Improving Identification of Cognitive Impairment in Fragility Fracture Patients: Impact of Educational Guidelines on Current Practice

Abstract

Introduction: Cognitive impairment can hinder a fracture patient’s capacity to consent to surgery and negatively impact their postoperative recovery and rehabilitation. National guidelines recommend screening for cognitive impairment upon admission, and the Abbreviated Mental Test Score (AMTS) is a commonly used tool for this. This project aimed to assess current practice regarding documentation of AMTS among frail fracture patients upon admission and to improve AMTS documentation following a simple intervention. Methods: Baseline data were obtained by inpatient chart review throughout November to December 2018 in a district general hospital with emergency fracture services. All patients admitted with a fragility hip fracture and patients over 65 years with any fracture were included. National guidelines and baseline results were then distributed among junior doctors. Following an intervention, further data were collected throughout January to February 2019. Results: Preintervention, 40 suitable patients (mean age: 82 years) were identified; 9 (22.0%) of whom had an AMTS recorded upon admission. Among the hip fracture subgroup (n = 25), 7 (26.9%) had an AMTS recorded. Postintervention, 39 patients (mean age: 80 years) were identified; 15 (38.5%) of whom had an AMTS recorded. Among the hip fracture subgroup (n = 30), 11 (36.7%) had an AMTS recorded. Statistical analysis demonstrated a significant improvement in AMTS documentation both among the overall cohort ( P = .001) and hip fracture patients ( P = .019). No significant association was found between AMTS documentation and patient age ( P = .566), grade of admitting doctor ( P = .058), or prior cognitive/mental health disorder ( P = .256). Discussion: A small yet significant improvement in AMTS documentation among elderly/hip fracture patients was observed following distribution of educational material. Further work should explore the effect of cognitive impairment on outcomes related to orthopedic injuries beyond hip fractures.

Brain Diseases and Fall-Related Surgery in Older Persons

“…It is known that age-related brain symptoms (encephalopathy, gait difficulty [Parkinsonism with/without sarcopenia] [1], and dementia/delirium [2]) increase the likelihood of fall-related surgery. In contrast, it is not known which types of brain disease underlie such symptoms most, although fall-related surgery is conducted in up to 51% of patients white matter disease (WMD, also called small-vessel disease, accounting for gait difficulty) [3][4][5], up to 55% of patients with Alzheimer's disease (AD, for dementia) [6,7], up to 60% of patients with dementia with Lewy bodies (DLB, for gait difficulty and dementia) [8,9], and up to 25.7% of patients with alcoholism (for gait difficulty and dementia) [10,11].…”