Moderate evidence supports that nutritional supplementation in patients with underlying deficiency improves functional outcomes and reduces mortality; therefore nutritional status should be assessed.

Rationale
One high strength (Duncan et al)130 and 2 low strength (Eneroth et al)131 and Espaulella et al 132 studies were used to evaluate the relationship between nutritional supplementation and outcomes in elderly patients with hip fractures. These studies report that protein energy malnutrition is an important determinant of outcome in older patients with hip fracture. Use of a dietary assistant decreased death acutely 2.5 times (Duncan et al 130) and at 4 months by half. Duncan et al is the largest randomized control study of nutritional support following hip fracture and the first that includes patients with cognitive impairment (57%). Energy intake in the intervention group (IV x 3d and PO x 7d) provided by supplements (Eneroth et al 131) was optimal in 100% of patients in the intervention group vs. 54% in the control group. Fracture related complication rate was 15% (intervention group) vs. 70% (control group).Greater than 58% of the patients in each group were malnourished on admission. A 20g protein supplement daily with 800mg of calcium did not decrease mortality or increase functional status but significantly decreased complications within the hospital (odds ratio 1.88 in-hospital and overall 1.94 after discharge (Espaulella et al 132).
 
Risks and Harms of Implementing these Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.
 
Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
 
 
  1. (130) Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward. Age Ageing 2006;35(2):148-153.
  2. (131) Eneroth M, Olsson UB, Thorngren KG. Nutritional supplementation decreases hip fracture-related complications. Clin Orthop Relat Res 2006;451):212-217.
  3. (132) Espaulella J, Guyer H, Diaz-Escriu F, Mellado-Navas JA, Castells M, Pladevall M. Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial. Age Ageing 2000;29(5):425-431.