the usefulness of routinely applied malnutrition screening tools. Given the high cost, prevalence, and incidence of malnutrition, and poor sensitivity of most screening tools, routine comprehensive nutrition assessment of all acute hip fracture inpatients is recommended. There is no gold standard for malnutrition diagnosis in the clinical setting in hip fracture. Malnutrition diagnosis is complex in this patient population, and often requires triangulation of multiple nutrition assessment measures from a variety of sources over multiple time periods. Single variable measures should not be relied upon to diagnose malnutrition, and commonly applied index measures may still require a subjective clinical judgment to inform a final diagnosis.


Malnutrition Hip fracture Screening Assessment Nutrition Orthopedic Neck of femur Protein Energy 


  1. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group (Producer) (2014), Australian and New Zealand guideline for hip fracture care (20 November, 2014). Retrieved from
  2. Auyeung TW, Lee JS, Kwok T, Leung J, Leung PC, Woo J (2009) Estimation of stature by measuring fibula and ulna bone length in 2443 older adults. J Nutr Health Aging 13(10):931–936CrossRefGoogle Scholar
  3. Avenell A, Smith TO, Curtain JP, Mak JC, Myint PK (2016) Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev, 11, CD001880.
  4. Bell JJ (2014) Identifying and overcoming barriers to nutrition care in acute hip fracture inpatients. PhD thesis, The University of QueenslandGoogle Scholar
  5. Bell JJ, Bauer JD, Capra S (2013a) The Malnutrition Screening Tool versus objective measures to detect malnutrition in hip fracture. J Hum Nutr Diet 26(6):519–526CrossRefGoogle Scholar
  6. Bell JJ, Bauer JD, Capra S, Pulle CR (2013b) Barriers to nutritional intake in patients with acute hip fracture: time to treat malnutrition as a disease and food as a medicine? Can J Physiol Pharmacol 91(6):489–495CrossRefGoogle Scholar
  7. Bell JJ, Bauer JD, Capra S, Pulle RC (2014a) Concurrent and predictive evaluation of malnutrition diagnostic measures in hip fracture inpatients: a diagnostic accuracy study. Eur J Clin Nutr 68(3):358–362CrossRefGoogle Scholar
  8. Bell JJ, Bauer JD, Capra S, Pulle RC (2014b) Multidisciplinary, multi-modal nutritional care in acute hip fracture inpatients – results of a pragmatic intervention. Clin Nutr 33(6):1101–1107CrossRefGoogle Scholar
  9. Bell JJ, Bauer JD, Capra S, Pulle RC (2014c) Quick and easy is not without cost: implications of poorly performing nutrition screening tools in hip fracture. J Am Geriatr Soc 62(2):237–243CrossRefGoogle Scholar
  10. Bell JJ, Pulle RC, Crouch AM, Kuys SS, Ferrier RL, Whitehouse SL (2016) Impact of malnutrition on 12-month mortality following acute hip fracture. ANZ J Surg 86(3):157–161CrossRefGoogle Scholar
  11. Bishop CW, Bowen PE, Ritchey SJ (1981) Norms for nutritional assessment of American adults by upper arm anthropometry. Am J Clin Nutr 34(11):2530–2539CrossRefGoogle Scholar
  12. Blackburn GL, Bistrian BR, Maini BS, Schlamm HT, Smith MF (1977) Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr 1(1):11–22CrossRefGoogle Scholar
  13. Bouillanne O, Hay P, Liabaud B, Duche C, Cynober L, Aussel C (2011) Evidence that albumin is not a suitable marker of body composition-related nutritional status in elderly patients. Nutrition 27(2):165–169CrossRefGoogle Scholar
  14. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF (1980) Prognostic nutritional index in gastrointestinal surgery. Am J Surg 139(1):160–167CrossRefGoogle Scholar
