A screening test is not enough to define the prognostic role of cognitive impairment after hip fracture: a short-term prospective study

Cognitive assessment to optimize prediction of functional outcome in subacute hip fracture: a short-term prospective study

BACKGROUND

Cognitive impairment is a long-known negative prognostic factor after hip fracture. Cognition is usually screened by a single easy-to-administer bedside tool, but recent studies have shown that screening tests may be not enough to rule out cognitive impairment with an unfavorable prognostic role. Unfortunately, data on outcome prediction by further cognitive assessments is sparse.

AIM

We focused on patients with subacute hip fracture defined cognitively intact or mildly impaired on the screening evaluation performed by the Short Portable Mental Status Questionnaire (SPMSQ). We hypothesized that each of 3 further cognitive tests could independently predict activities of daily living, with optimal prediction of function obtained by performing all three the tests.

DESIGN

Short-term prospective study.

SETTING

Rehabilitation ward.

POPULATION

Inpatients with subacute hip-fracture.

METHODS

Three cognitive tests were performed on admission to rehabilitation in the patients who made ≤4 errors on the SPMSQ: Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT, immediate and delayed recall) and Frontal Assessment Battery (FAB). We assessed activities of daily living by the Barthel index. Successful rehabilitation was defined with a Barthel Index Score ≥85.

RESULTS

Each of the three cognitive tests assessed before rehabilitation significantly predicted the Barthel index scores measured at the end of the rehabilitation course in our sample of 280 inpatients. However, only the MoCA score retained its significant predictive role when the scores from the three tests were included together as independent variables in a multiple regression model, with adjustments for a panel of potential confounders (P=0.007). The adjusted odds ratio to achieve successful rehabilitation for a seven-point change in MoCA score was 1.98 (CI 95% from 1.02 to 3.83; P=0.042).

CONCLUSIONS

Contrary to our hypothesis, MoCA but not RAVLT and FAB retained the prognostic role when the scores from the three tests were evaluated together as potential predictors of functional ability in activities of daily living.

CLINICAL REHABILITATION IMPACT

In the presence of a normal (or mildly altered) score on the SPMSQ in subacute hip fracture, MoCA scores improve prediction of activities of daily living and should be routinely performed.

Femoral bone mineral density at the time of hip fracture is higher in women with versus without type 2 diabetes mellitus: a cross-sectional study

PURPOSE

To compare femoral bone mineral density (BMD) levels in hip-fracture women with versus without type 2 diabetes mellitus (T2DM). We hypothesized that BMD levels could be higher in the women with T2DM than in controls and we aimed to quantify the BMD discrepancy associated with the presence of T2DM.

METHODS

At a median of 20 days after the occurrence of an original hip fracture due to fragility we measured BMD by dual-energy x-ray absorptiometry at the non-fractured femur.

RESULTS

We studied 751 women with subacute hip fracture. Femoral BMD was significantly higher in the 111 women with T2DM than in the 640 without diabetes: mean T-score between-group difference was 0.50, (95% CI from 0.30 to 0.69, P < 0.001). The association between the presence of T2DM and femoral BMD persisted after adjustment for age, body mass index, hip-fracture type, neurologic diseases, parathyroid hormone, 25-hydroxyvitamin D and estimated glomerular filtration rate (P < 0.001). For a woman without versus with T2DM, the adjusted odds ratio to have a femoral BMD T-score below the threshold of - 2.5 was 2.13 (95% CI from 1.33 to 3.42, P = 0.002).

CONCLUSIONS

Fragility fractures of the hip occurred in women with T2DM at a femoral BMD level higher than in control women. In the clinical assessment of fracture risk, we support the adjustment based on the 0.5 BMD T-score difference between women with and without T2DM, although further data from robust longitudinal studies is needed to validate the BMD-based adjustment of fracture risk estimation.