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The Influence of Cognitive Function on Outcome After a Hip Fracture
Anita Söderqvist, RN1; Ricard Miedel, MD1; Sari Ponzer, MD, PhD1; Jan Tidermark, MD, PhD1
1 Department of Orthopaedics, Stockholm Söder Hospital, S-118 83 Stockholm, Sweden. E-mail address for J. Tidermark: jan.tidermark@sodersjukhuset.se
View Disclosures and Other Information
In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Trygg-Hansa Insurance Company, the Swedish Orthopaedic Association, and the Department of Orthopaedics at Stockholm Söder Hospital. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Stryker Howmedica, Sweden [SGN] and Swemac, Sweden [MSP]). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Karolinska Institutet, Stockholm Söder Hospital, Stockholm, Sweden

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 Oct 01;88(10):2115-2123. doi: 10.2106/JBJS.E.01409
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Abstract

Background: Previous studies have indicated that patients with a hip fracture who have impaired cognitive function have an increased risk for complications, poor long-term outcome, and an increased mortality rate. An assessment of cognitive function is often lacking in nursing and medical records. We investigated whether an assessment of cognitive function obtained with use of a validated instrument would be a useful patient management adjunct.

Methods: We studied 213 patients with a hip fracture who had a mean age of eighty-four years and were entered in a prospective trial with a follow-up evaluation at four and twelve months. On admission to the orthopaedic ward, the patients were evaluated with use of the Short Portable Mental Status Questionnaire to assess their cognitive function. The outcome for patients with severe cognitive dysfunction, i.e., those with a score of <3 on the questionnaire, was compared with the outcome for patients with higher scores. The main outcome measurements were the Charnley hip score, activities of daily living status, health-related quality of life, and mortality.

Results: A Short Portable Mental Status Questionnaire score of <3 and male gender were associated with an increased mortality rate during the first twelve months. Moreover, patients with a score of <3 had a significantly worse outcome with regard to the ability to walk and to perform the activities of daily living, with 36% of these patients confined to a wheelchair and almost 39% totally dependent with regard to daily living functions at the time of the final follow-up (p < 0.001).

Conclusions: The systematic use of the Short Portable Mental Status Questionnaire upon admission to the orthopaedic ward identifies patients with a hip fracture who have severe cognitive dysfunction and effectively predicts their outcome with regard to the ability to walk, ability to perform the activities of daily living, and mortality, and it can be recommended for use in the care of elderly patients with a hip fracture.

Level of Evidence: Prognostic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Dominik Golicki, M.D., MSc
    Posted on November 06, 2006
    Cognitive function and mortality after hip fracture
    Department of Orthopaedics and Traumatology, Medical University of Warsaw, Warsaw, Poland

    To The Editor:

    In their recent paper on the influence of cognitive function on outcome after hip fracture, Soderqvist et al.(1)stated that cognitive impairment, especially severe (Short Portable Mental State Questionnaire score <3), is a strong predictor of poor outcome.

    In our own prospective observational study (PolHipQoL study) evaluating 153 patients for a mean duratlion of 14 months, any kind of cognitive dysfunction, i.e. mild, moderate or severe ( <8 points), was associated with increased mortality (49.2 vs 14.1%)(2). Instead of the Short Portable Mental State Questionnaire, we used the Abbreviated Mental State Questionnaire (AMTS), an instrument recommended for use in the Standardised Audit of Hip Fracture in Europe (SAHFE)(3). Both questionnaires are validated, and consist of 10-items that are similar in terms of content, administration, and scoring(4).

    Our study confirmed that cognitive impairment is the strongest prognostic factor of increased mortality (HR = 3.49; 95%CI: 1.92 – 6.36), better than age over 82 years old (HR = 2.13; 95%CI: 1.32 – 3.42), physical status III or IV in American Society of Anaesthesiologists ASA scale (HR = 1.95; 95%CI: 1.10 – 3.43) or anaemia (HR = 1.68; 95%CI: 1.07 – 2.62).

    We fully agree with the authors' conclusions that identification of cognitive dysfunction using a validated instrument, at the time of admission to the orthopaedic ward, should be considered a mandatory assessment for patients with hip fracture.

    The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

    References:

    1. Soderqvist A, Miedel R, Pozer S, Tidermark J. The influence of cognitive function on outcome after a hip fracture. J Bone Joint Surg Am. 2006;88:2115-23.

    2. Golicki D, Sliwka A, Fijewski G, Latek M. Quality of life according to EQ-5D after osteoporotic hip fracture in Poland. Value Health. 2006;9(6):A382.

    3. Standardised Audit of Hip Fracture in Europe (SAHFE). http://www.sahfe.ort.lu.se/

    4. Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing 1981;1:233-8.

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