  15. Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, Compher C, Correia I, Higashiguchi T, Holst M, Jensen GL, Malone A, Muscaritoli M, Nyulasi I, Pirlich M, Rothenberg E, Schindler K, Schneider SM, de van der Schueren MA, Sieber C, Valentini L, Yu JC, Van Gossum A, Singer P (2017) ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 36(1):49–64CrossRefGoogle Scholar
  16. Chevalley T, Hoffmeyer P, Bonjour J-P, Rizzoli R (2010) Early serum IGF-I response to oral protein supplements in elderly women with a recent hip fracture. Clin Nutr 29(1):78–83CrossRefGoogle Scholar
  17. Choi BC, Pak AW (2007) Multidisciplinarity, interdisciplinarity, and transdisciplinarity in health research, services, education and policy: 2. Promotors, barriers, and strategies of enhancement. Clin Invest Med 30(6):E224–E232CrossRefGoogle Scholar
  18. Correia MI, Waitzberg DL (2003) The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 22(3):235–239CrossRefGoogle Scholar
  19. Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA et al (1987) What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 11(1):8–13CrossRefGoogle Scholar
  20. Dietitian/Nutritionists from the Nutrition Education Materials Online team (2014) Estimating energy, protein & fluid requirements for adult clinical conditions. Retrieved 1 June 2015, from
  21. Duncan DG, Beck SJ, Hood K, Johansen A (2006) Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Age Ageing 35(2):148–153CrossRefGoogle Scholar
  22. Elia M (2003) Screening for malnutrition: a multidisciplinary responsibility. development and use of the malnutrition universal screening tool (MUST) for adults. BAPEN, RedditchGoogle Scholar
  23. Elia M, Stratton RJ (2011) Considerations for screening tool selection and role of predictive and concurrent validity. Curr Opin Clin Nutr Metab Care 14(5):425–433CrossRefGoogle Scholar
  24. Eneroth M, Olsson U-B, Thorngren K-G (2005) Insufficient fluid and energy intake in hospitalised patients with hip fracture. A prospective randomised study of 80 patients. Clin Nutr 24(2):297–303CrossRefGoogle Scholar
  25. Eneroth M, Olsson U-B, Thorngren K-G (2006) Nutritional supplementation decreases hip fracture-related complications. Clin Orthop Relat Res 451:212–217CrossRefGoogle Scholar
  26. Ferguson M, Capra S, Bauer J, Banks M (1999) Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15(6):458–464CrossRefGoogle Scholar
  27. Formiga F, Chivite D, Mascaro J, Ramon JM, Pujol R (2005) No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture. Aging-Clin Exper Res 17(4):343–346CrossRefGoogle Scholar
  28. Foster MR, Heppenstall RB, Friedenberg ZB, Hozack WJ (1990) A prospective assessment of nutritional status and complications in patients with fractures of the hip. J Orthop Trauma 4(1):49–57CrossRefGoogle Scholar
  29. Goisser S, Schrader E, Singler K, Bertsch T, Gefeller O, Biber R, Bail HJ, Sieber CC, Volkert D (2015) Malnutrition according to Mini Nutritional Assessment is associated with severe functional impairment in geriatric patients before and up to 6 months after hip fracture. J Am Med Dir Assoc 16(8):661–667CrossRefGoogle Scholar
  30. Guigoz Y, Vellas B, Garry P (1994) Mini nutritional assessment: a practical assessment tool for grading the nutritional state of elderly patients. Facts Res Gerontol 4:14–59Google Scholar
  31. Gumieiro DN, Rafacho BPM, Gradella LM, Azevedo PS, Gaspardo D, Zornoff LAM, Pereira GJ, Paiva SA, Minicucci MF (2012) Handgrip strength predicts pressure ulcers in patients with hip fractures. Nutrition 28(9):874–878CrossRefGoogle Scholar
  32. Gumieiro DN, Rafacho BPM, Gonçalves AF, Tanni SE, Azevedo PS, Sakane DT, Carneiro CA, Gaspardo D, Zornoff LA, Pereira GJ, Paiva SA, Minicucci MF (2013) Mini Nutritional Assessment predicts gait status and mortality 6 months after hip fracture. Br J Nutr 109(9):1657–1661CrossRefGoogle Scholar
