Association between dementia and mortality in the elderly patients undergoing hip fracture surgery: a meta-analysis

Comparative analysis of geriatric hip fracture management outcomes in teaching and nonteaching hospitals in Jordan

Hip fractures are common orthopedic injuries that have significant impacts on patients and healthcare systems. Previous studies have shown varying outcomes for hip fracture management in different settings, with diverse postoperative outcomes and complications. While teaching hospital settings have been investigated, no studies have specifically examined hip fracture outcomes in teaching hospitals in Jordan or the broader Middle East region. Therefore, the aim of this study was to investigate this important outcome. A cohort comprising 1268 patients who underwent hip fracture fixation from 2017 to 2020 was analyzed for nine distinct outcomes. These outcomes encompassed time to surgery, ICU admissions, perioperative hemoglobin levels, length of hospital stay, readmission rates, revision procedures, and mortality rates at three time points: in-hospital, at 6-months, and at 1-year post-surgery. The analysis of 1268 patients (616 in teaching hospitals, 652 in non-teaching hospitals) showed shorter mean time to surgery in teaching hospitals (2.2 days vs. 3.6 days, p < 0.01), higher ICU admissions (17% vs. 2.6%, p < 0.01), and more postoperative blood transfusions (40.3% vs. 12.1%, p < 0.01). In-hospital mortality rates were similar between groups (2.4% vs. 2.1%, p = 0.72), as were rates at 6-months (3.1% vs. 3.5%, p = 0.65) and 1-year post-surgery (3.7% vs. 3.7%, p = 0.96). Geriatric hip fracture patients in teaching hospitals have shorter surgery times, more ICU admissions, and higher postoperative blood transfusion rates. However, there are no significant differences in readmission rates, hospital stays, or mortality rates at various intervals.

Validation of the Charlson Comorbidity Index for the prediction of 30-day and 1-year mortality among patients who underwent hip fracture surgery

INTRODUCTION

The aim of our study was to validate the original Charlson Comorbidity Index (1987) (CCI) and adjusted CCI (2011) as a prediction model for 30-day and 1-year mortality after hip fracture surgery. The secondary aim of this study was to verify each variable of the CCI as a factor associated with 30-day and 1-year mortality.

METHODS

A prospective database of two-level II trauma teaching hospitals in the Netherlands was used. The original CCI from 1987 and the adjusted CCI were calculated based on medical history. To validate the original CCI and the adjusted CCI, the CCI was plotted against the observed 30-day and 1-year mortality, and the area under the curve (AUC) was calculated.

RESULTS

A total of 3523 patients were included in this cohort study. The mean of the original CCI in this cohort was 5.1 (SD ± 2.0) and 4.6 (SD ± 1.9) for the adjusted CCI. The AUCs of the prediction models were 0.674 and 0.696 for 30-day mortality for the original and adjusted CCIs, respectively. The AUCs for 1-year mortality were 0.705 and 0.717 for the original and adjusted CCIs, respectively.

CONCLUSIONS

A higher original and adjusted CCI is associated with a higher mortality rate. The AUC was relatively low for 30-day and 1-year mortality for both the original and adjusted CCIs compared to other prediction models for hip fracture patients in our cohort. The CCI is not recommended for the prediction of 30-day and 1-year mortality in hip fracture patients.

Which factor is more associated with survival of patients with hip fracture over 90 years: Type of fracture or treatment modality?

OBJECTIVE

We aimed to analyze prognostic factors affecting the mortality and to evaluate whether the fracture type (collum femoris or intertrochanteric fracture) or treatment method (proximal femoral nail or hemiarthroplasty) affects the mortality in patients with hip fractures and older than 90 years old.

METHODS

In our study, we retrospectively reviewed the patients aged >90 years and operatively treated hip fractures. Patients were categorized according to fracture type and treatment method. Finally, three groups were created. Demographic values, laboratory values were analyzed for prognostic factors and determining independent factors associated with survival for each group.

RESULTS

A total of 193 patients were included with an average age of 92.5±2.4 (range, 90-104) years. There were 144 women and 49 men. There were 126 (65.2%) patients with intertrochanteric fracture and 67 (34.8%) patients with collum femoris fracture. At the time of this study, 142 (73.5%) patients had deceased. Staying in intensive care unit for collum femoris group, general anesthesia for intertrochanteric fracture treated with hemiarthroplasty group and delay to surgery and preoperative albumin level for intertrochanteric fracture treated with proximal femoral nail group were associated with poor survival.

CONCLUSION

Staying intensive care unit, general anesthesia, delay to surgery and preoperative albumin levels should be carefully evaluated for patients aged over 90 years with hip fractures. Our study showed that both fracture type and treatment modality were not associated with poor overall survival of the patients aged >90 years following hip fracture surgery.

Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia

Importance

The decision for surgical vs nonsurgical treatment for hip fracture can be complicated among community-dwelling people living with dementia.

Objective

To compare outcomes of community-dwelling people living with dementia treated surgically and nonsurgically for hip fracture.

Design, Setting, and Participants

This retrospective cross-sectional study undertook a population-based analysis of national Medicare fee-for-service data. Participants included community-dwelling Medicare beneficiaries with dementia and an inpatient claim for hip fracture from January 1, 2017, to June 30, 2018. Analyses were conducted from November 10, 2022, to October 17, 2023.

Exposure

Surgical vs nonsurgical treatment for hip fracture.

Main Outcomes and Measures

The primary outcome was mortality within 30, 90, and 180 days. Secondary outcomes consisted of selected post-acute care services.

Results

Of 56 209 patients identified with hip fracture (73.0% women; mean [SD] age, 86.4 [7.0] years), 33 142 (59.0%) were treated surgically and 23 067 (41.0%) were treated nonsurgically. Among patients treated surgically, 73.3% had a fracture of the femoral head and neck and 40.2% had moderate to severe dementia (MSD). Among patients with MSD and femoral head and neck fracture, 180-day mortality was 31.8% (surgical treatment) vs 45.7% (nonsurgical treatment). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI, 0.49-0.62; P < .001) and the adjusted OR was 0.59 (95% CI, 0.53-0.66; P < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% (surgical treatment) vs 34.9% (nonsurgical treatment). For patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture, the unadjusted OR of 180-day mortality was 0.67 (95% CI, 0.60-0.76; P < .001) and the adjusted OR was 0.71 (95% CI, 0.63-0.79; P < .001). For patients with femoral head and neck fracture, there was no difference in admission to a nursing home within 180 days when treated surgically vs nonsurgically.

Conclusions and Relevance

In this cohort study of community-dwelling patients with dementia and fracture of the femoral head and neck, patients with MSD and mild dementia treated surgically experienced lower odds of death compared with patients treated nonsurgically. Although avoiding nursing home admission is important to persons living with dementia, being treated surgically for hip fracture did not necessarily confer a benefit in that regard. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach.

The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures

BACKGROUND

Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery.

METHODS

All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models.

RESULTS

An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77-0.80)].

CONCLUSION

Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

Risk Factors for 30-Days Mortality After Proximal Femoral Fracture Surgery, a Cohort Study

Purpose

The primary objective of this study was to identify new risk factors and to confirm previously reported risk factors associated with 30-day mortality after hip fracture surgery.

Patients and methods

A prospective hip fracture database was used to obtain data. In total, 3523 patients who underwent hip fracture surgery between 2011 and 2021 were included. Univariable and multivariable logistic regression was used to screen and identify candidate risk factors. Twenty-seven baseline factors and 16 peri-operative factors were included in the univariable analysis and 28 of those factors were included in multivariable analysis.

Results

8.6% of the patients who underwent hip fracture surgery died within 30 days after surgery. Prognostic factors associated with 30-day mortality after hip fracture surgery were as follows: age 90-100 years (OR = 4.7, 95% CI: 1.07-19.98, p = 0.041) and above 100 years (OR = 11.3, 95% CI: 1.28-100.26, p = 0.029), male gender (OR = 2.6, 95% CI: 1.97-3.33, p < 0.001), American Society of Anesthesiologists (ASA) 3 and ASA 4 (OR = 2.1, 95% CI: 1.44-3.14, p < 0.001), medical history of dementia (OR = 1.7, 95% CI: 1.25-2.36, p = 0.001), decreased albumin level (OR = 0.94, 95% CI: 0.92-0.97, p < 0.001), decreased glomerular filtration rate (GFR) (OR = 0.98, 95% CI: 0.98-0.99, p < 0.001), residential status of nursing home (OR = 2.1, 95% CI: 1.44-2.87, p < 0.001), higher Katz Index of Independence in Activities of Daily Living (KATZ-ADL) score (OR = 1.1, 95% CI: 1.01-1.16, p=0.018) and postoperative pneumonia (OR = 2.4, 95% CI: 1.72-3.38, p < 0.001).

