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01-02-2017 | Original Article

Early post-surgical cognitive dysfunction is a risk factor for mortality among hip fracture hospitalized older persons

Authors: C. Ruggiero, L. Bonamassa, L. Pelini, I. Prioletta, L. Cianferotti, A. Metozzi, E. Benvenuti, G. Brandi, A. Guazzini, G. C. Santoro, P. Mecocci, D. Black, M. L. Brandi

Published in: Osteoporosis International | Issue 2/2017

Abstract

Summary

This study investigates the relationship between cognitive dysfunction or delirium detected in the early post-surgical phase and the 1-year mortality among 514 hip fracture hospitalized older persons. Patients with early cognitive dysfunction or delirium experienced a 2-fold increased mortality risk. Early post-operative cognitive dysfunction and delirium are negative prognostic factors for mortality.

Background and purpose

Premorbid cognitive impairment and dementia in older individuals negatively affect functional recovery after hip fracture. Additionally, post-operative delirium is an established risk factor for negative outcomes among hip fracture patients. While the majority of hip fracture patients experience minor post-surgical cognitive dysfunction, the prognostic value of this phenomenon is unknown. Therefore, we investigated the relationship between minor cognitive dysfunction or delirium detected in the early post-surgical phase and the 1-year mortality after index hip fracture.

Subjects and methods

We enrolled 514 patients with hip fracture (77.4 % women), aged 65 years or older (mean age 83.1 ± 7.3 years), who underwent surgical hip fracture repair. Patients were assessed daily from the second to the fourth post-operative day and at 3, 6, and 12 months thereafter. All participants underwent comprehensive assessment, including detection of delirium by using the confusion assessment method and evaluation of cognitive function by using mini-mental state examination (MMSE; score range 0 to 30, with lower scores indicating poorer performance). In the absence of delirium, post-surgical cognitive dysfunction was defined as having low performance on MMSE. Vital status of 1 year after the index fracture and date of death were gathered from local registries.

Results

The observed 1-year mortality rate was 14.8 %. Men were more likely to die than women within 1 year of the index fracture (p < 0.01). Compared to participants with better cognitive performance, those with MMSE < 24, as well as those with delirium in the post-operative phase, showed a significantly higher 1-year mortality rate (23.3 versus 17.9 and 8.1 %, respectively). Independent of age and sex, post-operative cognitive dysfunction as well as delirium was both associated with a 2-fold increased mortality risk.

Conclusions

The presence of minor cognitive dysfunction in the early post-surgical phase is a negative prognostic factor for mortality among elderly hip fracture patients. The burden of minor cognitive dysfunction is likely superimposed on that of delirium in subgroups of frail patients.

Cummings SR, Melton LJ (2002) Epidemiology and outcomes of osteoporotic fractures. Lancet 359:1761–1767CrossRefPubMed

Hopkins RB, Pullenayegum E, Goeree R et al (2012) Estimation of the lifetime risk of hip fracture for women and men in Canada. Osteoporos Int 23:921–927. doi:10.1007/s00198-011-1652-8 CrossRefPubMed

Piscitelli P, Feola M, Rao C, Celi M et al (2014) Ten years of hip fractures in Italy: for the first time a decreasing trend in elderly women. World J Orthop 5:386. doi:10.5312/wjo.v5.i3.386 CrossRefPubMedPubMedCentral

Savino E, Martini E, Lauretani F et al (2013) Handgrip strength predicts persistent walking recovery after hip fracture surgery. Am J Med 126:1068–1075. doi:10.1016/j.amjmed.2013.04.017 CrossRefPubMed

Magaziner J, Hawkes W, Hebel JR et al (2000) Recovery from hip fracture in eight areas of function. J Gerontol A Biol Sci Med Sci 55:498–507CrossRef

Kelaiditi E, Cesari M, Canevelli M et al (2013) Cognitive frailty: rational and definition from an (I.A.N.A./I.A.G.G.) international consensus group. J Nutr Health Aging 17:726–734. doi:10.1007/s12603-013-0367-2 CrossRefPubMed

Newman S, Stygall J, Shashivadan H et al (2007) Postoperative cognitive dysfunction after non-cardiac surgery. Anesthesiology 106:572–590CrossRefPubMed

Inouye SK, Westendorp RGJ, Saczynski JS (2014) Delirium in elderly people. Lancet 383:911–922. doi:10.1016/S0140-6736(13)60688-1 CrossRefPubMed

Bellelli G, Mazzola P, Morandi A et al (2014) Duration of postoperative delirium is an independent predictor of 6-month mortality in older adults after hip fracture. J Am Geriatr Soc 62:1335–1340. doi:10.1111/jgs.12885 CrossRefPubMed

10.

