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

Patients With Moderate to Severe Dementia Who Undergo Elective TKA Face Elevated Risks of Death, Delirium, and Intensive Interventions: A Large, Propensity-weighted Database Study

BACKGROUND

Although TKA is one of the most commonly performed and successful orthopaedic interventions, its efficacy may be reduced in individuals living with dementia. Prior studies have not effectively accounted for confounding by indication or the use of intensive interventions, or considered the fact that cognitive impairment exists on a continuum and that patients with mild dementia may have different risk profiles when compared with those with moderate to severe dementia.

QUESTIONS/PURPOSES

(1) Are there differences in the risk of death after TKA in patients based on the severity of dementia? (2) Are there differences in intensive interventions and delirium after TKA in patients based on the severity of dementia?

METHODS

We used Medicare data to allow for complete surveillance of all medical encounters and events that transpired before and after TKA surgery. We retrospectively identified Medicare beneficiaries living with dementia who underwent primary elective TKA between January 1, 2017, and June 30, 2018. We used the Claims-based Frailty Index (CFI) to stratify dementia severity. Patients with CFI scores of 0.25 to 0.28 and an ICD-10 code for dementia were recorded as living with mild dementia. Patients with an ICD-10 code for dementia and CFI scores of ≥ 0.28 were classified as having moderate to severe dementia. Our cohort included 156,596 patients, with 98% (152,728 of 156,596) classified as not having dementia, 1% (2123 of 156,596) having mild dementia, and 1% (1745 of 156,596) having moderate to severe dementia. We had complete surveillance of outcomes and events after surgery for this cohort of patients. The primary outcome was death within 180 days of surgery. Intensive interventions (such as feeding tube insertion, intubation, resuscitation) and delirium were considered secondarily. We used inverse probability weights to account for confounding and compared outcomes between cohorts using Cox proportional hazards models, generalized estimation equations, and Fine and Gray models.

RESULTS

After adjusting for potentially confounding variables such as age, gender, and comorbidities, we found that individuals with mild dementia (HR 1.74 [95% confidence interval (CI) 1.12 to 2.70]; p = 0.01) and moderate to severe dementia (HR 3.05 [95% CI 1.80 to 5.17]; p < 0.001) both demonstrated elevated hazards of death compared with patients without dementia. Patients with mild dementia (HR 4.25 [95% CI 2.59 to 5.03]; p < 0.001) and moderate to severe dementia (HR 6.40 [95% CI 5.18 to 7.92]; p < 0.001) exhibited elevated hazards of delirium, and those with moderate to severe dementia were found to have greater hazards of one or more intensive interventions (HR 3.24 [95% CI 1.76 to 5.96]; p < 0.001).

CONCLUSION

We observed elevations in the risk of death and delirium in patients after TKA, irrespective of the severity of dementia and marked elevations in the likelihood of intensive interventions after surgery for those with moderate to severe dementia. We believe that TKA in patients with mild dementia should only proceed after clear communication about the increased risk of death, as well as effective management of chronic medical conditions and prophylactic enhancement of cognitive reserves. Performing TKA in patients with moderate to severe dementia might only be indicated in exceptional humanitarian circumstances.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Impact of Dementia on Outcomes Following Hemiarthroplasty for Femoral Neck Fracture: A National Database Study

BACKGROUND

Dementia poses an elevated risk of femoral neck fracture (FNF) in the elderly, often leading to the need for hemiarthroplasty. Yet, the outcomes of hemiarthroplasty in patients who have dementia remain uncertain. The purpose of this study was to assess whether dementia serves as a potential risk factor for outcomes following hemiarthroplasty.

METHODS

Dementia patients who underwent hemiarthroplasty for FNF with at least 1 year of follow-up were identified using a national insurance database. A 1:1 matched control cohort of patients who do not have dementia was created for comparison. Logistic regression analyses were used to evaluate the rates of complications between the two cohorts. A total of 89,072 patients, of whom half have dementia and half do not, undergoing hemiarthroplasty for FNF were identified.

RESULTS

Aside from increased risks of medical complications (P < 0.01), including pneumonia, cerebrovascular accident, acute kidney injury, urinary tract infection, and sepsis, within 90 days, dementia patients also demonstrated higher rates of surgical complications within 1 year, such as dislocation (odds ratio (OR) 1.87, 95% confidence interval (CI) 1.71 to 2.04), periprosthetic fractures (OR 1.29, 95% CI 1.16 to 1.45), and revision (OR 1.23, 95% CI 1.10 to 1.36). On the other hand, dementia patients displayed slightly reduced rates of 90-day deep vein thrombosis and pulmonary embolism. However, no significant increase was found in transfusion, myocardial infarction, wound complications, periprosthetic joint infection, or aseptic loosening between the two cohorts. Additionally, patients who have dementia demonstrated a higher likelihood of 90-day emergency department visits, whereas rates of 90-day hospital readmission remained similar.

CONCLUSIONS

Although dementia patients do not exhibit an elevated risk of periprosthetic joint infection, or aseptic loosening, they are more prone to experiencing higher risks of prosthetic dislocation, periprosthetic fracture, and revision. Furthermore, specific medical complications tend to be more prevalent among individuals who have dementia.

Group-based trajectories of potentially preventable hospitalisations among older adults after a hip fracture

Key predictors of three trajectory group membership of potentially preventable hospitalisations were age, the number of comorbidities, the presence of chronic obstructive pulmonary disease and congestive heart failure, and frailty risk at the occurrence of hip fracture. These predictors of their trajectory group could be used in targeting prevention strategies.

PURPOSE

Although older adults with hip fracture have a higher risk of multiple readmissions after index hospitalisation, little is known about potentially preventable hospitalisations (PPH) after discharge. This study examined group-based trajectories of PPH during a five-year period after a hip fracture among older adults and identified factors predictive of their trajectory group membership.

METHODS

This retrospective cohort study was conducted using linked hospitalisation and mortality data in New South Wales, Australia, between 2013 and 2021. Patients aged ≥ 65 years who were admitted after a hip fracture and discharged between 2014 and 2016 were identified. Group-based trajectory models were derived based on the number of subsequent PPH following the index hospitalisation. Multinominal logistic regression examined factors predictive of trajectory group membership.

RESULTS

Three PPH trajectory groups were revealed among 17,591 patients: no PPH (89.5%), low PPH (10.0%), and high PPH (0.4%). Key predictors of PPH trajectory group membership were age, number of comorbidities, dementia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), frailty risk, place of incident, surgery, rehabilitation, and length of hospital stay. The high PPH had a higher proportion of patients with ≥ 2 comorbidities (OR: 1.86, 95% confidence interval (CI): 1.04-3.32) and COPD (OR: 2.97, 95%CIs: 1.76-5.04) than the low PPH, and the low and high PPHs were more likely to have CHF and high frailty risk as well as ≥ 2 comorbidities and COPD than the no PPH.

CONCLUSIONS

Identifying trajectories of PPH after a hip fracture and factors predictive of trajectory group membership could be used to target strategies to reduce multiple readmissions.

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.

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.