Conclusion

A high mortality rate in patients after acute hip fracture surgery is known. Factors that are associated with an increased mortality are age above 90 years, male gender, ASA 3 and ASA 4, medical history of dementia, decreased albumin, decreased GFR, residential status of nursing home, higher KATZ-ADL score and postoperative pneumonia.

Mind the Gap: Unraveling the Intricate Dance Between Alzheimer's Disease and Related Dementias and Bone Health

PURPOSE OF REVIEW

This review examines the linked pathophysiology of Alzheimer's disease/related dementia (AD/ADRD) and bone disorders like osteoporosis. The emphasis is on "inflammaging"-a low-level inflammation common to both, and its implications in an aging population.

RECENT FINDINGS

Aging intensifies both ADRD and bone deterioration. Notably, ADRD patients have a heightened fracture risk, impacting morbidity and mortality, though it is uncertain if fractures worsen ADRD. Therapeutically, agents targeting inflammation pathways, especially Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) and TNF-α, appear beneficial for both conditions. Additionally, treatments like Sirtuin 1 (SIRT-1), known for anti-inflammatory and neuroprotective properties, are gaining attention. The interconnectedness of AD/ADRD and bone health necessitates a unified treatment approach. By addressing shared mechanisms, we can potentially transform therapeutic strategies, enriching our understanding and refining care in our aging society. This review article is part of a series of multiple manuscripts designed to determine the utility of using artificial intelligence for writing scientific reviews.

Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern

Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.

Dementia, osteoporosis and fragility fractures: Intricate epidemiological relationships, plausible biological connections, and twisted clinical practices

Dementia, osteoporosis, and fragility fractures are chronic diseases, often co-existing in older adults. These conditions pose severe morbidity, long-term disability, and mortality, with relevant socioeconomic implications. While in the research arena, the discussion remains on whether dementia is the cause or the consequence of fragility fractures, healthcare professionals need a better understanding of the interplay between such conditions from epidemiological and physiological standpoints. With this review, we summarized the available literature surrounding the relationship between cognitive impairment, dementia, and both low bone mineral density (BMD) and fragility fractures. Given the strength of the bi-directional associations and their impact on the quality of life, we shed light on the biological connections between brain and bone systems, presenting the main mediators, including gut microbioma, and pathological pathways leading to the dysregulation of bone and brain metabolism. Ultimately, we synthesized the evidence about the impact of available pharmacological treatments for the prevention of fragility fractures on cognitive functions and individuals' outcomes when dementia coexists. Vice versa, the effects of symptomatic treatments for dementia on the risk of falls and fragility fractures are explored. Combining evidence alongside clinical practice, we discuss challenges and opportunities related to the management of older adults affected by cognitive impairment or dementia and at high risk for fragility fracture prevention, which leads to not only an improvement in patient health-related outcomes and survival but also a reduction in healthcare cost and socio-economic burden.

Dementia and Hip Fractures: A Comprehensive Review of Management Approaches

» The elderly population is the fastest growing demographic, and the number of dementia cases in the United States is expected to double to 10 million by 2050.» Patients with dementia are at 3× higher risk of hip fractures and have higher morbidity and mortality after hip fractures.» Hip fracture patients with dementia benefit from early analgesia and timely surgical fixation of fracture.» Early and intensive inpatient rehabilitation is associated with improved postoperative outcomes in patients with dementia.» Coordination of care within a "orthogeriatric" team decreases mortality, and fracture liaison services show potential for improving long-term outcomes in hip fracture patients with dementia.

Impact of Dementia on Incidence and Severity of Postoperative Pulmonary Complications Following Hip Fracture Surgery Among Older Patients

Postoperative pulmonary complications (PPCs) are the leading cause of death following hip fracture surgery. Dementia has been identified as a PPC risk factor that complicates the clinical course. By leveraging electronic health records, this retrospective observational study evaluated the impact of dementia on the incidence and severity of PPCs, hospital length of stay, and postoperative 30-day mortality among 875 older patients (≥65 years) who underwent hip fracture surgery between October 1, 2015 and December 31, 2018 at a health system in the southeastern United States. Inverse probability of treatment weighting using propensity scores was utilized to balance confounders between patients with and without dementia to isolate the impact of dementia on PPCs. Regression analyses revealed that dementia did not have a statistically significant impact on the incidence and severity of PPCs or postoperative 30-day mortality. However, dementia significantly extended the hospital length of stay by an average of 1.37 days.

Surgical Approach and Dislocation Risk After Hemiarthroplasty in Geriatric Patients With Femoral Neck Fracture With and Without Cognitive Impairments-Does Cognitive Impairment Influence Dislocation Risk?

OBJECTIVES

To determine whether there is an association between surgical approach and dislocation risk in patients with cognitive impairment compared with those without cognitive impairment treated with hemiarthroplasty for femoral neck fracture.

DESIGN

Retrospective study.

SETTING

Large, multicenter health system.

PATIENTS/PARTICIPANTS

One thousand four hundred eighty-one patients who underwent hemiarthroplasty for femoral neck fractures. 828 hips met inclusion criteria, 290 (35.0%) were cognitively impaired, and 538 (65.0%) were cognitively intact.

INTERVENTION

Hemiarthroplasty.

MAIN OUTCOME MEASURE

Prosthetic hip dislocation.

RESULTS

The overall dislocation rate was 2.1% (17 of 828), 3.4% (10 of 290) in the cognitively impaired group, and 1.3% (7 of 538) in the cognitively intact group with a median time to dislocation of 20.5 days (range 2-326 days), 24.5 days (range 3-326 days), and 19.0 days (range 2-36 days), respectively. In the entire cohort, there were no dislocations (0 of 58) with the direct anterior approach (DA); 1.1% (6 of 553) and 5.1% (11 of 217) dislocated with the modified Hardinge (MH) and posterior approaches (PA), respectively. In the cognitively impaired group, there were no dislocations with the DA (0 of 19); 1.5% (3 of 202) and 10.1% (7 of 69) dislocated with the MH and PA, respectively. In the cognitively intact group, there were no dislocations (0 of 39) with the DA; 0.85% (3 of 351) and 2.7% (4 of 148) dislocated with the MH and PA, respectively. There were statistically significant associations between surgical approach and dislocation in the entire cohort and the cognitively impaired group when comparing the MH and PA groups. This was not observed in the cognitively intact group. Patients who dislocated had 3.2 times (95% CI 1.2, 8.7) ( P = 0.0226) the hazard of death compared with patients who did not dislocate. Dislocation effectively increased the risk of death by 221% (HR 3.2 95% CI 1.2, 8.7) ( P = 0.0226).

CONCLUSIONS

In this patient population, the PA has a higher dislocation rate than other approaches and has an especially high rate of dislocation when the patients were cognitively impaired. The authors of this study suggest careful consideration of surgical approach when treating these injuries.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis

BACKGROUND

Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity.

METHODS

We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data.

RESULTS

A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)].

CONCLUSIONS

No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery.

TRIAL REGISTRATION

10.17605/OSF.IO/3DJ6C.

Outcomes for patients with dementia undergoing emergency and elective colorectal surgery: A large multi-institutional comparative cohort study

BACKGROUND

Alzheimer's Disease and Related Dementias (ADRD) may result in poor surgical outcomes. The current study aims to characterize the risk of ADRD on outcomes for patients undergoing colorectal surgery.

METHODS

Colorectal surgery patients with and without ADRD from 2007 to 2017 were identified using electronic health record-linked Medicare claims data from two large health systems. Unadjusted and adjusted analyses were performed to evaluate postoperative outcomes.

RESULTS

5926 patients (median age 74) underwent colorectal surgery of whom 4.8% (n = 285) had ADRD. ADRD patients were more likely to undergo emergent operations (27.7% vs. 13.6%, p < 0.001) and be discharged to a facility (49.8% vs 28.9%, p < 0.001). After multi-variable adjustment, ADRD patients were more likely to have complications (61.1% vs 48.3%, p < 0.001) and required longer hospitalization (7.1 vs 6.1 days, p = 0.001).