Saczynski JS, Marcantonio ER, Quach L et al (2012) Cognitive trajectories after postoperative delirium. N Engl J Med 367:30–39. doi:10.1056/NEJMoa1112923 CrossRefPubMedPubMedCentral

11.

Deiner S, Silverstein JH (2009) Postoperative delirium and cognitive dysfunction. Br J Anaesth 103(Suppl):i41–i46. doi:10.1093/bja/aep291 CrossRefPubMedPubMedCentral

12.

Berger M, Nadler JW, Browndyke J et al (2015) Postoperative cognitive dysfunction minding the gaps in our knowledge of a common postoperative complication in the elderly. Anesthesiol Clin 33:517–550. doi:10.1016/j.anclin.2015.05.008 CrossRefPubMedPubMedCentral

13.

Funder KS, Steinmetz J, Rasmussen LS (2010) Methodological issues of postoperative cognitive dysfunction research. Semin Cardiothorac Vasc Anesth 14:119–122. doi:10.1177/1089253210371520 CrossRefPubMed

14.

Piscitelli P, Metozzi A, Benvenuti E et al (2012) Connections between the outcomes of osteoporotic hip fractures and depression, delirium or dementia in elderly patients: rationale and preliminary data from the CODE study. Clin Cases Miner Bone Metab 9:40–44PubMedPubMedCentral

15.

Folstein MF, Folstein SE, McHugh PR (1975) Mini-mental state” a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198. doi:10.1016/0022-3956(75)90026-6 CrossRefPubMed

16.

Sheehan DV, Lecrubier Y (1998) The Mini-Interational Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 59:34–57

17.

Yesavage JA, Brink TL, Rose TL, et al (1982) Development and validation of a geriatric depression screening scale: a preliminary report. doi:10.1016/0022-3956(82)90033-4

18.

Leslie AW, Fearing AM, Sternberg EJ, Inouye SK (2008) The confusion assessment method (CAM): a systematic review of current usage. Int J 56:823–830. doi:10.1111/j.1532-5415.2008.01674.x.

19.

Berry JM, West RL (1993) Cognitive self-efficiacy in relation to personal mastery and goal setting across the life span. Int J Behav Dev 16:351–379CrossRef

20.

Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel index. M D Med State J 14:61–65

21.

Kristensen MT, Andersen L, Bech-Jensen R et al (2009) High intertester reliability of the cumulated ambulation score for the evaluation of basic mobility in patients with hip fracture. Clin Rehabil 23:1116–1123. doi:10.1177/0269215509342330 CrossRefPubMed

22.

Charlson ME, Pompei P, Ales KL, MacKenzie R (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validatiom. J Chronic Dis 40:373–383CrossRefPubMed

23.

Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal APHR (1990) Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Inter Med 113(12):941–948CrossRef

24.

Söderqvist A, Ekström W, Ponzer S et al (2009) Prediction of mortality in elderly patients with hip fractures: a two-year prospective study of 1,944 patients. Gerontology 55:496–504. doi:10.1159/000230587 CrossRefPubMed

25.

Bentler SE, Liu L, Obrizan M et al (2009) The aftermath of hip fracture: discharge placement, functional status change, and mortality. Am J Epidemiol 170:1290–1299. doi:10.1093/aje/kwp266 CrossRefPubMedPubMedCentral

26.

Hu F, Jiang C, Shen J et al (2012) Preoperative predictors for mortality following hip fracture surgery: a systematic review and meta-analysis. Injury 43:676–685. doi:10.1016/j.injury.2011.05.017 CrossRefPubMed

27.

Moller JT, Cluitmans P, Rasmussen LS et al (1998) Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet 351:857–861. doi:10.1016/S0140-6736(97)07382-0 CrossRefPubMed

28.

Tucker AM, Stern Y (2011) Cognitive reserve in aging. 1:354–360. doi:10.1016/j.str.2010.08.012.Structure

29.

Monk TG, Weldon BC, Garvan CW et al (2008) Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 108:18–30CrossRefPubMed

30.

