Dietary intervention in elderly patients prevent loss of activities of daily living after orthopaedic surgery

Page 64 

Introduction

In Denmark, approximately 20,000 patients aged 65 years and over undergo surgery each year for fractured neck of femur or hip- or knee alloplasty, and there is nothing to suggest that the number of operations will decrease in the future. It is not uncommon for the nutritional status of patients to alter in connection with surgical intervention. Patients lose weight and subsequently muscle mass (1), which applies also to surgical orthopaedic patients (2). In addition, the postoperative period can be complicated by infections and the onset of postoperative fatigue. Changes in the patient's nutrititional status and development of postoperative complications can adversely affect the patient's postoperative level of activity (3-5). Patients who have undergone surgery for a fractured neck of femur postoperatively suffer a deterioration in their ability to perform activities that are vital in order to lead a normal daily life (2, 3, 6-8). Consequently, several patients feel that their general health has deteriorated six months after surgery, while 75 per cent feel less able to perform daily activities in comparison with their ability prior to their operation (3). This decline concerns not only an ability to perform normal daily functions, such as personal hygiene, mobility and dressing, but also an ability to perform more complex activities, such as maintaining a home, using transport and pursuing interests. A decrease in activity can be linked to an interplay between the loss of muscle tissue, increased postoperative fatigue and a general lack of well-being.

Increased perioperative nutrition can reduce postoperative deterioration such as weight loss, infections and fatigue, as well as sustain or increase muscle mass, even in undernourished patients (9-15). The effect of postoperative nutritional intervention has been previously studied in relation to minimising the risk of complications and reducing the length of hospital stays in emergency and rehabilitation wards (9, 13-21). However, no previous studies have been conducted on the issue of whether increased postoperative energy and protein intake can help sustain activity in elderly surgical orthopaedic patients.

The hypothesis is that patients aged 65 or over can be stimulated postoperatively to consume a sufficient intake of energy and protein. This will lead to a shorter stay in hospital, a reduction in the number of complications, as well as less breakdown of muscle tissue. This will in turn result in less postoperative fatigue and help the patients regain their ability to perform daily activities of a physical, psycho-social and intellectual nature. The hypothesis has been tested using a nursing programme that focuses on involving the patients actively in their own dietary care. This article outlines the results of the level of postoperative activity and the energy and protein intake. The effect of actively involving patients in their own dietary care has been described in an earlier article (22), and the results concerning the onset of complications, fatigue and the preservation of muscle tissue will be presented in an article at a later date.

Materials and methods

The study was carried out at surgical orthopaedic ward H, Roskilde County Hospital in Køge from 1995/11/15 to 1997/3/15. The patients were chosen among patients consecutively admitted for elective hip- or knee alloplasty or emergency surgery for fractured neck of femur, all of whom were expected to stay in hospital for more than seven days. The patients were also required to be at least 65 years of age and able to understand information given in Danish.

The study was designed as a single-blind and non-randomised controlled investigation. Changes in the patients' physical, psycho-social and intellectual activities were recorded during the ward's standard routines in control patients from 1995/11/15 to 1996/6/30. Intervention consisted of increasing the patients' energy and protein intake by systematically involving the patients in their own dietary care during their hospital stay. Physical, psycho-social and intellectual activities were then recorded among intervention patients during the ward's new routines from 1996/9/1 to 1997/3/30. The effect of increasing energy and protein intake was determined by comparing changes in the patients' activities in the two patient groups. In both groups, the activity level was recorded prior to admission, discharge and four months after surgery at the ward's out-patient clinic. Recordings were taken each day of dietary intake while any changes in weight were noted.

Altogether, 369 patients were allocated to the study. A total of 116 patients (31 per cent) were unable to take part. Seventeen declined to take part, 37 were unable to understand the information given, 26 were already receiving dietary treatment, 16 had cancer, gastrointestinal disorders or were undergoing treatment with steroids. Five patients were unable to participate due to serious uncompensated heart disorders, while 11 patients were transferred to intensive/cardiac units after their operation and did not return to the surgical orthopaedic ward. Four more patients were prevented

Page 65

from participating for other reasons and 11 patients withdrew from the study. Altogether, 242 patients took part in the study. Sixty-seven patients failed to turn up for their final follow-up appointment at the out-patient clinic four months after the operation. Of these, seven had died, 42 were living at home, four had moved to a nursing home, three were still hospitalised, ten lived outside the county whereas it was impossible to discover the whereabouts of one patient. Consequently, it was possible to monitor 175 patients (73 per cent) altogether throughout the whole period, distributed between 95 and 85 patients in the control and intervention groups, respectively. Patients monitored during the whole period did not differ in composition from the overall patient group in terms of gender and patient classification, although their mean age was 75.9 years (±7.) The mean age of the group that could not be monitored was 78.6 years (±7.9) (p<0.01). 