CONCLUSIONS

The diagnosis of ADRD is an independent risk factor for prolonged hospitalization and postoperative complications after colorectal surgery.

Development and validation of a novel nomogram of 1-year mortality in the elderly with hip fracture: a study of the MIMIC-III database

OBJECTIVE

Hip fracture is a prevalent condition with a significant death rate among the elderly. We sought to develop a nomogram-based survival prediction model for older patients with hip fracture.

DESIGN

A retrospective case-control study.

SETTING

The data from Medical Information Mart for Intensive Care III (MIMIC-III V.1.4).

PARTICIPANTS

The clinical features of elderly patients with hip fracture, including basic information, comorbidities, severity score, laboratory tests and therapy, were filtered out based on the MIMIC-III V.1.4.

METHODS AND MAIN OUTCOME MEASURES

All patients included in the study were from critical care and randomly divided into training and validation sets (7:3). On the basis of retrieved data, the least absolute shrinkage and selection operator (LASSO) regression and multiple logistic regression analysis were used to identify independent predictive variables of 1-year mortality, and then constructed a risk prediction nomogram. The predictive values of the nomogram model were evaluated by the concordance indexes (C-indexes), receiver operating characteristic curve, decision curve analysis (DCA) and calibration curve.

RESULTS

A total of 341 elderly patients with hip fracture were included in this study; 121 cases died within 1 year. After LASSO regression and multiple logistic regression analysis, a novel nomogram contained the predictive variables of age, weight, the proportion of lymphocyte count, liver disease, malignant tumour and congestive heart failure. The constructed model proved satisfactory discrimination with C-indexes of 0.738 (95% CI 0.674 to 0.802) in the training set and 0.713 (95% CI 0.608 to 0.819) in the validation set. The calibration curve shows a good degree of fitting between the predicted and observed probabilities and the DCA confirms the model's clinical practicability.

CONCLUSIONS

The novel prediction model provides personalised predictions for 1-year mortality in elderly patients with hip fractures. Compared with other hip fracture models, our nomogram is particularly suitable for predicting long-term mortality in critical patients.

Effect of dementia on all-cause mortality in hip fracture surgery: a retrospective study on a nationwide Korean cohort

OBJECTIVES

We aimed to evaluate the effect of dementia on the 1-year all-cause mortality in elderly patients who underwent hip fracture surgery, using a nationwide cohort in Korea.

DESIGN, SETTING, AND PARTICIPANTS

This was a nationwide, retrospective study. Elderly patients (≥60 years) with and without dementia who underwent hip fracture surgery between January 2005 and December 2012 were distinguished using the data from the Korean National Health Insurance Service-Senior cohort.

INTERVENTIONS

None.

PRIMARY AND SECONDARY OUTCOME MEASURES

The mortality rates with 95% CIs and the impact of dementia on all-cause mortality were calculated using a generalised linear model with Poisson distribution and a multivariable-adjusted Cox proportional hazards model, respectively.

RESULTS

Among the 10 833 patients who underwent hip fracture surgery, 13.4% were diagnosed with dementia. During the 1-year follow-up period, 1586 patients with hip fracture without dementia died in 8356.5 person-years (incidence rate (IR)=189.2 per 1000 person-years, 95% CI 179.91 to 198.99), while 340 deaths were confirmed in patients with hip fracture with dementia in 1240.8 person-years (IR, 273.1 per 1000 person-years, 95% CI 244.94 to 304.58). Patients with hip fracture and dementia were 1.23 times more likely to die than those in the control group in the same period (HR=1.23, 95% CI 1.09 to 1.39).

CONCLUSION

Dementia is a risk factor for 1-year all-cause mortality after hip fracture surgery. To improve the postoperative outcomes of patients with dementia who have undergone hip fracture surgery, effective treatment models such as multidisciplinary diagnosis and strategic rehabilitation should be established.

Geriatric nutritional risk index as the prognostic factor in older patients with fragility hip fractures

This study investigated the long-term survival and incidence of secondary fractures after fragility hip fractures. The 5-year survival rate was 62%, and the mortality risk was seen in patients with GNRI < 92. The 5-year incidence of secondary fracture was 22%, which was significantly higher in patients with a BMI < 20.

BACKGROUND

Malnutrition negatively influences the postoperative survival of patients with fragility hip fractures (FHFs); however, little is known about their association over the long term.

OBJECTIVE

This study evaluated the ability of the geriatric nutritional risk index (GNRI) as a risk factor for long-term mortality after FHFs.

METHODS

This study included 623 Japanese patients with FHFs over the age of 60 years. We prospectively collected data on admission and during hospitalization and assessed the patients' conditions after discharge through a questionnaire. We examined the long-term mortality and the incidence of secondary FHFs and assessed the prognostic factors.

RESULTS

The mean observation period was 4.0 years (range 0-7 years). The average age at the time of admission was 82 years (range 60-101 years). The overall survival after FHFs (1 year, 91%; 5 years, 62%) and the incidence of secondary FHFs were high (1 year, 4%; 5 years, 22%). The multivariate Cox proportional hazard analysis revealed the risk factors for mortality as older age (hazard ratio [HR] 1.04), male sex (HR 1.96), lower GNRI score (HR 0.96), comorbidities (malignancy, HR 2.51; ischemic heart disease, HR 2.24; revised Hasegawa dementia scale ≤ 20, HR 1.64), no use of active vitamin D3 on admission (HR 0.46), and a lower Barthel index (BI) (on admission, HR 1.00; at discharge, HR 0.99). The GNRI scores were divided into four risk categories: major risk (GNRI, < 82), moderate risk (82-91), low risk (92-98), and no risk (> 98). Patients at major and moderate risks of GNRI had a significantly lower overall survival rate (p < 0.001). Lower body mass index (BMI) was also identified as a prognostic factor for secondary FHFs (HR 0.88 [p = 0.004]).

CONCLUSIONS

We showed that older age, male sex, a lower GNRI score, comorbidities, and a lower BI are risk factors for mortality following FHFs. GNRI is a novel and simple predictor of long-term survival after FHFs.

Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes

Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.

The prediction of early mortality following hip fracture surgery in patients aged 90 years and older: the Almelo Hip Fracture Score 90 (AHFS90)

The AHFS⁹⁰ was developed for the prediction of early mortality in patients ≥ 90 years undergoing hip fracture surgery. The AHFS⁹⁰ has a good accuracy and in most risk categories a good calibration. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

PURPOSE

Identifying hip fracture patients with a high risk of early mortality after surgery could help make treatment decisions and information about the prognosis. This study aims to develop and validate a risk score for predicting early mortality in patients ≥ 90 years undergoing hip fracture surgery (AHFS⁹⁰).

METHODS

Patients ≥ 90 years, surgically treated for a hip fracture, were included. A selection of possible predictors for mortality was made. Missing data were subjected to multiple imputations using chained equations. Logistic regression was performed to develop the AHFS⁹⁰, which was internally and externally validated. Calibration was assessed using a calibration plot and comparing observed and predicted risks.

RESULTS

One hundred and two of the 922 patients (11.1%) died ≤ 30 days following hip fracture surgery. The AHFS⁹⁰ includes age, gender, dementia, living in a nursing home, ASA score, and hemoglobin level as predictors for early mortality. The AHFS⁹⁰ had good accuracy (area under the curve 0.72 for geographic cross validation). Predicted risks correspond with observed risks of early mortality in four risk categories. In two risk categories, the AHFS⁹⁰ overestimates the risk. In one risk category, no mortality was observed; therefore, no analysis was possible. The AHFS⁹⁰ had a maximal prediction of early mortality of 64.5% in this study population.

CONCLUSION

The AHFS⁹⁰ accurately predicts early mortality after hip fracture surgery in patients ≥ 90 years of age. Predicted risks correspond to observed risks in most risk categories. In our study population, the AHFS⁹⁰ yielded a maximum prediction of early mortality of 64.5%.

