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Cognitive Impairment and 1-Year Outcome in Elderly Patients with Hip Fracture.....hip fracture death rates are 11% to 34%
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From Jules: another aging concern never discussed across all our stakeholders in HIV: patients, doctors, researchers, advocates. If hip fracture in HIV-neg is such a bad outcome imagine its affect in HIV+ !!!!
1 - Hip fracture is associated with much lower rates of functional recovery in the elderly population.
2 - Fracture of the hip in elderly persons is a significant healthcare concern, with mortality in the first year after hip fracture at about 18-33%
3 - 244 elderly hip fracture patients were prospectively followed up for 12 months.
4 - patients aged 61-99 [46% > 75], diagnosed with acute hip fracture and who then underwent hip repair surgery.
6 - hip fracture, as like other major trauma, triggers an unbalanced local and systemic inflammatory response to trauma, featuring especially the elevation of a group of pro-inflammatory cytokines [11]
7 - Compared to those without cognitive impairment, the 30-day, 6-month, and 1-year mortalities in the impaired patients were significantly higher than that of the cognitively intact patients. Six months after hip repair surgery, the cognitively intact patients presented significantly higher activities of daily living (ADL) scores than the cognitively impaired patients, and only 38.5% of impaired patients returned to their pre-operation baseline levels afterwards.
8 - In patients with cognitive impairment, the mortality was 11.2% (5/43) at 30 days, 25.6% (11/43) at 6 months, and 34.9% (15/43) at 1 year. In contrast, the mortality in cognitively intact patients was 7.9% (16/201), 15.4% (31/201) and 21.8% (44/201). Cognitively impaired patients were approximately 1.5-1.9 times more likely to die within 1 year than the cognitively intact patients. In patients with cognitive impairment, the mortality was 11.2% (5/43) at 30 days, 25.6% (11/43) at 6 months, and 34.9% (15/43) at 1 year. In contrast, the mortality in cognitively intact patients was 7.9% (16/201), 15.4% (31/201) and 21.8% (44/201). Cognitively impaired patients were approximately 1.5-1.9 times more likely to die within 1 year than the cognitively intact patients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4211422/
"......hip fracture, as like other major trauma, triggers an unbalanced local and systemic inflammatory response to trauma, featuring especially the elevation of a group of pro-inflammatory cytokines [11]. The hypothesis of proinflammatory response cascade was supported by our previous human study [11] and animal studies [12] in which anti-inflammatory cytokine antibodies reverse the development of organ dysfunction and decreases mortality.".....
Compared to those without cognitive impairment, the 30-day, 6-month, and 1-year mortalities in the impaired patients were significantly higher than that of the cognitively intact patients. Six months after hip repair surgery, the cognitively intact patients presented significantly higher activities of daily living (ADL) scores than the cognitively impaired patients, and only 38.5% of impaired patients returned to their pre-operation baseline levels afterwards. The ADL scores in the impaired patients were similar to the intact ones at 1 year after the operation.
Inclusion criteria were: patients aged 61-99 [46% > 75], diagnosed with acute hip fracture and who then underwent hip repair surgery; patients must be ambulatory at home before admission; and patients had no end-stage disease or cancer within the past 6 months. Among the cognitively impaired patients, there were more patients aged 75 or older than among the cognitively intact patients. Consented and eligible patients were categorized into 2 groups based on cognitive status - with and without cognitive impairment. Functional evaluation, both at before-injury and up to 1 year after the hip repair surgery, was assessed by board-certificated psychiatrists using the Barthel index (original version). The Barthel index, which ranges from 0 (total dependence) to 100 (total independence), is a functional index for the assessment of performance in activities of daily living (ADL) with a certain degree of independence
MORTALITY: The effect of cognitive impairment on survival is shown in Figure 1. In patients with cognitive impairment, the mortality was 11.2% (5/43) at 30 days, 25.6% (11/43) at 6 months, and 34.9% (15/43) at 1 year. In contrast, the mortality in cognitively intact patients was 7.9% (16/201), 15.4% (31/201) and 21.8% (44/201). Cognitively impaired patients were approximately 1.5-1.9 times more likely to die within 1 year than the cognitively intact patients. The most common cause of mortality following hip fracture was pulmonary infection in cognitively impaired patients and cardiovascular disease (myocardial infarction) in cognitively intact patients.