Table 1. Types of care for control and intervention patients

Actions	Standard care Control patients	Intervention care Intervention patients
Distribution of the leaflet 'Diet before operation' to elective patients one month prior to admission	No	Yes
Systematic completion of admission interviews about eating habits and problems	No	Yes
Systematic calculation of energy and protein requirements	No	Yes
Daily dietary recording	Yes	Yes
Daily evaluation of dietary intake in relation to current requirements. Carried out by the patient and the nurse	No	Yes
Systematic help for patients with eating problems	No	Yes
Systematic information, guidance and instruction about appropriate diet in connection with an operation	No	Yes
Implementation of the primary nurse scheme for nutrition	No	Yes

Table 2. Gender, age and patient classification for included/excluded patients admitted 95.7.1 to 96.6.31 in Roskilde County and nationwide in 1994

Intervention

Intervention is based on stimulating the patients to independently increase their energy and protein intake. In order to achieve this goal the study applies Salling's humanistically inspired nursing model (23). The model refers to motivation and development theories described by Murray, Maslow and Piaget. Nursing actions specifically focus on involving the patients and their personalities in the care, thereby stimulating the individuals' personal activity both in hospital and after discharge (24). The nursing model necessitates an admission interview, daily interviews with the patient in conjunction with the primary nurse scheme, which involves the same nurse throughout the hospital stay (23, 24).

In this study the admission interview was defined as a dialogue in connection with drawing up a dietary journal, which was followed up with daily interviews on how the patient's current nutritional requirements were being met. Information, guidance and instruction were given in conjunction with the interviews. Continuity in the interviews was ensured by the appointment of a project nurse, who acted as the primary nurse for nutrition for all the patients. In the primary nurse's absence the interviews were carried out by the research co-ordinator. One month prior to planned admission, the intervention patients were each sent a leaflet containing preoperative dietary advice. Every patient completed a dietary journal on admission, which lay by the patient's bed and contained information about the patient's eating problems and habits as well as needs at meal times. This journal also lay

Page 66

together with a chart of the patient's energy and protein requirements and patient information about diet and surgery. The course of the interviews was determined on the basis of the results recorded in the journal the previous day. Each patient was given individual guidance on how to sensibly put together the next day's meals, taking into account the patient's wishes and availability. The difference in the care given to the control and intervention patients is illustrated in Table 1. During the interviews, there was no discussion of rehabilitation problems. If raised, these were referred to other staff on the ward. No change was made in relation to the ward menu, its nutritional value or the ward's rehabilitation procedure for the duration of the study.

Dietary recording

Dietary intake was recorded daily between 7:00am and 7:00pm, commencing the first full postoperative day until the last day before discharge, although only up to a maximum of 20 days. The patient and/or nursing staff recorded the dietary intake on a regular basis. In addition, the previous day's entries were discussed with the patient each morning in an effort to prevent errors in the journal. The record of dietary intake assumed that patients were served the hospital's standard portions and that both patients and staff were able to assess the amount eaten. All intake was described according to the following scale: ''Consumed everything or almost everything'', ''Consumed about half'', or '' Consumed almost nothing or nothing''. For hot meals the estimates were made with respect to meat/fish, potatoes and vegetables. The accuracy and consistency of the dietary recordings were tested in relation to the hot meal. Uniformity in the portions of; meat r=0.88, potatoes r=0.62, and vegetables r=0.51. Accuracy regarding the information given by patients about what they had actually eaten: meat r=0.88, potatoes r=0.95 and vegetables r=0.95. Accuracy of the scale used: meat r=0.95, potatoes r=0.95 and vegetables r=0.95.

The consistency of the staff's estimate about what was eaten: meat ±=0.76, potatoes ±=0.76 and vegetables ±=0.70. Accuracy and consistency were therefore in order. The testing was carried out by the project nurse and the author. Calculation of the dietary recordings was performed by a specially designed computer programme (25). All input concerning the size of portions was described in terms of grammes, segments or millilitres and also in regard to more practical forms of measurement such as spoons, glasses and cups. In addition, the size of the portions for all meals was illustrated in a series of photos. The energy and protein content in the diet was calculated by the ward's clinical dietician on the basis of the hospital kitchen's recipes and standard table measurements.