Effects of Dementia on Outcomes after Cervical Spine Injuries in Elderly Patients: Evaluation of 1512 Cases in a Nationwide Multicenter Study in Japan

We aimed to retrospectively investigate the demographic characteristics and short-term outcomes of traumatic cervical spine injuries in patients with dementia. We enrolled 1512 patients aged ≥ 65 years with traumatic cervical injuries registered in a multicenter study database. Patients were divided into two groups according to the presence of dementia, and 95 patients (6.3%) had dementia. Univariate analysis revealed that the dementia group comprised patients who were older and predominantly female and had lower body mass index, higher modified 5-item frailty index (mFI-5), lower pre-injury activities of daily living (ADLs), and a larger number of comorbidities than patients without dementia. Furthermore, 61 patient pairs were selected through propensity score matching with adjustments for age, sex, pre-injury ADLs, American Spinal Injury Association Impairment Scale score at the time of injury, and the administration of surgical treatment. In the univariate analysis of the matched groups, patients with dementia had significantly lower ADLs at 6 months and a higher incidence of dysphagia up to 6 months than patients without dementia. Kaplan-Meier analysis revealed that patients with dementia had a higher mortality than those without dementia until the last follow-up. Dementia was associated with poor ADLs and higher mortality rates after traumatic cervical spine injuries in elderly patients.

Impact of Dementia on Long-Term Hip Fracture Surgery Outcomes: An Electronic Health Record Analysis

OBJECTIVE

Older adults with dementia are at higher risk for sustaining hip fracture and their long-term health outcomes after surgery are usually worse than those without dementia. Widespread adoption of electronic health records (EHRs) may allow hospitals to better monitor long-term health outcomes in patients with dementia after hospitalization. This study aimed to (1) estimate how dementia influences discharge location, mortality, and readmission 180 days and 1 year after hip fracture surgery in older adults, and (2) demonstrate the feasibility of using selection-bias reduced EHR data for research and long-term health outcomes monitoring.

DESIGN

Retrospective observational cohort study using EHRs.

SETTING AND PARTICIPANTS

A cohort of 1171 patients over age 65 years who had an initial hip fracture surgery between October 2015 and December 2018 was extracted from EHRs of one health system; 376 of these patients had dementia.

METHODS

Logistic regression was applied to estimate influences of dementia on discharge disposition and Cox proportional hazards model for mortality. The Fine and Gray regression model was used to analyze readmission, accounting for the competing risk of death. To reduce selection bias in EHRs, inverse probability of treatment weighting using propensity scores was implemented before modeling.

RESULTS

Dementia had significant impacts on all outcomes: being discharged to facilities [odds ratio (OR) = 2.11, 95% confidence interval (CI) 1.19-3.74], 180-day mortality [hazard ratio (HR) = 1.69, 95% CI 1.20-2.38], 1-year mortality (HR = 1.78, 95% CI 1.33-2.38), 180-day readmission (HR = 1.62, 95% CI 1.39-1.89), and 1 year readmission (HR = 1.39, 95% CI 1.21-1.58).

CONCLUSIONS AND IMPLICATIONS

Dementia was a significant risk factor for worse long-term outcomes. The inverse probability of treatment weighting approach can be used to reduce selection bias in EHR data for research and monitoring long-term health outcomes in the target population. Such monitoring could foster collaborations with post-acute and long-term health care services to improve recovery outcomes in patients with dementia after hip fracture surgery.

Effect of Marital Status on Outcomes Following Total Joint Arthroplasty

INTRODUCTION

The purpose of this study is to investigate whether the specific socioeconomic factor such as marital status has any effect on clinical outcomes and patient-reported outcome measures (PROMs) after primary total hip (THA) and knee (TKA) arthroplasty.

MATERIALS AND METHODS

We retrospectively reviewed patients who underwent primary THA or TKA from January 2019 to August 2019 who answered all PROM questionnaires. Both THA and TKA patients were separated into two groups based on their marital status at the time of surgery (married vs. non-married). Demographics, clinical data, and PROMs (FJS-12, HOOS, JR, KOOS, JR, and VR-12 PCS&MCS) were collected at various time-periods. Demographic differences were assessed using chi-square and independent sample t tests. Clinical data and mean PROMs were compared using multilinear regressions while accounting for demographic differences.

RESULTS

This study included 389 patients who underwent primary THA and 193 that underwent primary TKA. In the THA cohort, 256 (66%) patients were married and 133 (34%) were non-married. In the TKA cohort, there were 117 (61%) married patients and 76 (39%) non-married patients. Length of stay was significantly shorter for married patients in both the THA (1.30 vs. 1.64; p = 0.002) and TKA (1.89 vs. 2.36; p = 0.024) cohorts. Surgical-time, all-cause emergency department visits, discharge disposition, and 90-day all-cause adverse events (readmissions/revisions) did not statistically differ between both cohorts. Both HOOS, JR and KOOS, JR score improvements from baseline to 1-year did not statistically differ for the THA and TKA cohorts, respectively. Although VR-12 PCS (p = 0.012) and MCS (p = 0.004) score improvement from baseline to 1-year statistically differed for the THA cohort, they did not for the TKA cohort.

CONCLUSION

Total joint arthroplasty may yield similar clinical benefits in all patients irrespective of their marital status. Although some PROMs statistically differed among married and non-married patients, the differences are likely not clinically significant. Surgeons should continue to assess levels of psychosocial support in their patients prior to undergoing TJA to optimize outcomes.

LEVEL OF EVIDENCE

III, Retrospective Cohort Study.

Risk factors of mortality and second fracture after elderly hip fracture surgery in Shanghai, China

INTRODUCTION

Hip fracture is one of the leading causes of death and disability in the elderly. We analyzed the risk factors of mortality and second fracture within 2 years after hip fracture surgery in elderly Chinese patients.

MATERIALS AND METHODS

A total of 613 elderly patients after hip fracture surgery were selected, including 181 males and 432 females, and the patients were followed for at least 24 months. Information about patients and surgery was collected from medical records. Information on death, secondary fracture, and postoperative activities of daily living (ADL) was obtained by telephone follow-up. Cox regression was performed to identify risk factors associated with mortality and second fracture, measured by hazard ratio (HR).

RESULTS

The 1-year and 2-year mortality rates after hip fracture were 13.4% and 20.7%, respectively. The second fracture rate within 2 years was 9.5%. Male gender (HR 1.51, P = 0.035), increased age (HR 1.07, P < 0.001), preoperative hypoalbuminemia (HR 1.79, P = 0.004), preoperative pneumonia (HR 2.60, P = 0.005) and poor ADL (P = 0.048) were independent risk factors for 2-year mortality, while high preoperative hemoglobin (HR 0.98, P = 0.002), high preoperative eGFR (HR 0.99, P = 0.031), high preoperative LVEF (HR 0.92, P = 0.048) were protective factors for 2-year mortality. Poor ADL (P = 0.002) was the independent risk factor for second fracture within 2 years.

CONCLUSIONS

The 2-year mortality rate and second fracture rate after hip fracture in elderly remained high, which was related to old age and complications exists. Postoperative rehabilitation and improving ADL were very important to reduce mortality and second fracture.

Montreal cognitive assessment (MoCA) is highly correlated with 1-year mortality in hip fracture patients

Prevalence of cognitive impairment in hip fractures was 86.5%. MoCA is an independent risk factor of mortality. MoCA score of < 15 is correlated with 11.71 times increased risk of mortality. Early attention and caution should be given to these patients for appropriate intervention to decrease mortality rates.

INTRODUCTION

Hip fractures rank amongst the top 10 causes of disability and current mortality of hip fractures is high. Objectives were to determine 1) prevalence of cognitive impairment, 2) whether Montreal Cognitive Assessment (MoCA) score was an independent risk factor associated with mortality, 3) MoCA cut-off that result in high risk of mortality.

METHODS

This was a cohort study between July 2019 to June 2020. Inclusion criteria were 1) hip fracture, 2) >  = 65 years old, and 3) low-energy trauma. Patients undergo assessment for cognitive impairment with MoCA. Prevalence was assessed, MoCA cut-off point, and accuracy of statistical model was evaluated. Logistic regression modelling was used to assess association between mortality and MoCA.

RESULTS

There were 260 patients recruited. Two hundred twenty-five patients had MoCA score < 22 signifying cognitive impairment, and 202 patients had MoCA score of < 19. 46 hip fracture patients died at 1-year follow-up. 45 of these patients had MoCA score < 19, and 1 patient had a MoCA > 22. Results showed statistical significance and good model effect (at least 0.8) with MoCA cut-off points between < 15 and < 19 (p < 0.05). After controlling confounding factors, statistical significance still existed in MoCA cut-off point at < 15 (odds ratio (95% CI) = 11.71 (1.14, 120.71); p = 0.04).

