Nutritional assessment in a falls clinic--unanswered questions. (Leading Article).

People hospitalised with hip fractures secondary to falls are often undernourished (1). Tertiary preventive strategies after fractures can be initiated and coordinated by attendance at a falls clinic, and this approach has been recommended (2). The wider role of falls clinics, for example their role in primary prevention of falls and fractures, remains uncertain. However, the number of falls clinics is increasing in Australia (3).

Within this context it is timely that the nutritional status of people attending a falls clinic has been investigated. Stolz and colleagues enrolled 90 older people attending a falls clinic in Adelaide (4). Their carefully conducted observations show that about half of the attendees were screened as 'high nutritional risk'. However, when this risk is examined a further 26 had a BMI > 30 and 24 had a BMI < 22. Only 11 were undernourished using this study's definition.

These data are surprising, which the authors acknowledge. The expectation is that people attending the falls clinic would have a considerably higher prevalence of undernutrition. This leaves unanswered questions.

The age and gender of study participants looks typical of an older population who could be expected to be at risk of falls. Almost all attendees have had falls and many have had multiple falls. No data are presented about educational and social status of the clinic attendees. Whether the clinic attendees have also had a fracture is not documented. People from residential aged care facilities are clearly under-represented, as are people with dementia.

Therefore the reader is left with the wider question of how representative the clinic attendees are of older people who fall. They are not typical of people who sustain hip fractures, which is the most severe common consequence of a fall (1). The available information suggests that the clinic attendees are a selected sample of older people who sustain falls, whose nutritional status may be better and fracture risk less than the wider group.

How then should the issue of nutritional assessment in a falls clinic be approached? Stolz and colleagues provide a comprehensive discussion of possible methods. In the group they studied the Australian Nutrition Screening Initiative (ANSI) tool had poor specificity for detecting undernutrition. The criterion of BMI < 22 detected all participants who had mid-upper arm circumference or triceps skinfold thickness less than the criteria set by the authors for undernutrition, so it may be a reasonable choice for a relatively 'healthy' falls clinic population. As Stolz and colleagues discuss this method is not suitable for a frailer older population who have lost height because of vertebral crush fractures or other chronic conditions.

The prevalence of overnutrition in this falls clinic population raises interesting challenges. While overnutrition is associated with functional limitation, padding over the greater trochanter, whether by adipose tissue or external hip protectors, is associated with reduced risk of hip fracture. The preferred approach to overnutrition in this population remains to be defined.

As often occurs in exploratory studies, this research has raised a number of questions that require further examination. Future studies should be prospective in design and should enroll a large group of older people who are representative of all older people who fall.

Ian Cameron

Rehabilitation Studies Unit

University of Sydney 

References

(1.) Hanger HC, Smart EJ, Merrilees M. Frampton CM. The prevalence of malnutrition in elderly hip fracture patients. N Z Med J 1999;112:88-90.

(2.) Scottish Intercollegiate Guideline Network. Prevention and management of hip fracture in older people. SIGN Publication 56. www.sign.ac.uk/guidelines/fulltext/56/ accessed 15 November 2002.

(3.) Hill K, Smith R, Schwarz J. Falls clinics in Australia: a survey of current practice, and recommendations for future development. Aust Health Rev 2001;24:163-74.

(4.) Stolz D, Miller M, Bannerman H, whitehead C, Crotty M, Daniels L. Nutrition screening and assessment of patients attending a multidisciplinary falls clinic. Nutr Diet 2002;59:234-9.