Activities

Physical, psycho-social and intellectual activities were recorded in a standardised chart designed by A.L.Salling for her thesis, '' Stimulation of a patient's level of activity and development'' (23). The activity chart covered ten areas of patient activity. These physical, psycho-social and intellectual activities were measured according to three scales (23). The activity chart has earlier been item-analysed using the RASH model, which means that the scales have been tested for objectivity, information value and item-bias (23). In this respect, the activity chart was found particularly suitable for evaluating patient activities related to care and treatment programmes and was designed on the basis of studies carried out in surgical orthopaedic and medical wards (23). The physical scale covered the functions of personal hygiene, dressing and undressing, mobility as well as emptying the bowels and bladder. The psycho-social scale focused on the activities of performing everyday tasks in the home and pursuing interests both inside and outside the home. The intellectual scale focused on the activities that involved seeking information about the reasons for hospitalisation as well as about treatment and its consequences. The activities were graded in the following way: '' Without help'', '' With little help'', '' With some help'' and '' Only with help''.

Information about physical and intellectual activities was gathered on admission, on discharge and at the out-patient clinic four months after the operation. Psycho-social activities were registered only on admission and four months after the operation. The description of physical and psycho-social activities on admission and four months after the operation covered those activities that the patient was able to perform at home. The description of physical and psycho-social activities was based on data volunteered by the patient. Intellectual activities were evaluated by the primary nurse.

Other variables

The ability to walk was measured on a scale of five categories ranging from '' Walking without difficulty'' to '' Unable to walk''. The patient's pain was measured on a nominal scale of '' Yes'' or '' No'' in response to

Page 67

whether pain-killing medicine was used by the patient within the last week for postoperative pain in the leg. The patients were weighed on the same set of scales on the ward and at the out-patient clinic, dressed only in their underwear. On admission, the elective patients were weighed the day before their operation, while emergency patients were weighed the first day they were able to move, although no later than the third postoperative day. Height was measured in metres without shoes. Body Mass Index (BMI) was calculated using the formula kg/height². 

Ethics

Patients were allowed to participate after providing verbal and written informed consent. The study was reported to the Data Surveillance Authority and approved by the Regional Committee on Scientific Ethics for Roskilde County, case number 1995-1-62. 

Statistics

Data was processed using the statistics programme SPSS. The T-test for unpaired data was used for data measurements on the ratio-interval level. This data was tested using the F-test for normal distribution. The mean values are indicated ±1 SD. The confidence interval was used to test data measured on the nominal or ordinal scaled level. The confidence interval is indicated on the table results (26). No power calculation was conducted.

Table 2. Gender, age and patient classification for included/excluded patients admitted 95.7.1 to 96.6.31 in Roskilde County and nationwide in 1994

	Allocated patients n=369	Excluded patients n=116	Patients in the study n=253	Patients fol- lowed for 4 mths n=175	Roskilde County n=406	Nationwide n=23.101
Gender:
Male	31%	38%	29%	32%	26%	25%
Female	69%	62%	71%	68%	74%	75%
Mean age	76	77	76	75	77	*
Range	65-99 years	65-99 years	65-97 years	65-95 years	65-98 years
Patient classification:
Elective (hip/knee alloplasty	35%	20%	45%	47%	39%	35%
Emergency (fractured neck of femur)	65%	80%	55%	53%	61%	65%

* Age only indicated as being over 65.

Results

Patient composition in the study corresponded to patients in both Roskilde County and the rest of Denmark, calculated on an annual basis in relation to gender, age and patient classification for both included and excluded patients (27).

There was no difference between the control and intervention patients in terms of gender, patient classification and mean age (Table 2).

The check-up at the out-patient clinic for the control and intervention patients occurred 125 (±10.7) days and 112 (±18.4) days (p<0.001) after the operation, respectively. On admission no difference was registered in relation to physical, psycho-social and intellectual activities between patients that failed to attend the out-patient clinic and the group that was monitored over a four-month period. 

Nutritional status

BMI on admission measured 25.2 (±4.4) and 25.8 (±4.45) (NS) for control and intervention patients, respectively.

No difference in BMI was registered for emergency patients. BMI measured 23.4 (±3.5) in the control group and 22.5 (±3.8) for patients in the intervention group. There was also no difference between elective patients of the control and intervention groups. For these patients, BMI measured 27.1 (±4.5) for the

Page 68

control group and 27.8 (±4.3) for the intervention group. 