FUNCTIONAL OUTCOME: Twenty-six patients with cognitive impairment survived up to 1 year after operation. Table 4showed the ADL scores for all patients throughout the study period. No significant differences in functional outcomes were identified between the 2 groups before fracture. However, at 6-month follow up, the cognitively intact patients presented significantly higher (P=0.000) ADL scores than the cognitively impaired patients did. ADL scores in 38.5% (10/26) of the cognitively impaired patients returned to the pre-injury status, and among cognitively impaired patients, 47.1% (98/208) of cognitively intact patients returned to their previous ADL status. In all survivors, the ADL scores became similar between the 2 groups at 1-year follow-up (69.15±15.97 vs. 70.45±19.36, P=0.89).
Fracture of the hip in elderly persons is a significant healthcare concern, with mortality in the first year after hip fracture at about 18-33% [1,2]. The survivors often suffer from impaired quality of life. Previous studies have suggested that cognitive impairment, which has been found in 31-88% of elderly patients experiencing hip fracture, was a predictor of poor functional recovery after hip fracture surgery
Many studies have investigated the effect of the history of cognitive impairment on hip fracture prognosis in elderly patients [5,7-9]. Most results were from retrospective clinical studies, so the prevalence of mortality varied due to selection and information biases.
The data from our prospective study showed a high prevalence of mortality in cognitively impaired patients: 11.2%, at 30-day, 25.6% at 6-month, and 34.9% at 1-year follow- up, compared to 7.9% at 30-day, 15.4% at 6-month, and 21.8% at 1-year follow-up in cognitively intact patients. By using the COX Cox proportional hazard model, cognitively impaired patients had a 50-60% higher risk of death than cognitively intact patients (adjusted HR 1.54-1.65). The underlying mechanism of the close association between cognitive impairment and 1-year mortality was unknown. One of the interpretations is that patients with cognitive impairment may have more clinical multiple co-morbidities than those without [10]. Another possible interpretation is that hip fracture, as like other major trauma, triggers an unbalanced local and systemic inflammatory response to trauma, featuring especially the elevation of a group of pro-inflammatory cytokines [11]. The hypothesis of proinflammatory response cascade was supported by our previous human study [11] and animal studies [12] in which anti-inflammatory cytokine antibodies reverse the development of organ dysfunction and decreases mortality. As Because the lungs are is the first and primary target organ infiltrated by pro-inflammatory cytokines in the post-injury period, cytokines infiltration in cognitively impaired patients may lead to clinical pulmonary dysfunction and then initiate a multiple organ failures. Chronic trauma would also worsen the systemic inflammatory response and raises increases mortality by amplification of cytokine production [13]. Additionally, cognitively impaired patients usually had long been bedridden and thus more likely to develop pulmonary complications (e.g., infection). In fact, our data showed that the most common cause of death in the cognitively impaired patients was pulmonary infection compared to that of cognitively intact patients (46.6% vs. 20.5% P<0.05). Interesting, ischemic cardiovascular disease was the most common cause of death in cognitively intact patients in our study, which was consistent with the finding by Monvcada et al. [7].
Hip fracture is associated with much lower rates of functional recovery in the elderly population. Even Although surgical repair may increase the possibility of independent living, to live independently, physicians and caretakers often defer the surgery in the cognitively impaired patients because they were concerned that those patients will not benefit from postoperative functional recovery; therefore,. So surgery in cognitively impaired patients may be deferred secondary to concerns that the patient will not receive functional benefit. It was shown in our data that the cognitively impaired patients did h months after surgical repair, but they re-gained daily living function at 1 year post-surgery. Although they might require longer rehabilitation, they seemed to benefit from hip fracture surgery as much as the cognitive intact patients did. Moreover, our results are supported by Goldstein et al. [14] who reported no difference of functional gain in self-care, sphincter control, and locomotion (with the exception of mobility and transfers) between the cognitively impaired and intact patients. Heruti et al. [15] and Rolland et al. [16] also demonstrated that the cognitive status was not associated with the absolute motor function gain. Thus, although this study is limited by the small sample size, these results suggest that some cognitively impaired patients may have functional recovery similar to that of patients without cognitive impairment.
Conclusions
The results of this study suggest that cognitive impairment status should not be used to determine whether the cognitively impaired patients would benefit from hip repair surgery. Therefore, we conclude that although cognitively impaired patients had a higher risk of mortality, functional gain was similar to that in cognitively impaired patients at 1-year follow-up.
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