CONCLUSION

Prevalence of cognitive impairment in hip fractures was 86.5%. MoCA is an independent risk factor of mortality in hip fracture patients. MoCA score of < 15 is correlated with 11.71 times increased risk of mortality at 1-year after a hip fracture. AUC with MoCA score < 15 was 0.948. Early attention and caution should be given to these patients for appropriate intervention to decrease mortality rates.

Mode of anesthesia is not associated with outcomes following emergency hip fracture surgery: a population-level cohort study

Background

Hip fractures often occur in frail patients with several comorbidities. In those undergoing emergency surgery, determining the optimal anesthesia modality may be challenging, with equipoise concerning outcomes following either spinal or general anesthesia. In this study, we investigated the association between mode of anesthesia and postoperative morbidity and mortality with subgroup analyses.

Methods

This is a retrospective study using all consecutive adult patients who underwent emergency hip fracture surgery in Orebro County, Sweden, between 2013 and 2017. Patients were extracted from the Swedish National Hip Fracture Registry, and their electronic medical records were reviewed. The association between the type of anesthesia and 30-day and 90-day postoperative mortality, as well as in-hospital severe complications (Clavien-Dindo classification ≥3a), was analyzed using Poisson regression models with robust SEs, while the association with 1-year mortality was analyzed using Cox proportional hazards models. All analyses were adjusted for potential confounders.

Results

A total of 2437 hip fracture cases were included in the study, of whom 60% received spinal anesthesia. There was no statistically significant difference in the risk of 30-day postoperative mortality (adjusted incident rate ratio (IRR) (95% CI): 0.99 (0.72 to 1.36), p=0.952), 90-day postoperative mortality (adjusted IRR (95% CI): 0.88 (0.70 to 1.11), p=0.281), 1-year postoperative mortality (adjusted HR (95% CI): 0.98 (0.83 to 1.15), p=0.773), or in-hospital severe complications (adjusted IRR (95% CI): 1.24 (0.85 to 1.82), p=0.273), when comparing general and spinal anesthesia.

Conclusions

Mode of anesthesia during emergency hip fracture surgery was not associated with an increased risk of postoperative mortality or in-hospital severe complications in the study population or any of the investigated subgroups.

Level of evidence: Therapeutic/Care Management, level III

Rehabilitation interventions for persons with hip fracture and cognitive impairment: A scoping review

Background

Hip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.

Objective

To examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.

Methods

Articles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.

Results

Seventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants’ needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.

Conclusions

More work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

Effect of Perioperative Dexmedetomidine Anesthesia on Prognosis of Elderly Patients with Gastrointestinal Tumor Surgery

It was to investigate the influence of perioperative dexmedetomidine (DEX) anesthesia on the prognosis of elderly patients with gastrointestinal tumor (GIT) surgery. 90 patients who underwent laparoscopic radical gastrectomy for GIT were included. They were randomly divided into the experimental group (45 cases) with DEX+general anesthesia, and the control group (45 cases) with epidural anesthesia+general anesthesia. The indicators after surgery were compared between the two groups. The mean arterial pressure (MAP) was 74.8 ± 3.5 mmHg and the heart rate (HR) was 52.7 ± 8.2 beats/min⁻¹ in the experimental group, significantly lower than those of the control group (P < 0.05). The Visual Analog Scale (VAS) scores of both groups decreased greatly associated to those before surgery (P < 0.05). The levels of cortisol (COR) and immune adhesion inhibitor (FEIR) in the experimental group were significantly dissimilar from those in the control group (P < 0.05). The tumor necrosis factor-alpha (TNF-α) was 96.4 ± 21.8 ng/L in the experimental group, observably lower than that in the control group (P < 0.05). The postoperative diamine oxidase (DAO) and D-lactate (D-lac) were 62.4 ± 9.3 μmol/mL and 33.8 ± 7.2 ng/L, respectively, in the experimental group, much lower than those in the control group (P < 0.05). There were also significant differences in the initial recovery of bowel sounds, defecation, and total length of hospital stay (LOHS) between the groups (P < 0.05). DEX anesthesia had ideal sedative and analgesic effects, improving the prognosis of patients during surgery, and shortening the LOHS. Thus, it deserved a clinical application value.

Internal fixation or hip replacement for undisplaced femoral neck fractures? Pre-fracture health differences reflect survival and functional outcome

BACKGROUND AND PURPOSE

Internal fixation (IF) has been the standard procedure for undisplaced femoral neck fractures (FNFs). However, there is a changing trend towards hip replacement (HR). Yet there is a knowledge gap regarding the benefits of this surgical method. We investigated functional outcomes in patients ≥ 70 years following HR compared to IF for undisplaced FNFs.

PATIENTS AND METHODS

Patients ≥ 70 years with undisplaced FNF registered in the Swedish National Hip Fracture Registry (SHR) who underwent either IF or HR (hemiarthroplasty [HA)] or total hip arthroplasty [THA]) were investigated in terms of 1-year survival and proportion of reoperation. In a subsample with 4-month follow-up data (n = 3,623), pain, changes in living status, and physical function were additionally analyzed.

RESULTS

7,758 patients were included with a mean age of 85 years. 93% of the patients were operated on with IF, 5% with HA, and 2% with THA. Patients with THA more often lived independently and were able to walk outdoors, both before and after the hip fracture. The IF and HA groups were similar in baseline characteristics, and in functional and survival outcomes. The THA group had a 54% lower adjusted risk of 1-year mortality. The proportion of reoperations within 1 year was 9.5% for IF, 5.3% for HA, and 7% for THA.

INTERPRETATION

The pre-fracture difference in health and function between patients operated on with IF, HA, and THA maked it difficult to compare outcomes of the 2 methods. Decision on surgical method must be taken on an individual level, considering patients' well-being and allocation of resources.

Factors Associated with In-Patient Mortality in the Rapid Assessment of Adult Earthquake Trauma Patients

OBJECTIVE

To date, there is limited evidence for health care providers regarding the determinants of early assessment of poor outcomes of adult in-patients due to earthquakes. This study aimed to explore factors related to early assessment of adult earthquake trauma patients (AETPs).

METHODS

The data on 29,933 AETPs in the West China Earthquake Patients Database (WCEPD) were analyzed retrospectively. Then, 37 simple variables that could be obtained rapidly upon arrival at the hospital were collected. The least absolute shrinkage and selection operator (LASSO) regression analyses were performed. A nomogram was then constructed.

RESULTS

Nine independent mortality-related factors that contributed to AETP in-patient mortality were identified. The variables included age (OR:1.035; 95%CI, 1.027-1.044), respiratory rate ([RR]; OR:1.091; 95%CI, 1.050-1.133), pulse rate ([PR]; OR:1.028; 95%CI, 1.020-1.036), diastolic blood pressure ([DBP]; OR:0.96; 95%CI, 0.950-0.970), Glasgow Coma Scale ([GCS]; OR:0.666; 95%CI, 0.643-0.691), crush injury (OR:3.707; 95%CI, 2.166-6.115), coronary heart disease ([CHD]; OR:4.025; 95%CI, 1.869-7.859), malignant tumor (OR:4.915; 95%CI, 2.850-8.098), and chronic kidney disease ([CKD]; OR:5.735; 95%CI, 3.209-10.019).

CONCLUSIONS

The nine mortality-related factors for ATEPs, including age, RR, PR, DBP, GCS, crush injury, CHD, malignant tumor, and CKD, could be quickly obtained on hospital arrival and should be the focal point of future earthquake response strategies for AETPs. Based on these factors, a nomogram was constructed to screen for AETPs with a higher risk of in-patient mortality.

What is the subtype of dementia in patients with fragility hip fracture?

Introduction

Cognitive function is an important factor that affects functional recovery after hip fracture (HipFx) surgery. The literature on the pathophysiology of dementia in HipFx patients is scarce. We performed a differential diagnosis of dementia in HipFx patients using clinical and brain MRI findings.

Methods

This is a prospective study in which brain MRI was evaluated for patients with HipFx for research purposes. One-hundred-and-five HipFx patients (85 females and 20 males) who underwent surgery and were subsequently able to undergo brain MRI at our hospital were evaluated. The mean age was 84 years. The presence of dementia was determined based on clinical findings and whether the patient meets its diagnostic criteria according to the International Classification of Diseases 10th Edition (ICD-10). The differential diagnosis of dementia was made based on brain MRI findings and the dementia diagnostic flow chart published in the Clinical Practice Guideline for Dementia 2017 (Japanese Society of Neurology). The Voxel-based Specific Regional Analysis System for Alzheimer’s Disease (VSRAD) advance 2 diagnostic software was used to evaluate atrophy of the para-hippocampal gyrus.

