bs_bs_banner
Geriatr Gerontol Int 2015; 15: 289–295
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture Francisco José Tarazona-Santabalbina,1 Ángel Belenguer-Varea,1 Eduardo Rovira Daudi,2 Enmanuel Salcedo Mahiques,3 David Cuesta Peredó,4 Juan Ramón Doménech-Pascual,1 Homero Gac Espínola5 and Juan Antonio Avellana Zaragoza1 1
Department of Geriatrics, 2Department of Internal Medicine, 3Department of Traumatology, 4Department of Quality Management, Hospital Universitario de la Ribera, Alzira, Spain; and 5Department of Geriatrics, Pontifical Catholic University of Chile, Santiago de Chile, Chile
Aim: To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture. Methods: An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12-month follow-up period, functional recovery and mortality outcomes were measured. Results: Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140–0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197–0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020–2.635, P = 0.04). Conclusions: We observed higher 12-month mortality and less functional recovery with increasing severity of dementia. Geriatr Gerontol Int 2015; 15: 289–295. Keywords: cognitive impairment, comprehensive geriatric assessment, functional recovery, hip fractures, mortality.
Introduction Hip fractures are a healthcare issue associated with high morbidity and mortality.1 The incidence is rising as the population ages,2 and is expected to double by 2040 according to several projections.3 From a clinical perspective, hip fractures entail costly procedures, and are
Accepted for publication 21 January 2014. Correspondence: Dr Francisco José Tarazona Santabalbina MD PhD, Servicio de Geriatría, Hospital de la Ribera, Carretera de Corbera n°1, 46600 Alzira, Valencia, Spain. Email: [email protected]
© 2014 Japan Geriatrics Society
associated with considerable loss of mobility and function,4 higher morbidity,1 lower quality of life, and higher mortality.5,6 The prevalence of dementia increases with age, rising from 2.4% at 65 years to 34.5% at 85 years.7 Increased life expectancy is raising the overall number of patients with dementia.8 Dementia plays a role in the genesis of hip fractures,9 as it increases the risk of falling by a factor of 5, and risk of significant injury after a fall by a factor of 2.2.10 Dementia has varying degrees of severity, with greater severity linked to poorer prognosis; specifically, higher mortality11,12 and poorer functional recovery.13,14 Dementia is also an independent risk factor for poorer functional doi: 10.1111/ggi.12271
| 289
FJ Tarazona-Santabalbina et al.
outcomes,15 non-ambulation,16 bedriddenness, institutionalization,17 and shorter post-fracture survival.11,13–18 Previous studies have used as a severity dementia tool the Mini-Mental State Examination (MMSE). This point has been described in a review paper.19 The MMSE is a very good screening test, but it is not so good to establish different degrees of functional and cognitive severity. We have used the Reisberg Global Deterioration Scale (GDS) to improve the correct stratification of patients diagnosed with dementia. Orthogeriatric units with an early approach have described a better management of comorbidity, a higher functional recovery and a lower mortality.20 The aim of the present study was to identify how the severity of dementia affects survival and recovery of walking ability through the first year after hospital admission for fracture of the hip when early interdisciplinary care is provided at an orthogeriatric unit.
Methods Study design This was an observational retrospective study.
Setting Hospital Universitario de la Ribera serves the county of La Ribera (Comunidad Valenciana, Spain), which has a total population of 256 090, with 13.5% of inhabitants aged over 69 years.
Patients The study included all patients aged over 69 years admitted with a diagnosis of hip fracture from 1 January 2004 through 31 December 2008. Exclusion criteria were pathological fractures and terminal disease with a life expectancy of less than 6 months. Patients were classified as having or lacking dementia according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. Patients who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for dementia were further classified into three groups according to severity, using the GDS:21 stage 3 (equivalent to MMSE]scores ranging 21–2522) was defined as mild dementia; GDS stages 4 and 5 (equivalent to MMSE scores ranging 11–20) were defined as moderate dementia; and GDS stages 6 and 7 (equivalent to MMSE scores of 10 or less) were defined as severe dementia.