Physical activities

There was no difference in the level of physical activity of control and intervention patients prior to admission.

The percentage of patients in the control group who could perform all physical activities without any help (Table 3) fell significantly between admission and discharge. At the out-patient clinic four months postoperatively only those activities linked to emptying the bowels and bladder could be performed at a preoperative level. In the intervention group the percentage of patients who could manage dressing/undressing and bowel evacuation without help fell until discharge. At the out-patient clinic the group had regained their preoperative level of ability in all areas except dressing/undressing.

From before the operation until four months later the ability to walk improved or remained unchanged for 76 per cent of the control patients and 86 per cent for the intervention patients (p<0.01). According to information volunteered by patients themselves, patients in the control group used no more medicine in the final week to alleviate pain in the operated leg than patients in the intervention group.

The reduction in activity was not related to gender or age, but to the patient classification. Several emergency patients reduced their level of physical activity in all areas (p<0.01). 

Table 3. The patients' level of physical activity on admission, discharge and four months postoperatively

		Manage personal hygiene		Manage dressing/ undressing		Manage mobility		Manage emptying bowels and bladder
		Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %
Without help	Admission Discharge Out-patient clinic	86 712 781	92 85 85	86 442 742 4	93 292 782 4	93 792 851	95 90 93	93 851 91	99 911 95
With little help	Admission Discharge Out-patient clinic	6 182 81	5 8 5	8 452 141	5 642 124	4 10 10	2 6 6	6 11 5	1 5 4
With some help	Admission Discharge Out-patient clinic	5 10 9	3 8 9	3 8 8	4 8 10	2 8 5	2 4 1	0 3 3	0 4 1
Only with help	Admission Discharge Out-patient clinic	1 3 4	0 0 1	2 2 4	0 0 0	1 3 0	0 0 0	1 1 1	0 0 0

Psycho-social activities

There was no difference between the control and intervention groups regarding the percentage of patients who prior to admission and without any help were able to perform activities necessary for maintaining a home. In contrast, significantly (p<0.01) more control patients than intervention patients were able to pursue interests inside and outside the home without any help.

Page 69

Fewer control patients were able to perform psycho-social activities (Table 4) four months postoperatively compared to preoperatively. However, the intervention group sustained activity at the preoperative level. The difference between the control and intervention groups was not conditioned by gender, age or patient classification. 

Table 4. The patients' level of psycho-social activity on admission and our months postoperatively

		Perform activities associated with maintaining a home		Pursue hobby interests inside the home		Pursue hobby interests outside the home
		Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %
Without help	Admission Discharge	54 352	58 53	72 611	88 80	71 581	83 76
With little help	Admission Discharge	35 44	38 35	17 281	9 16	12 13	13 12
With some help	Admission Discharge	7 12	4 10	10 11	3 4	8 202	3 111
Only with help	Admission Discharge	4 10	1 2	1 0	0 0	9 10	1 1

1 Significant change from admission p<0.05

2 Significant change from admission p<0.01

Intellectual activities

There was no difference between the control and intervention group on admission in the areas of seeking information about the reasons for hospitalisation (Table 5).

However, in the intervention group, 70 per cent of elective patients compared to only 4 per cent of emergency (p<0.01) patients independently sought information about nutritional treatment (p<0.01) and its consequences (p<0.01).

In both groups a significant increase occurred in all intellectual activities between admission and the check-up at the out-patient clinic.

There was no link between gender, age or patient classification in relation to how the level of intellectual activity developed. 

The mean intake of energy and protein in patients and weight change

The mean daily intake of energy and protein from the first day in hospital to the last day measured for the control and intervention groups respectively 5316kJ (±1338) and 6539kJ (±1621) (p<0.001), and for protein 47g (±12.3) and 68g (±15.4) (p<0.001). Between admission and four months after the operation patients in the control group lost 1.7kg (±3.1) while patients in the intervention group gained 0.4kg (±3.1)(p<0.001).

Control and intervention patients who on admission independently sought information about treatment and its consequences respectively consumed a mean daily intake of 67g (±16) protein compared to 54g (±16)(p<0.001) and 6510kJ (±1771) compared to 5720kJ (±1516) (p<0.001). Consequently, this group of patients had increased their weight by 0.9kg (±3.6) four months after the operation, whereas patients who needed help to seek information had lost 1.1kg (±3.0) (p<0.01).