  33. Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang T (2010) The effects of different nutritional measurements on delayed wound healing after hip fracture in the elderly. J Surg Res 159(1):503–508CrossRefGoogle Scholar
  34. Helminen H, Luukkaala T, Saarnio J, Nuotio MS (2017) Changes in nutritional status and associated factors in a geriatric post-hip fracture assessment. Eur Geriatr Med 8(2):134–139CrossRefGoogle Scholar
  35. Hernlund E, Svedbom A, Ivergard M, Compston J, Cooper C, Stenmark J, EV MC, Jönsson B, Kanis JA (2013) Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos 8:136CrossRefGoogle Scholar
  36. Hoekstra JC, Goosen JHM, de Wolf GS, Verheyen CCPM (2011) Effectiveness of multidisciplinary nutritional care on nutritional intake, nutritional status and quality of life in patients with hip fractures: a controlled prospective cohort study. Clin Nutr 30(4):455–461CrossRefGoogle Scholar
  37. Inoue T, Misu S, Tanaka T, Sakamoto H, Iwata K, Chuman Y, Ono R (2016) Pre-fracture nutritional status is predictive of functional status at discharge during the acute phase with hip fracture patients: A multicenter prospective cohort study. Clin Nutr Scholar
  38. Jensen GL, Compher C, Sullivan DH, Mullin GE (2013) Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. J Parenter Enter Nutr 37(6):802–807CrossRefGoogle Scholar
  39. Johansen A, Boulton C, Hertz K, Ellis M, Burgon V, Rai S, Wakeman R (2017) The National Hip Fracture Database (NHFD) – Using a national clinical audit to raise standards of nursing care. Int J Orthop Trauma Nurs 26:3–6. Scholar
  40. Juliebo V, Bjoro K, Krogseth M, Skovlund E, Ranhoff AH, Wyller TB (2009) Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc 57(8):1354–1361CrossRefGoogle Scholar
  41. Kaiser MJ, Bauer JM, Ramsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony P, Charlton KE, Maggio M, Tsai AC, Grathwohl D, Vellas B, Sieber CC, MNA-International Group (2009) Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 13(9):782–788CrossRefGoogle Scholar
  42. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z (2003) Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 22(3):321–336CrossRefGoogle Scholar
  43. Koren-Hakim T, Weiss A, Hershkovitz A, Otzrateni I, Grosman B, Frishman S, Salai M, Beloosesky Y (2012) The relationship between nutritional status of hip fracture operated elderly patients and their functioning, comorbidity and outcome. Clin Nutr 31(6):917–921CrossRefGoogle Scholar
  44. Koren-Hakim T, Weiss A, Hershkovitz A, Otzrateni I, Anbar R, Gross Nevo RF, Schlesinger A, Frishman S, Salai M, Beloosesky Y (2016) Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients. Clin Nutr 35(5):1053–1058CrossRefGoogle Scholar
  45. Leal J, Gray AM, Prieto-Alhambra D, Arden NK, Cooper C, Javaid MK, Judge A, REFReSH study group (2016) Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int 27:549–558CrossRefGoogle Scholar
  46. Lindholm C, Sterner E, Romanelli M, Pina E, TorrayBou J, Hietanen H, Iivanainen A, Gunningberg L, Hommel A, Klang B, Dealey C (2008) Hip fracture and pressure ulcers – the Pan-European Pressure Ulcer Study – intrinsic and extrinsic risk factors. Int Wound J 5(2):315–328CrossRefGoogle Scholar
  47. Marshall WJ (2008) Nutritional assessment: its role in the provision of nutritional support. J Clin Pathol 61(10):1083–1088CrossRefGoogle Scholar
  48. Mueller C, Compher C, Ellen DM (2011) A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr 35(1):16–24CrossRefGoogle Scholar
  49. Myint MWW, Wu J, Wong E, Chan SP, To TSJ, Chau MWR, Ting KH, Fung PM, Au KSD (2013) Clinical benefits of oral nutritional supplementation for elderly hip fracture patients: a single blind randomised controlled trial. Age Ageing 42(1):39–45CrossRefGoogle Scholar