Results

Fifty-six (53%) patients were clinically diagnosed with dementia according to the ICD-10 criteria. The MRI findings were diverse: Alzheimer’s disease (AD)-type, asymptomatic multiple ischemic cerebral lesions, past symptomatic cerebral infarction or cerebral hemorrhage, Binswanger’s disease (BW)-type, chronic subdural hematoma, disproportionately enlarged subarachnoidal hydrocephalus (DESH), and their combinations thereof. A combination of MRI and clinical findings of dementia patients demonstrated the following distribution of dementia subtypes: AD (n = 20), vascular dementia (n = 33), AD and BW vascular dementia (n = 3).

Conclusion

This study revealed that the brain MRI findings of HipFx patients were diverse. Although vascular dementia is found to be common in this particular population, this could be an incidental finding. Further study is warranted to clarify the specificity of our findings by increasing the number of patients, setting the control, and investigating whether dementia subtypes affect postoperative gait acquisition and fall risk.

Profile of Patients with Dementia or Cognitive Impairment Hospitalized with a Proximal Femur Fracture Requiring Surgery

This study reports the characteristics of patients with dementia or cognitive impairment hospitalized with a proximal femur fracture requiring surgery. Methods: Multicentric descriptive longitudinal study conducted in three traumatology units, representing high-technology public hospitals across Spain. Data collection took place between August 2018 and December 2019 upon admission to hospital, discharge, one month and three months after discharge. Results: Study participants (n = 174) were mainly women (81.6%), and the mean age was 90.7± 6.3 years old. Significant statistical differences were noted in the decline of functional capacity at baseline and one month later, and after three months they had still not recovered. Malnutrition increased from baseline to the one-month follow-up. The use of physical restraints increased during hospitalization, especially bilateral bedrails and a belt in the chair/bed. After one month, 15.2% of patients had pressure ulcers. Although pain decreased, it was still present after three months. Conclusion: Hospitalization after hip surgery for elderly people with dementia or cognitive impairment negatively impacted their global health outcomes such as malnutrition and the development of pressure ulcers, falls, functional impairment and the use of physical restraints and pain management challenges. Hospitals should implement policy-makers’ strategic dementia care plans to improve their outcomes.

Factors related to early and rapid assessment of in-hospital mortality among older adult trauma patients in an earthquake

BACKGROUND

There is limited evidence for emergency physicians and emergency trauma surgeons regarding the determinants of early and rapid assessment of older adult in-hospital mortality due to earthquakes. This study explored factors related to the early and rapid assessment of the mortality among older adult earthquake trauma patients (OAETPs) and created a screening model.

METHODS

Data on 7,308 OAETPs from the West China Earthquake Patients Database were analyzed retrospectively. The 35 variables that can be obtained rapidly on arrival at the hospital were collected. Least absolute shrinkage and selection operator (LASSO) regression analysis was performed. Then, the nomogram for assessing the mortality of OAETPs was constructed.

RESULTS

We identified 10 independent mortality-related factors that contributed to the in-hospital mortality of OAETPs. The 10 factors included age (odds ratio [OR]=1.061, 95% confidence interval [CI]:1.031-1.090), dementia (OR=5.146, 95%CI: 1.169-17.856), coronary heart disease (CHD; OR=23.441, 95%CI: 4.799-83.927), malignant tumor (OR=8.497, 95%CI: 3.583-17.967), deep vein thrombosis (DVT; OR=7.110, 95%CI: 1.369-27.168), chronic kidney disease(CKD; OR=11.783, 95%CI: 5.419-24.407), pulse rate (PR; OR=1.036, 95%CI: 1.022-1.048), mean artery pressure (MAP; OR=0.960, 95%CI: 0.945-0.975), Glasgow Coma Scale (GCS; OR=0.864, 95%CI: 0.760-0.972), and Triage Revised Trauma Score (T-RTS, OR=0.485, 95%CI: 0.351-0.696).

CONCLUSION

The 10 mortality-related factors could be quickly obtained on hospital arrival and should be the focal point of future earthquake response strategies regarding hospitalized older adults with trauma. A nomogram was constructed based on the factors for screening OAETPs with a higher risk of in-hospital mortality.

Prognostication in dementia

Dementia is a progressive, irreversible illness and leading global cause of death defined by cognitive and subsequent functional decline. Current treatments have limited impact on mortality. In this chapter, we discuss the trajectory of dementia and its variability, markers associated with poorer prognosis (such as poor nutrition, pneumonia, comorbid conditions), the impact of hospitalization on prognosis, and current models of end-of-life palliative care/hospice eligibility (with the use of the Functional Assessment Staging tool and other markers). We then discuss strategies to discuss prognosis with patients and their healthcare proxies using a mental model (Ask, Discover, Anticipate, Provide, Track: ADAPT) and specific skills. Because of progression of dementia variability, prognosis is better discussed in terms of function. For patients with dementia, initiating advance care planning earlier in their disease course allows for more patient involvement (such as to identify a surrogate decision maker).

The effects of dementia on the prognosis and mortality of hip fracture surgery: a systematic review and meta-analysis

OBJECTIVES

Dementia is a common mental disorder that affects the life quality in elders. Recently, emerging studies reported the negative impacts of dementia on prognosis after hip surgeries. However, the integrated and reliable role of dementia in hip surgery is not illustrated.

METHODS

We searched the relevant literatures before June 2020 and extracted the data that met the inclusion criteria. The influence of dementia on postoperative walking ability, complications including infection, cardiovascular complications, hip dislocation, delirium, and respiratory complications, and survival rate at different periods were evaluated. Qualitative and quantitative analysis were conducted using Review Manager Version 5.3.

RESULTS

The meta-analysis enrolled a total of 30 studies with 1,037,049 patients. The pooled results revealed that there were significant negative impacts of dementia on the recovery of postoperative walking ability, postoperative infection, hip dislocation, delirium and respiratory complications and mortality at different periods.

CONCLUSIONS

Dementia is a crucial risk factor for the poor prognosis after hip fracture surgery. Therefore, when making clinical strategies for hip fracture patients with dementia, countermeasures for possible complications should be generated.

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture

BACKGROUND

The aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis.

METHODS

This study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson's comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality.

RESULTS

The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07-3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23-1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46-1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70-2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17-1.90; P = 0.027).

CONCLUSION

In elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.

Effect of Dementia on Outcomes After Surgically Treated Hip Fracture in Older Adults

BACKGROUND

Hip fractures are associated with increased mortality and functional limitations. However, the effect that dementia has on these outcomes in individuals in aged care settings after fracture is not well established. This study examined the association of dementia with post-hip fracture mortality, permanent residential aged care entry, transition care use, and change in activities of daily living (ADL) needs.

METHODS

A retrospective cohort study using data from the Registry of Senior Australians (2003-2015) was conducted. Individuals with a hip fracture while receiving aged care services were included. Associations of dementia with mortality, risks of transition and permanent care use, and ADL needs progression were estimated using multivariable Cox, Fine-Gray, and logistic regression methods, respectively.

RESULTS

Of 4771 individuals evaluated, 76% were women, the median age was 86 years (IQR 82-90), and 71% already lived in permanent residential aged care at the time of fracture. Within two years of their hip fracture, 50.4% (95% CI 48.9%-51.8%) of individuals died, 16.2% (95% CI 14.2%-18.2%) entered a transition care program, 59.1% (95% CI 56.5%-61.7%) entered permanent residential aged care, and 32% had greater ADL needs. Dementia was associated with higher risk of two-year mortality (HR = 1.19, 95% CI 1.09-1.30), 90-day entry into permanent care (sHR = 1.96, 95% CI 1.60-2.38), and increased likelihood of ADL limitations (OR = 1.36, 95% CI 1.00-1.85). Minor differences were seen in transition care use by dementia status.

CONCLUSION

Dementia is a strong risk factor for mortality after hip fractures in individuals in aged care settings and associated with a high risk of entry into permanent care.

LEVEL OF EVIDENCE

Prognostic level III.

The 30-day survival and recovery after hip fracture by timing of mobilization and dementia : a UK database study

AIMS

The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

METHODS

Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability.