Patients who sustained or increased their physical and psycho-social level of activity consumed over 65 per cent of the recommended amount of protein and 90 per cent of the recommended amount of energy. This corresponded to a mean daily intake of 60g (±17) protein and 6256kJ (±1569) throughout their stay in hospital.

This was true regardless of whether the patient belonged to the control group or the intervention group.

Page 70

Table 5. The patients' intellectual level of activity on admission, discharge and four months postoperatively

		Seeking information about reasons for hospitalisation		Seeking information about treatment		Seeking information about the consequences of treatment
		Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %	Control n=95 %	Intervention n=80 %
Without help	Admission Discharge Out-patient clinic	60 751 751	73 792 912, 4	4 152 552, 4	40 50 832, 4	4 152 542, 4	40 50 832, 4
With little help	Admission Discharge Out-patient clinic	10 8 6	9 11 43	27 35 214	26 28 122, 4	26 34 224	26 28 132, 4
With some help	Admission Discharge Out-patient clinic	18 10 15	16 6 5	50 401 202, 4	30 191 52, 4	50 41 202, 4	30 191 52, 4
Hjælp til alt	Admission Discharge Out-patient clinic	11 7 42	2 4 0	20 11 42, 4	4 3 0	20 10 42, 4	4 4 0

Discussion

This study showed that the intervention patients to a large extent sustained physical, psycho-social and intellectual activities four months after a surgical orthopaedic operation. The study also showed a link between sustaining activity and postoperative energy and protein intake.

The patient group studied was representative of patients aged 65 and over who were admitted for elective hip- or knee surgery or emergency surgery for fractured neck of femur. The patients in the study also correlate with respect to age and gender as well as the annual number of patients admitted in Roskilde County and in Denmark in general. The patient group that was observed for a four-month period did not differ from the whole group in terms of gender or diagnosis, although they were younger. This element of youth may have affected the level of activity in general, but not the difference in the activities between the control and intervention groups.

There was also no difference in the nutritional status between emergency and elective patients of the control and intervention groups. In contrast more intervention patients than control patients were able to perform activities associated with interests both inside and outside the home without any help prior to surgery. The control group had a longer postoperative rehabilitation period. On average, they attended the out-patient clinic 13 days later than the intervention patients. For practical reasons the control and intervention periods were not carried out during the same season. Consequently, more control patients may have had the opportunity to rehabilitate outdoors. Both the prolonged rehabilitation period and the opportunity to rehabilitate outdoors may have positively influenced the development of the level of activity within the control group.

The results of dietary recording were first calculated at the end of the study. However, the daily completion of dietary journals most likely increased the intake among control patients by virtue of the fact that the attention of patients and staff was drawn to dietary issues. The recorded intake is therefore most likely higher in the control group than it would otherwise have been.

Parallel to the dietary intervention study, the ward set up a baseline description of the quality of the

Page 71

treatment, care and rehabilitation of patients admitted with emergency fractured neck of femur. This meant that during the study the ward did not alter its routines except for those related to diet.

It has been shown that patients spontaneously reduce the amount of time they walk and stand postoperatively (4), and that this decrease in activity correlates to weight loss and the onset of fatigue (4). It is not uncommon for patients after major operations to lose three or more kilos within the first few postoperative weeks (1). Weight loss is likewise spread between loss of fat and protein-rich tissue, especially muscle (1). After surgical intervention elderly patients have more difficulty in regaining the weight and muscle mass lost (1). Increased protein intake has shown itself to be important for the wound healing process, the strengthening of the immune system, the maintenance of muscle mass and the prevention of postoperative fatigue (1, 9). With a mean daily intake of 5,000 kJ and 40-50g of protein, a positive effect is seen in relation to the outcome of the treatment (9, 14, 28, 29). Energy and protein intake in the intervention patients in this study lay above this figure. The increased intake of energy and protein among intervention patients prevented weight loss and reduced the likelihood of postoperative loss of muscle mass. 

Activities

Information about the activities could be gathered from the patients themselves, by objective assessment of what the person was actually capable of doing, by testing or a combination of these methods (30). Information about physical and psycho-social activities stemmed from data offered by the patients themselves. There was no reason to believe that the control and intervention groups systematically over- or underestimated their level of activity when volunteering information.

Using a multivariant analysis of the scales used in the activity chart it is shown that the external variables such as gender, age, occupation and main diagnoses exert no influence on the level of activity (23). In this study gender and age played no role in the development of psycho-social and intellectual activities. As regards physical activities, several patients with fractured neck of femur were unable to perform the activities on their own.

