The relationship and predictive value of dementia and frailty for mortality in patients with surgically managed hip fractures

Abstract

Background Both dementia and frailty have been associated with worse outcomes in patients with hip fractures. However, the interrelation and predictive value of these two entities has yet to be clarified. The current study aimed to investigate the predictive relationship between dementia, frailty, and in-hospital mortality after hip fracture surgery. Methods All patients registered in the 2019 National Inpatient Sample Database who were 50 years or older and underwent emergency hip fracture surgery following a traumatic fall were eligible for inclusion. Logistic regression (LR) models were constructed with in-hospital mortality as the response variables. One model was constructed including markers of frailty and one model was constructed excluding markers of frailty [Orthopedic Frailty Score (OFS) and weight loss]. The feature importance of all variables was determined using the permutation importance method. New LR models were then fitted using the top ten most important variables. The area under the receiver-operating characteristic curve (AUC) was used to compare the predictive ability of these models. Results An estimated total of 216,395 patients were included. Dementia was the 7th most important variable for predicting in-hospital mortality. When the OFS and weight loss were included, they replaced dementia in importance. There was no significant difference in the predictive ability of the models when comparing the model that included markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77–0.81)] with the model that excluded markers of frailty [AUC for in-hospital mortality (95% CI) 0.79 (0.77–0.80)]. Conclusion Dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients. This finding highlights the importance of early frailty screening for improvement of care pathways and discussions with patients and their families in regard to expected outcomes.

Comparative Analysis of Frailty Scores for Predicting Adverse Outcomes in Hip Fracture Patients: Insights from the United States National Inpatient Sample

“…This difference could be due to the lack of an admission hemoglobin or the fact that the current investigation focused on in-hospital mortality rather than 30-day postoperative mortality [ 11 ]. An analysis utilizing the NIS to explore the relationship between dementia and frailty also found that the OFS was the most important predictor of in-hospital mortality among the 52 variables analyzed, providing further support for its robust predictive capability in comparison to other scoring systems [ 7 ]. In a study conducted by Thorne et al, the AUC for in-hospital mortality was reported as 0.69 (95% CI: 0.64–0.74) for the NHFS, slightly higher than the NHFS’s performance and on the same level as the OFS observed in the current investigation [ 26 ].…”

“…Studies reveal stark contrasts, with crude 30-day and 90-day mortality rates among frail individuals reaching up to ten times higher than those among non-frail hip fracture patients [ 6 ]. Furthermore, frailty has been found to be the single most important predictor of in-hospital mortality in hip fracture patients [ 7 ]. Complicating matters, however, is the proliferation of published frailty scores, leading to uncertainty regarding their use and effectiveness.…”

Focus on the proximal femur

“…Robioneck et al therefore analysed a cohort of 202 patients with trochanteric fractures and found that osteoporosis was not significantly associated with implant failure while good fracture reduction and optimal implant positioning remain of the highest importance [ 2 ]. As dementia and frailty have been associated with worse outcomes in patients with hip fractures, Loannidis et al investigated the predictive relationship between these co-morbidities and in-hospital mortality after hip fracture surgery [ 3 ]. The authors included 216,395 patients and found that dementia functions as a surrogate for frailty when predicting in-hospital mortality in hip fracture patients.…”