Data collection and variables analyzed We obtained prior permission from our hospital’s research ethics committee and prior informed consent 290 |
from the patients involved. We analyzed hospital records and discharge reports for patients diagnosed with hip fracture within the study period. Follow-up information was obtained from the outpatient clinic, emergency department and postdischarge hospitalization records. Data were retrieved from the SIAS (Ribera Salud II UTE, Alzira, Comunidad Valenciana, Spain) electronic medical records information system. Patients for whom no follow-up data were available for the 12 months after discharge were contacted by telephone. Information about survival and walking status was thus reported by the patients themselves or by their relatives or caregivers. Data were collected by two research assistants who had no information about study design or objectives.
Admission variables Demographic data obtained included sex, age, marital status, living arrangement and place of residence (rural versus urban). Functional variables included the Barthel Index23 for activities of daily living, and prior walking ability classified as independent, cane-assisted, walkerassisted, dependent or none. Medical history data included prior fractures, heart failure (Framingham criteria24), diabetes mellitus, ischemic heart disease, stroke, prior renal failure, comorbidity (Charlson comorbidity score25), number of prior conditions and number of drugs taken by the patient before hip fracture. Perioperative medical complications collected included urinary tract infections, pneumonia, constipation, vascular disease, acute confusional syndrome (ACS) diagnosed with the Confusion Assessment Method (CAM),26 blood transfusion, intensive care stay, total number of complications during hospitalization, mortality, hospital stay and discharge destination (home, nursing home or hospital-based home healthcare). Surgical data collected included preoperative stay, type of hip fracture (subcapital, basocervical, intertrochanteric or subtrochanteric), surgical treatment and postoperative surgical complications (surgical wound infection, prosthetic dislocation and reoperation).
Postdischarge variables Patients’ ability to walk was assessed at 1 month and 6 months. Recovery of walking ability was defined as the ability to walk further than 5 m,27 with or without an assistive device. Mortality was recorded at 1 month, 6 months and 1 year from discharge. Information was obtained from electronic medical reports and phone calls for patients without reports during the follow-up period. Other data collected were new fractures, nonunion over the follow-up year, readmissions (defined as admissions for the same International Classification of Diseases code within 30 days of discharge) and © 2014 Japan Geriatrics Society
Cognitive impairment severity and hip fracture
rehospitalizations (defined as all hospital admissions within 365 days of discharge except for readmissions).
Data processing and statistical analysis The data obtained were entered in an Excel 2003 spreadsheet and analyzed using SPSS 15.0 for Windows (SPSS, Chicago, IL, USA). Categorical variables were expressed as percentages, and quantitative variables were characterized in terms of mean, standard deviation and 95% confidence interval (CI). Bivariate analysis was carried out using the Student–Fisher t-test to compare means, the Pearson χ2-test and the Mantel–Haenszel linear trend test to compare proportions, and the Pearson correlation model for quantitative variables. Statistical significance was set at a P-value of
Geriatr Gerontol Int 2015; 15: 289–295
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Severity of cognitive impairment as a prognostic factor for mortality and functional recovery of geriatric patients with hip fracture Francisco José Tarazona-Santabalbina,1 Ángel Belenguer-Varea,1 Eduardo Rovira Daudi,2 Enmanuel Salcedo Mahiques,3 David Cuesta Peredó,4 Juan Ramón Doménech-Pascual,1 Homero Gac Espínola5 and Juan Antonio Avellana Zaragoza1 1
Department of Geriatrics, 2Department of Internal Medicine, 3Department of Traumatology, 4Department of Quality Management, Hospital Universitario de la Ribera, Alzira, Spain; and 5Department of Geriatrics, Pontifical Catholic University of Chile, Santiago de Chile, Chile