The ability to perform normal daily functions and more complex activities was assessed using various instruments and graded as an overall score or in groups. It is therefore difficult to determine which specific activities patients no longer performed, or to make a direct comparison between the different studies, although the studies all portray the same picture (2, 3, 6, 7).

On discharge approximately 35-40 patients aged 60 or over operated for fractured neck of femur are able to carry out normal daily functions (2, 7). The ability to independently perform such activities is regained gradually, so that three months after surgery for the fracture 50-60 per cent are able to perform these activities (2, 7). After one year 50-75 per cent of patients are able to perform these activities at the prefracture level (6, 7). For more complex activities the pattern of development is the same, although only 30-50 per cent are able to perform these activities one year after the fracture (6, 31). For patients with fractured neck of femur the ability to walk is regained at the prefracture level for 60 per cent of patients one year after the fracture (6, 7), while with regard to alloplasty patients 75 per cent claim to be able to walk without pain (32). The ability to perform normal daily functions and more complex activities of alloplasty patients was not assessed.

A fractured neck of femur also affects the patient's general well-being. There is a fall from 80 per cent before the fracture to 60 per cent six months after the fracture where patients report that they generally feel well enough to do what they want to, while below 50 per cent report that ''pursuing interests forms an integral part of their daily life'' (3). 

Physical and psycho-social activities

Patients in the control group suffered a deterioration in their ability to perform physical and psycho-social activities in the same way as discovered in other studies (2, 6, 7). Four months after the operation only activities related to emptying the bowels and bladder could be performed by the control patients at the preoperative level. It was particularly in patients who ate the least and lost the most weight that the level of activity was diminished. The intervention patients sustained their physical and psycho-social level of activity, their energy increased as did their protein intake in particular whilst in hospital. In addition, they avoided postoperative weight loss and most likely reduced muscle mass loss. The maintenance of activity applied to both emergency and elective patients in the intervention group.

In both the control group and the intervention group few patients were able to manage dressing and undressing on discharge. This was primarily because the ward recommended the use of anti-embolic stockings for a period of three months postoperatively.

Page 72

Approximately 75 per cent of the patients needed help to put on and remove stockings (33), which placed the patients in the category '' With little help'' on the activity chart. The fact that several intervention patients needed help to perform this activity could be explained by the fact that during the intervention period a study was carried out on the ward where the use of anti-embolic stockings was charted. This may have increased the staff's awareness of how much they needed to help patients who used anti-embolic stockings on a daily basis. In this respect, there is a strong probability that staff did not report all instances of help given to the control patients in reality. 

Intellectual activity

It is described that up to 60 per cent of patients admitted for emergency surgery for fractured neck of femur and 25 per cent of patients admitted for elective surgery for hip- or knee alloplasty became seriously confused both on admission and during the first postoperative days (34-36). The condition shows that the patients became irate, disorientated, irritable or withdrawn. The short-term memory was also affected (34). The condition differed from dementia in that it normally cleared up by the fifth postoperative day.

Data concerning the patient's intellectual activity was collected from patients at precisely the time when the occurrence of serious confusion is described at being at its peak. This may explain the relatively small number of patients in the control group who independently sought information about treatment and its consequences. It is therefore not surprising that intervention did not result in an increase in the number of emergency patients who independently sought information.

The rise in the level of intellectual activity between admission and discharge and between discharge and the check-up at the out-patient clinic corresponded in both the control group and the intervention group. However, more intervention patients altogether independently performed intellectual activities. The difference can be attributed to the type of care given rather than to any increased energy intake. The care given built on the idea that the patients should be activated and involved in their care immediately on their admission into hospital. The fact that several patients already showed greater activity on admission may have been a result of the admission interview, which gave the patients the opportunity to discuss what they believed to be important. An increased number of elective patients raised the issue of nutritional problems on their own accord. This may have happened as a result of receiving the leaflet '' Diet before operation'' through the post four weeks prior to the operation. The purpose of the leaflet was to offer information about the importance of nutrition in connection with an operation and rehabilitation as well as some concrete suggestions for what patients could do themselves to prevent a deterioration of their preoperative nutritional status. The leaflet may have led the individual patient to develop a sense of ''control and independence'' whilst in hospital, which has been shown to reduce the risk of serious confusion (34).