Schaller F, Sidelnikov E, Theiler R et al (2012) Mild to moderate cognitive impairment is a major risk factor for mortality and nursing home admission in the first year after hip fracture. Bone 51:347–352. doi:10.1016/j.bone.2012.06.004 CrossRefPubMed

31.

Raspopovic D, Markovic DL, Marinkovic J, et al (2014) Early mortality after hip fracture: what matters? Psychogeriatrics 95–101. doi:10.1111/psyg.12076

32.

McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E (2002) Delirium predicts 12-month mortality. Arch Intern Med 162:457–463CrossRefPubMed

33.

Maniar HS, Lindman BR, Escallier K et al (2015) Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality. J Thorac Cardiovasc Surg 151:815–823.e2. doi:10.1016/j.jtcvs.2015.10.114 CrossRefPubMedPubMedCentral

34.

Leslie DL, Zhang Y, Holford TR et al (2005) Premature death associated with delirium at 1-year follow-up. Arch Intern Med 165:1657–1662. doi:10.1001/archinte.165.14.1657 CrossRefPubMed

35.

Bellelli G, Speciale S, Barisione E, Trabucchi M (2007) Delirium subtypes and 1-year mortality among elderly patients discharged from a post-acute rehabilitation facility. J Gerontol 62:1182–1183. doi:10.1080/13518040701205365 CrossRef

36.

Juliebø V, Krogseth M, Skovlund E et al (2010) Delirium is not associated with mortality in elderly hip fracture patients. Dement Geriatr Cogn Disord 30:112–120. doi:10.1159/000318819 CrossRefPubMed

37.

Pauley E, Lishmanov A, Schumann S et al (2015) Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unit. Am Heart J 170:79–86.e1. doi:10.1016/j.ahj.2015.04.013 CrossRefPubMed

38.

Witlox J, Eurelings LSM, De Jonghe JFM et al (2010) Delirium in elderly patients and the risk of post-discharge mortality. JAMA 304:443–451. doi:10.1001/jama.2010.1013 CrossRefPubMed

39.

Edlund A, Lundstrom M, Lundstrom G et al (1999) Clinical profile of delirium in patients treated for femoral neck fractures. Dement Geriatr Cogn Disord 10:325–329. doi:10.1159/000017163 CrossRefPubMed

40.

Nightingale S, Holmes J, Mason J (2001) Psychiatric illness and mortality after hip fracture. Lancet 357:1264–1265. doi:10.1016/S0140-6736(00)04422-6 CrossRefPubMed

41.

Edelstein DM, Aharonoff GB, Karp A et al (2004) Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res 422:195–200CrossRef

42.

Lundström M, Edlund A, Bucht G et al (2003) Dementia after delirium in patients with femoral neck fractures. J Am Geriatr Soc 51:1002–1006. doi:10.1046/j.1365-2389.2003.51315.x CrossRefPubMed

43.

Kat MG, de Jonghe JFM, Vreeswijk R et al (2011) Mortality associated with delirium after hip-surgery: a 2-year follow-up study. Age Ageing 40:312–318. doi:10.1093/ageing/afr014 CrossRefPubMed

44.

Steinmetz J, Christensen KB, Ph D, et al (2009) Long-term consequences of postoperative cognitive dysfunction. 548–555

45.

Guo Y, Sun T, Wang X, Li S, Liu Z (2014) Cognitive impairment and 1-year outcome in elderly patients with hip fracture. Med Sci Monit 20:1963–1968. doi:10.12659/MSM.892304 CrossRefPubMedPubMedCentral

Title: Early post-surgical cognitive dysfunction is a risk factor for mortality among hip fracture hospitalized older persons
Authors: C. Ruggiero
L. Bonamassa
L. Pelini
I. Prioletta
L. Cianferotti
A. Metozzi
E. Benvenuti
G. Brandi
A. Guazzini
G. C. Santoro
P. Mecocci
D. Black
M. L. Brandi
Publication date: 01-02-2017
Publisher: Springer London
Published in: Osteoporosis International / Issue 2/2017
Print ISSN: 0937-941X
Electronic ISSN: 1433-2965
DOI: https://doi.org/10.1007/s00198-016-3784-3

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Early post-surgical cognitive dysfunction is a risk factor for mortality among hip fracture hospitalized older persons

Abstract

Summary

Background and purpose

Subjects and methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Summary

Background and purpose

Subjects and methods

Results

Conclusions

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