Aim: To identify how the severity of dementia influences functional recovery and mortality in elderly patients hospitalized for hip fracture. Methods: An observational retrospective study of 1258 patients aged older than 69 years and diagnosed with hip fracture who received care within an orthogeriatrics unit from 2004 to 2008 was carried out. During a 12-month follow-up period, functional recovery and mortality outcomes were measured. Results: Dementia was present in 383 (28.1%) patients: it was mild in 183 (48%), moderate in 102 (26.5%) and severe in 98 (25.5%). Compared with patients with preserved cognitive status, patients with dementia had the following statistically significant differences (means [standard deviation] or percentage): older age (preserved, 82.29 years [6.5 years]; mild, 83.63 years [6.1 years]; moderate, 83.47 years [5.9 years]; severe, 84.46 years [6.1 years]; P < 0.001); lower Barthel Index (89.7 [21.6], 72.7 [24.6], 58.9 [28.6], 38.0 [28.1]; P < 0.001); delirium (11.7%, 25.6%, 37.6%, 44.7%; P < 0.001); less ambulation at 6 months postdischarge (83.9%, 72.8%, 56.9%, 41.7%; P < 0.001); and higher mortality at discharge (4%, 5.7%, 8.2%, 10.6%; P < 0.001) and 12 months after discharge (21.2%, 32.3%, 46.3%, 53.5%; P < 0.001). Patients with severe dementia had lower probability of functional recovery at discharge (OR 0.272, 95% CI 0.140–0.526, P < 0.001) and 6 months after discharge (OR 0.439, 95% CI 0.197–0.979, P = 0.04), as well as a greater probability of dying (HR 1.640, 95% CI 1.020–2.635, P = 0.04). Conclusions: We observed higher 12-month mortality and less functional recovery with increasing severity of dementia. Geriatr Gerontol Int 2015; 15: 289–295. Keywords: cognitive impairment, comprehensive geriatric assessment, functional recovery, hip fractures, mortality.
Introduction Hip fractures are a healthcare issue associated with high morbidity and mortality.1 The incidence is rising as the population ages,2 and is expected to double by 2040 according to several projections.3 From a clinical perspective, hip fractures entail costly procedures, and are
Accepted for publication 21 January 2014. Correspondence: Dr Francisco José Tarazona Santabalbina MD PhD, Servicio de Geriatría, Hospital de la Ribera, Carretera de Corbera n°1, 46600 Alzira, Valencia, Spain. Email: [email protected]
© 2014 Japan Geriatrics Society
associated with considerable loss of mobility and function,4 higher morbidity,1 lower quality of life, and higher mortality.5,6 The prevalence of dementia increases with age, rising from 2.4% at 65 years to 34.5% at 85 years.7 Increased life expectancy is raising the overall number of patients with dementia.8 Dementia plays a role in the genesis of hip fractures,9 as it increases the risk of falling by a factor of 5, and risk of significant injury after a fall by a factor of 2.2.10 Dementia has varying degrees of severity, with greater severity linked to poorer prognosis; specifically, higher mortality11,12 and poorer functional recovery.13,14 Dementia is also an independent risk factor for poorer functional doi: 10.1111/ggi.12271
| 289
FJ Tarazona-Santabalbina et al.
outcomes,15 non-ambulation,16 bedriddenness, institutionalization,17 and shorter post-fracture survival.11,13–18 Previous studies have used as a severity dementia tool the Mini-Mental State Examination (MMSE). This point has been described in a review paper.19 The MMSE is a very good screening test, but it is not so good to establish different degrees of functional and cognitive severity. We have used the Reisberg Global Deterioration Scale (GDS) to improve the correct stratification of patients diagnosed with dementia. Orthogeriatric units with an early approach have described a better management of comorbidity, a higher functional recovery and a lower mortality.20 The aim of the present study was to identify how the severity of dementia affects survival and recovery of walking ability through the first year after hospital admission for fracture of the hip when early interdisciplinary care is provided at an orthogeriatric unit.