From admission until the check-up at the out-patient clinic four months after discharge, a marked rise occurred in the number of control patients who independently sought information about the treatment and its consequences. No data is available to explain this increase. One explanation, however, could be that as a result of the dietary recording, the gathering of other data, as well as the process of making an appointment for the out-patient clinic and arranging the necessary transport, a close relationship and trust developed between the control patients and the project nurse. In this respect, it should be noted that the project nurse attempted to remain neutral towards all the patients. Every patient had 15 instances of contact with the primary nurse. The dietary recording alone involved 9 instances on average (22). In addition, the daily dietary recording served to demonstrate that diet was important. The increase in the intellectual activity of control patients is therefore most likely a weakness of the chosen design, as the patients were exposed to a systematic influence.

Both control and intervention patients who independently sought information on admission consumed more energy and protein during their hospital stay and thereby avoided weight loss. This study has not investigated whether the patients altered their eating habits at home as a result of the guidance and advice they received.

Prevention

Maintaining contact with the social network is of immense importance for successful rehabilitation as well as sustaining and improving the ability to perform normal daily functions and more complex activities (6). After four months, the patients in the intervention group had sustained their level of activity and thereby had the opportunity to maintain contact with their social network.

Preventive efforts among elderly patients were directed particularly towards preventing, postponing,

Page 73

minimising or alleviating problems that reduce the ability to be active. The explanation for this is that there is a clear link between the ability to be active, to continue living in one's own home and survival (37). Trauma in connection with fractured neck of femur and surgical stress can re-trigger a process that can gradually lead to reduced dietary intake and an adverse effect on the nutritional status, thereby leading to a general deterioration in the health of the patient (38).

The ideal situation would have been to monitor the patients for at least a 12-month period in order to assess the long-term effect of nutritional intervention in relation to altered dietary intake postoperatively at home, the maintenance of activities after four months and the prevention of disorders requiring treatment. Unfortunately, it was not feasible in this study to follow the patients for longer than a four-month period after surgery.

In conclusion, the increased intake of energy and protein postoperatively led to an ability to perform the majority of physical activities and all psycho-social activities four months after emergency or elective surgery on a hip or knee. At the same time the study demonstrated that patients who on admission already showed interest in their diet also consumed more energy and protein whilst in hospital. 

Keywords: ADL, dietary intervention, elderly patients, energy and protein intake, nutrition, postoperative.