RESULTS

A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia.

CONCLUSION

Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article: Bone Joint J 2021;103-B(7):1317-1324.

β-Adrenergic blockade in patients with dementia and hip fracture is associated with decreased postoperative mortality

Purpose

Dementia, present in 20% of hip fracture patients, is associated with an almost threefold increase in postoperative mortality risk. These patients have a substantially higher incidence of cardiovascular, respiratory, and cerebrovascular mortality after hip fracture surgery compared to patients without dementia. This study aimed to investigate the association between beta-blocker therapy and postoperative mortality in patients with dementia undergoing hip fracture surgery.

Methods

This nationwide study included all patients in Sweden with the diagnosis of dementia who underwent emergency surgery for a hip fracture between January 2008 and December 2017. Cases where the hip fracture was pathological or conservatively managed were not included. Poisson regression analysis with robust standard errors was performed while controlling for confounders to determine the relationship between beta-blocker therapy and all-cause, as well as cause-specific, postoperative mortality.

Results

A total of 26,549 patients met the study inclusion criteria, of whom 8258 (31%) had ongoing beta-blocker therapy at time of admission. After adjusting for clinically relevant variables, the incidence of postoperative mortality in patients receiving beta-blocker therapy was decreased by 50% at 30 days [adj. IRR (95% CI) 0.50 (0.45–0.54), p < 0.001] and 34% at 90 days [adj. IRR (95% CI) 0.66 (0.62–0.70), p < 0.001]. Cause-specific mortality analysis demonstrated a significant reduction in the incidence of postoperative cardiovascular, respiratory, and cerebrovascular death within 30 and 90 days postoperatively.

Conclusion

Beta-blocker therapy is associated with decreased postoperative mortality in hip fracture patients with dementia up to 90 days after surgery. This finding warrants further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-021-01723-y.

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England

We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia.

INTRODUCTION

Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England.

METHODS

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission.

RESULTS

We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001).

CONCLUSION

Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

The risk-adjusted Charlson comorbidity index as a new predictor of one-year mortality rate in elderly Chinese patients who underwent hip fracture surgery

INTRODUCTION

Recently, many studies used the Charlson comorbidity index (CCI) to predict the postoperative mortality rate of elderly patients with hip fractures. However, as a predictor, CCI did not include other preoperative risk factors, resulting in decreasing its predictive value. Therefore, we performed a study to focus on two questions as follows: (1) What is the one-year mortality rate of elderly Chinese patients who underwent surgery for hip fracture? (2) Could risk-adjusted CCI act as a new predictor to predict the one-year mortality rate?

HYPOTHESIS

The risk-adjusted CCI could exhibit a good predictive value for one-year mortality of elderly Chinese patients who underwent surgery for hip fracture.

MATERIAL AND METHODS

This retrospective observational cohort study is based on data collected from July 2012 to April 2016. Patients aged 65 years and older who underwent hip fracture surgery were included. The clinical patient data were obtained, including gender, age, BMI, types of fracture, smoking, injury side, time from injury to surgery, and CCI. Stepwise, multiple logistic regression analysis was used to identify risk factors contributed to the occurrence of postoperative death at one-year follow-up. The risk-adjusted CCI scores of patients were calculated by the formula based on the coefficient regression and independent variables. Receiver operating characteristic (ROC) curve analysis was used for determining the diagnostic value of different factors.

RESULTS

A total of 445 elderly patients who underwent surgery for hip fracture, including 171 males and 274 females, were enrolled in the study cohort. The mean CCI scores of all enrolled patients were 1.20±1.62. Sixty-four patients died within one year, and the one-year mortality rate was 14.38%. The multivariate logistic regression analysis reported that age, time from injury to surgery, and CCI were associated with death after surgical treatment within one year. The risk-adjusted CCI scores of patients=0.099×age (years)+0.355×time from injury to surgery (days)+0.434×CCI scores. The predictive value of the risk-adjusted CCI was highest among these risk predictors, whose AUC value was 0.816.

DISCUSSION

The risk-adjusted Charlson comorbidity index could be used as a guide to predict one-year mortality rate in elderly Chinese patients after the surgical treatment of hip fractures.

LEVEL OF EVIDENCE

III; cohort comparative study.

Predicting in-hospital mortality for dementia patients after hip fracture surgery - A comparison between the Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index

BACKGROUND

Considerable in-hospital mortality was reported in geriatric patients with dementia sustaining femoral neck or inter-trochanteric fracture. We intended to establish a predictive model of in-hospital mortality for dementia patients after hip fracture surgery.

METHODS

We collected 8080 registrants ≧ 65 years old from the subset (LHID2000) of the National Health Insurance Research Database (NHIRD) that met the following inclusion criteria:1. Admitted with the ICD of hip fracture; 2. Underwent operation of hip fracture during the same hospitalization; 3. Co-existing diagnosis of dementia (ICD-9-CM codes 290). The co-morbidity was recorded according to validated Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index (ECI) from the diagnoses of hospitalization. The main outcome measure was in-hospital mortality that was defined as death being reported during hospitalization. The comparison of predictability was conducted by Receiver operating characteristic (ROC) curves and the area under the ROC curve (AUC) among different predictive models.

RESULTS

The Charlson Comorbidity Index (CCI) score and Elixhauser Comorbidity Index (ECI) score showed similar ability in predicting in-hospital mortality (AUC = 0.653, 95% CI = 0.611-0.695 for CCI; AUC = 0.624, 95% CI = 0.582-0.665 for ECI, p = 0.0717). By adding age grouping (≥80 yrs = 1, 65-80 yrs = 0) and gender difference (Male = 1, Female = 0), these two models were shifted to models CCI_new1 and ECI_new1. Consequently, the AUC greatly increased in the CCI_new1 (AUC = 0.682, 95% CI = 0.643-0.722). It therefore provided better prediction of in-hospital mortality than ECI_new1 (AUC = 0.651, 95% CI = 0.611-0.691) (p = 0.0444).

CONCLUSIONS

Utilizing the CCI with addition of grouping for age and gender provides a better prediction for in-hospital mortality than the ECI among elderly patients with concomitant dementia and hip fracture who underwent surgical intervention.

The incidence of mental disorder increases after hip fracture in older people: a nationwide cohort study

Background

People living with dementia seem to be more likely to experience delirium following hip fracture. The association between mental disorders (MD) and hip fracture remains controversial. We conducted a nationwide study to examine the prevalence of MD in geriatric patients with hip fractures undergoing surgery and conducted a related risk factor analysis.

Material and methods

This retrospective cohort study used data from Taiwan’s National Health Insurance Research Database between 2000 and 2012 and focused on people who were older than 60 years. Patients with hip fracture undergoing surgical intervention and without hip fracture were matched at a ratio of 1:1 for age, sex, comorbidities, and index year. The incidence and hazard ratios of age, sex, and multiple comorbidities related to MD and its subgroups were calculated using Cox proportional hazards regression models.

Results

A total of 1408 patients in the hip fracture group and a total of 1408 patients in the control group (no fracture) were included. The overall incidence of MD for the hip fracture and control groups per 100 person-years were 0.8 and 0.5, respectively. Among MD, the incidences of transient MD, depression, and dementia were significantly higher in the hip fracture group than in the control group.

Conclusions

The prevalence of newly developed MD, especially transient MD, depression, and dementia, was higher in the geriatric patients with hip fracture undergoing surgery than that in the control group. Prompt and aggressive prevention protocols and persistent follow-up of MD development is highly necessary in this aged society.

Surgical management of displaced femoral neck fractures in patients with dementia: a comparison in mortality between hemiarthroplasty and pins/screws

Introduction

Dementia is common in patients with hip fractures and is strongly associated with increased postoperative mortality. The choice of surgical intervention for displaced femoral neck fractures (dFNF) in patients with dementia has been a matter of debate. This study aims to investigate how short- and long-term mortality differs between those who have been operated with hemiarthroplasty or pins/screws.

Methods

All patients with dementia and dFNF, i.e., Garden III and IV, who underwent primary emergency hip fracture surgery, with either hemiarthroplasty or pins/screws, in Sweden between Jan 1, 2008 and Dec 31, 2017 were eligible for inclusion in the current study. Patients were divided into two groups based on the surgical intervention: hemiarthroplasty and pins/screws. The primary outcome of interest was 30-day postoperative mortality, and the secondary outcome was 1-year postoperative mortality. Poisson and Cox regression analyses were performed both before and after propensity score matching.