Methods Study design This was an observational retrospective study.
Setting Hospital Universitario de la Ribera serves the county of La Ribera (Comunidad Valenciana, Spain), which has a total population of 256 090, with 13.5% of inhabitants aged over 69 years.
Patients The study included all patients aged over 69 years admitted with a diagnosis of hip fracture from 1 January 2004 through 31 December 2008. Exclusion criteria were pathological fractures and terminal disease with a life expectancy of less than 6 months. Patients were classified as having or lacking dementia according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria. Patients who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for dementia were further classified into three groups according to severity, using the GDS:21 stage 3 (equivalent to MMSE]scores ranging 21–2522) was defined as mild dementia; GDS stages 4 and 5 (equivalent to MMSE scores ranging 11–20) were defined as moderate dementia; and GDS stages 6 and 7 (equivalent to MMSE scores of 10 or less) were defined as severe dementia.
Data collection and variables analyzed We obtained prior permission from our hospital’s research ethics committee and prior informed consent 290 |
from the patients involved. We analyzed hospital records and discharge reports for patients diagnosed with hip fracture within the study period. Follow-up information was obtained from the outpatient clinic, emergency department and postdischarge hospitalization records. Data were retrieved from the SIAS (Ribera Salud II UTE, Alzira, Comunidad Valenciana, Spain) electronic medical records information system. Patients for whom no follow-up data were available for the 12 months after discharge were contacted by telephone. Information about survival and walking status was thus reported by the patients themselves or by their relatives or caregivers. Data were collected by two research assistants who had no information about study design or objectives.
Admission variables Demographic data obtained included sex, age, marital status, living arrangement and place of residence (rural versus urban). Functional variables included the Barthel Index23 for activities of daily living, and prior walking ability classified as independent, cane-assisted, walkerassisted, dependent or none. Medical history data included prior fractures, heart failure (Framingham criteria24), diabetes mellitus, ischemic heart disease, stroke, prior renal failure, comorbidity (Charlson comorbidity score25), number of prior conditions and number of drugs taken by the patient before hip fracture. Perioperative medical complications collected included urinary tract infections, pneumonia, constipation, vascular disease, acute confusional syndrome (ACS) diagnosed with the Confusion Assessment Method (CAM),26 blood transfusion, intensive care stay, total number of complications during hospitalization, mortality, hospital stay and discharge destination (home, nursing home or hospital-based home healthcare). Surgical data collected included preoperative stay, type of hip fracture (subcapital, basocervical, intertrochanteric or subtrochanteric), surgical treatment and postoperative surgical complications (surgical wound infection, prosthetic dislocation and reoperation).
Postdischarge variables Patients’ ability to walk was assessed at 1 month and 6 months. Recovery of walking ability was defined as the ability to walk further than 5 m,27 with or without an assistive device. Mortality was recorded at 1 month, 6 months and 1 year from discharge. Information was obtained from electronic medical reports and phone calls for patients without reports during the follow-up period. Other data collected were new fractures, nonunion over the follow-up year, readmissions (defined as admissions for the same International Classification of Diseases code within 30 days of discharge) and © 2014 Japan Geriatrics Society
Cognitive impairment severity and hip fracture
rehospitalizations (defined as all hospital admissions within 365 days of discharge except for readmissions).
Data processing and statistical analysis The data obtained were entered in an Excel 2003 spreadsheet and analyzed using SPSS 15.0 for Windows (SPSS, Chicago, IL, USA). Categorical variables were expressed as percentages, and quantitative variables were characterized in terms of mean, standard deviation and 95% confidence interval (CI). Bivariate analysis was carried out using the Student–Fisher t-test to compare means, the Pearson χ2-test and the Mantel–Haenszel linear trend test to compare proportions, and the Pearson correlation model for quantitative variables. Statistical significance was set at a P-value of