Literature

1. Hill GL, Douglas RG, Schroeder D. Metabolic basis for the management of patients undergoing major surgery. World J Surg 1993; 17: 146-53
2. Andersen Y, Pedersen PU, Pedersen EM. Hvordan klarer patienter sig efter hoftebrud? En undersøgelse af pleje- og rehabiliteringsforløbet af patienter, der udskrives til eget hjem. København. Dansk Sygeplejeråd. 1996.
3. Ankjær-Jensen A, Jacobsen E.T, Thomsen I.S. Rehabilitering af ældre med hoftebrud ­ omkostninger og effekt. København. Dansk Sygehus Institut. 1994; 94.08.
4. Stock SE, Clauge MB, Johnston IDA. Post-operative fatigue ­ a real phenomenon attributable to the metabolic effects on body nutritional stores. Clin Nutr 1991; 10: 251-7.
5. Morales-Rodriguez P, Gonzáles-Reimers E, Santolaria-Fernández F, Batista-Lopez N, González-Reyes A. Functional decline and nutritional status in a hospitalized geriatric population: Sequential study. Nutrition 1990; 6 (6): 469-73.
6. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. J. Gerontol 1990; 45 (3): 101-7.
7. Jette AM, Harris BA, Cleary PD, Campion EW. Functional recovery after hip fracture. Arch Phys Med Rehabil 1987; 68: 735-40.
8. Egol KA, Koval KJ, Zuckerman JD. Functional recovery following hip fracture in the elderly. J Orthop Trauma 1997; 11: 594-9.
9. Delmi M, Rapin CH, Bengoa JM, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335: 1013-6.
10. Beier-Holgersen R, Boesby S. Influence of postoperative enteral nutrition on postsurgical infections. Gut 1996; 39: 833-5.
11. Keele AM, Bray MJ, Emery PW, Duncan HD, Silk DBA. Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients. Gut 1997; 40: 393-9.
12. Jensen MB. Ernæringens betydning for muskelfunktionen efter operation. Ugeskr Laeger 1998; 159: 923-6.
13. Hessov I. Impact of sip therapy on postoperative surgical outcome. Nutrition 1995; 11 (2 supp): 221-3.
14. Stableforth PG. Supplement feeds and nitrogen and calorie balance following femoral neck fracture. Br J Surg 1986; 73: 651-5.
15. Tkatch L, Rapin CH, Rizzoli R, Slosman D, Nydegger V, Vasey H, Bonjour JP. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr 1992; 11: 519-25.
16. Larsson J, Unosson M, Ek AC, Nilsson L, Thorslund S, Bjurulf P. Effect of dietary supplement on nutritional status and clinical outcome in 501 geriatric patients ­ a randomised study. Clin Nutr 1990; 9: 179-84.
17. Campos AC, Meguin MM. A critical appraisal of the usefulness of perioperative nutritional support. Am J Clin Nutr 1992; 55: 117-30.
18. Frost P, Bihari D. The route of nutritional support in the critically ill: Physiological and economical considerations. Nutrition 1997; 13 (supp): 58-63
19. Buzby GP. Overview of randomized clinical trials of total parenteral nutrition for malnourished surgical patients. World J Surg 1993; 17: 173-7.
20. Tibbling L, Lundgren J, Edholm E, Wersäll J. Näringsstöd till patienter med nutritionsproblem ­ till vilket pris? Läkartidningen 1991; 88: 209-10
21. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. BMJ 1983; 287: 1589-92.
22. Pedersen PU. Medindrages patienten i egen kostforplejening øges energi og proteinindtagelse postoperativt. Sygeplejersken 1999; 21: 28-35.
23. Salling Larsen A. Stimulation af patienters aktivitet og udvikling.1990; Odense Universitet.
24. Salling Larsen A. Klinisk sygepleje. Maanedsskr Prakt Laegegern 1996; 74: 1253-60.
25. Grønhøj L, Hagen F.E., Holdt M. et al. Informatikkens rolle ved kostregistrering. 1996; Aalborg Universitetscenter.
26. Diem K, Seldrup J, Lentner C, editor. Introduction to statistics, statistical tables, mathematical formulae. 8. ed. Basle: Ciba-Geigy Limited; 1982.
27. Operationsmønsteret ved danske sygehuse 1992. København: Sundhedsstyrelsen. 1994; 3.
28. Jallut D, Tappy L, Kohut M, Bloesch D, Munger R, Schutz Y, Chiolero R, Felber JP, Livio JJ, Jéquier E. Energy balance in elderly patients after surgery for a femoral neck fracture. JPEN 1990; 14: 563-8.
29. Elmstaahl S, Steen B. Hospital nutrition in geriatric Long-term care medicin: II. Effects of dietary supplements. Age and Aging 1987; 16: 73-80.
30. Hulter-Aasberg K. ADL-Trappan. Lund. Studentlitteratur; 1990.
31. de Castro JM. Age-related changes in spontaneous food intake and hunger in humans. Appetite 1993; 21: 255-72.
32. Ekelund A, Rydell N, Nilsson OS. Total hip arthroplasty in patients 80 years of age and older. Clinical Orthopaedics and Related Research 1992; 281: 101-6.
33. Cameron U, Pedersen PU. Postoperativ anvendelse af anti-embolistrømper ­ patientanvendelse, -praksis og -viden. Vård i Norden 1999; 19 (1): 11-7.
34. OKeeffe ST, Chonchubhair AN. Postoperative delirium in the elderly. Br J Anaesth 1994; 73: 673-87.
35. Gustafson Y, Brännström B, Norberg A, Bucht G, Winblad B. Underdiagnosis and poor documentation of acute confusional state in elderly hip fracture patients. JAGS 1991; 39: 760-5.
36. Milisen K, Abraham IL, Broos PL. Postoperative variation in neurocognitive and functional status in elderly hip fracture patients. J Adv Nurs 1998; 27: 59-67.
37. Schroll M. Helbred. København: EGV Fonden; 1989.
38. Vellas BJ, Albarede J, Garry PJ. Diseases and aging: patterns of morbidity with age; relationship between aging and age-associated diseases. Am J Clin Nutr 1992; 55: 1225-30. 

Acknowledgements

The study was carried out as part of a PhD programme at the Unit for Clinical Nursing Research, the Clinical Institute, Odense University. My sincere thanks to Anne-Lise Salling Larsen, professor, doctor of medicine, RN, for her invaluable guidance and also to the Danish Health Insurance Fund for offering financial support towards the study. Grateful thanks also to all staff at Roskilde County Hospital, Køge for their wholehearted participation in the study