Results

A total of 9394 cases met the inclusion criteria; 84% received hemiarthroplasty and 16% received pins/screws. In the unmatched analysis, the adjusted incidence rate ratio (IRR) for 30-day postoperative mortality was not affected by the chosen surgical method (adj. IRR 0.96, CI 95% 0.83–1.12, p = 0.629). After propensity score matching, similar results were observed with no difference in 30-day postoperative mortality (adj. IRR 0.89, CI 95% 0.74–1.09, p = 0.286). There was a statistically significant decrease in the risk of 1-year postoperative mortality in the hemiarthroplasty group compared to the pins/screws group, both before and after propensity score matching.

Conclusion

This study could not demonstrate any difference in 30-day mortality in patients with dementia and dFNFs when comparing hemiarthroplasty with pins/screws. Patients that received hemiarthroplasties did, however, have a lower risk of 1-year postoperative mortality.

Preexisting dementia is associated with higher mortality rate in patients with femoral neck fracture

OBJECTIVE

This study aimed to assess the mortality and the influence of age, Abbreviated Mental Test (AMT) scores, and American Society of Anesthesiologists (ASA) grades on patients with dementia and femoral neck fracture (FNF) at 30 days, 4 months, 1 year, and 2 years after undergoing surgery.

METHODS

Of 1296 patients admitted with FNF, 180 had had prefracture dementia. A retrospective study of these 180 patients was carried out. The patient demographics, including age, sex, presence of diabetes mellitus (DM), lipid profile, AMT score, preoperative comorbidities, ASA grade, and incidence of postoperative delirium, were documented.

RESULTS

A total of 113 patients (62.8%) died postoperatively. The mortality rate was 17.7% (20 patients) at 30 days, 54.9% (62 patients) at 4 months, 77.9% (88 patients) at 1 year, and 87.6% (99 patients) at 2 years. The mortally rate in dementia with FNF was three times higher than that in FNF without dementia and was independent of age, ASA grades, DM, lipid profile, AMT scores, and development of postoperative delirium.

CONCLUSIONS

Dementia should be a principal predictive factor in mortality of FNF and should be a key determinant in all frailty scores.

The mortality burden in patients with hip fractures and dementia

Purpose

Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population.

Methods

All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality.

Results

134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60–1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99–11.07), p < 0.001].

Conclusions

Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

Mortality and Medical Complications of Subtrochanteric Fracture Fixation

The aim of this study was to define the incidence and investigate the associations with mortality and medical complications, in patients presenting with subtrochanteric femoral fractures subsequently treated with an intramedullary nail, with a special reference to advancement of age. Materials and Methods: A retrospective review, covering an 8-year period, of all patients admitted to a Level 1 Trauma Centre with the diagnosis of subtrochanteric fractures was conducted. Normality was assessed for the data variables to determine the further use of parametric or non-parametric tests. Logistic regression analysis was then performed to identify the most important associations for each event. A p-value < 0.05 was considered significant. Results: A total of 519 patients were included in our study (age at time of injury: 73.26 ± 19.47 years; 318 female). The average length of hospital stay was 21.4 ± 19.45 days. Mortality was 5.4% and 17.3% for 30 days and one year, respectively. Risk factors for one-year mortality included: Low albumin on admission (Odds ratio (OR) 4.82; 95% Confidence interval (95%CI) 2.08-11.19), dementia (OR 3.99; 95%CI 2.27-7.01), presence of pneumonia during hospital stay (OR 3.18; 95%CI 1.76-5.77) and Charlson comorbidity score (CCS) > 6 (OR 2.94; 95%CI 1.62-5.35). Regarding the medical complications following the operative management of subtrochanteric fractures, the overall incidence of hospital acquired pneumonia (HAP) was 18.3%. Patients with increasing CCS (CCS 6-8: OR 1.69; 95%CI 1.00-2.84/CCS > 8: OR 2.02; 95%CI 1.03-3.95), presence of asthma/chronic obstructive pulmonary disease (COPD) (OR 2.29; 95%CI 1.37-3.82), intensive care unit (ICU)/high dependency unit (HDU) stay (OR 3.25; 95%CI 1.77-5.96) and a length of stay of more than 21 days (OR 8.82; 95%CI 1.18-65.80) were at increased risk of this outcome. The incidence of post-operative delirium was found to be 10.2%. This was associated with pre-existing dementia (OR 4.03; 95%CI 0.34-4.16), urinary tract infection (UTI) (OR 3.85; 95%CI 1.96-7.56), need for an increased level of care (OR 3.16; 95%CI 1.38-7.25), pneumonia (OR 2.29; 95%CI 1.14-4.62) and post-operative deterioration of renal function (OR 2.21; 95%CI 1.18-4.15). The incidence of venous thromboembolism (VTE) was 3.7% (pulmonary embolism (PE): 8 patients; deep venous thrombosis (DVT): 11 patients), whilst the incidence of myocardial infarction (MI)/cerebrovascular accidents (CVA) was 4.0%. No evidence of the so called "weekend effect" was identified on both morbidity and mortality. Regression analysis of these complications did not reveal any significant associations. Conclusions: Our study has opened the field for the investigation of medical complications within the subtrochanteric fracture population. Early identification of the associations of these complications could help prognostication for those who are at risk of a poor outcome. Furthermore, these could be potential "warning shots" for clinicians to act early to manage and in some cases prevent these devastating complications that could potentially lead to an increased risk of mortality.

Relationship of Prevalent Fragility Fracture in Dementia Patients: Three Years Follow up Study

Introduction: dementia increases the risk of falls by 2–3 times and cognitively impaired patients are three times more likely to have hip fracture following a fall when compared to cognitively intact individuals. However, there is not enough evidence that explores the relationship between dementia and fragility fractures. The aim of this study is to explore the relationships of prevalent fragility fracture in patients with dementia admitted with an acute illness to the hospital. Methods: the existing Health Board records were reviewed retrospectively for all patients admitted diagnosed with dementia in the year 2016. All patients were followed up for a maximum of three years. All of the the dementia patients were divided into three groups: group 1—“no fractures”; group 2—“all fractures”; group 3—“fragility fractures”. Clinical outcomes were analysed for hospital stay, discharge destination (new care home), post-discharge hip fracture data, and mortality. Results: dementia patients with a prevalent fracture were significantly older, 62% were women. A significantly higher proportion of dementia patients with prevalent fractures were care home residents and taking a significantly higher number of medications. The mean Charlson comorbidity index was similar in patients with or without fracture. Dementia patients with a prevalent fracture required a new care home and this is significantly higher when compared to those with no fracture. Mortality at one year and three year was not statistically different in patients with or without prevalent fractures. A significantly higher number (21.5%) of dementia patients with prevalent fragility fracture sustained a new hip fracture when compared to those with no prevalent osteoporotic fracture (2.9%) over the three years follow up (p < 0.0001). Conclusion: dementia patients with a prevalent fragility fracture is associated with a statistically significant higher risk of a new care home placement following acute hospital admission. This sub-group is also at risk of a new hip fracture in the next three years. Whilst clinical judgement remains crucial in the care of frail older people, it is prudent to consider medical management of osteoporosis in dementia if deemed to be beneficial following the comprehensive geriatric assessment.

Clinical management of hip fractures in elderly patients with dementia and postoperative 30-day mortality: A population-based cohort study

OBJECTIVES

Patients with dementia have an increased 30-day mortality after hip fracture. We investigated clinical management including time to surgery, out-of-hours admission and surgery, surgery on weekends, surgery volume per ward, and anesthesia technique for this excess mortality risk.

METHOD

This register- and population-based study comprised 12,309 older adults (age 70+) admitted to hospital for a first-time hip fracture in 2013-2014, of whom 11,318 underwent hip fracture surgery. Cox proportional hazards regression models were applied for the analysis.

RESULTS

The overall postoperative 30-day mortality was 11.4%. Patients with dementia had a 1.5 times increased mortality risk than those without (HR = 1.50 [95% CI 1.31-1.72]). We observed no time-to-surgery difference by patient dementia status; additionally, the excess mortality risk in patients with dementia could not be explained by the clinical management factors we examined.

CONCLUSIONS

Increased mortality in patients with dementia could not be explained by the measured preoperative clinical management. Suboptimal handling of postoperative complication and rehabilitation are to be investigated for their role in the witnessed increased mortality for patients with dementia.