  50. National Centre for Classification in Health (2006) The international statistical classification of diseases and related health problems, tenth revision, Australian modification (ICD-10-AM): tabular list of diseases, 5th edn. Shannon Books, SydneyGoogle Scholar
  51. National Institute for Health and Clinical Excellence (2011) NICE guidelines – National Clinical Guideline Centre. NICE Clinical guideline 124, The management of hip fracture in adultsGoogle Scholar
  52. Nematy M, Hickson M, Brynes AE, Ruxton CHS, Frost GS (2006) Vulnerable patients with a fractured neck of femur: nutritional status and support in hospital. J Hum Nutr Diet 19(3):209–218CrossRefGoogle Scholar
  53. Nikkel LE, Fox EJ, Black KP, Davis C, Andersen L, Hollenbeak CS (2012) Impact of comorbidities on hospitalization costs following hip fracture. J Bone Joint Surg Am 94(1):9–17CrossRefGoogle Scholar
  54. Nuotio M, Tuominen P, Luukkaala T (2016) Association of nutritional status as measured by the Mini-Nutritional Assessment Short Form with changes in mobility, institutionalization and death after hip fracture. Eur J Clin Nutr 70(3):393CrossRefGoogle Scholar
  55. Peak H (2000) Determining the incidence of hospital trust malnutrition to plan and target nutritional support strategies. Proc Nutr Soc 59:139AGoogle Scholar
  56. Rainey-Macdonald CG, Holliday RL, Wells GA, Donner AP (1983) Validity of a two-variable nutritional index for use in selecting candidates for nutritional support. JPEN J Parenter Enteral Nutr 7(1):15–20CrossRefGoogle Scholar
  57. Rasmussen HH, Holst M, Kondrup J (2010) Measuring nutritional risk in hospitals. Clin Epidemiol 2:209–216CrossRefGoogle Scholar
  58. Rutishauser IHE (2005) Dietary intake measurements. Public Health Nutr 8(7A):1100–1107CrossRefGoogle Scholar
  59. Scottish Intercollegiate Guidelines Network (2009) Management of hip fracture in older people. A national clinical guideline. Retrieved from
  60. Sivakumar BS, McDermott LM, Bell JJ, Pulle CR, Jayamaha S, Ottley MC (2013) Dedicated hip fracture service: implementing a novel model of care. ANZ J Surg 83(7-8):559–563CrossRefGoogle Scholar
  61. Villani AM, Miller MD, Cameron ID, Kurrle S, Whitehead C, Crotty M (2013) Development and relative validity of a new field instrument for detection of geriatric cachexia: preliminary analysis in hip fracture patients. J Cachex Sarcopenia Muscle 4(3):209–216CrossRefGoogle Scholar
  62. Weimann A, Braga M, Carli F, Higashiguchi T, Hübner M, Klek S, Laviano A, Ljungqvist O, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P (2017) ESPEN guideline: clinical nutrition in surgery. Clin Nutr 36(3):623–650. Scholar
  63. White JV, Guenter P, Jensen G, Malone A, Schofield M (2012) Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 36(3):275–283CrossRefGoogle Scholar
  64. Williamson DA, Allen HR, Martin PD, Alfonso AJ, Gerald B, Hunt A (2003) Comparison of digital photography to weighed and visual estimation of portion sizes. J Am Diet Assoc 103(9):1139–1145CrossRefGoogle Scholar
  65. Wilson MM, Thomas DR, Rubenstein LZ, Chibnall JT, Anderson S, Baxi A et al (2005) Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. Am J Clin Nutr 82(5):1074–1081CrossRefGoogle Scholar
  66. Yuwen P, Chen W, Lv H, Feng C, Li Y, Zhang T, Hu P, Guo J, Tian Y, Liu L, Sun J, Zhang Y (2017) Albumin and surgical site infection risk in orthopaedics: a meta-analysis. BMC Surg 17(1):7CrossRefGoogle Scholar

Copyright information

© Crown Copyright 2017

Authors and Affiliations

  1. 1.Allied Health, Metro North HHS & School of Human Movement and Nutrition Sciences, The University of Queensland. Building 14The Prince Charles HospitalChermsideAustralia

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