Dataset Information

Fracture prevention in patients with cognitive impairment presenting with a hip fracture: secondary analysis of data from the HORIZON Recurrent Fracture Trial.

ABSTRACT: Patients with cognitive impairment (CI) often do not receive secondary fracture prevention. Use of zoledronic acid led to a similar reduction in re-fracture risk but the survival benefit was limited to those without CI.We tested whether the effects of zoledronic acid (Zol) on re-fracture and mortality differed in patients presenting with a hip fracture by cognitive status.We used data from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly Recurrent Fracture Trial, of yearly intravenous 5 mg Zol vs. placebo in patients presenting with a hip fracture. Primary outcome was new fracture and secondary outcome mortality. Short Portable Mental Status Questionnaire (SPMSQ) with a cut-point of >2 was used to identify CI. Fine-Gray models for competing events were fitted to study the effect of Zol on re-fracture and Cox regression for death. A multiplicative term was introduced to study a potential interaction between treatment and cognitive status on outcomes.Baseline SPMSQ of 1,966/2,127 (92.4%) patients was measured. Three hundred fifty (17.8%) had CI, balanced between treatment arms. In the placebo arm, there was similar fracture incidence between those with and without CI (15.4 vs. 12.3%, p = 0.26). There was no significant interaction for the effect of CI on Zol and re-fracture (p = 0.66). CI was associated with higher 1-year mortality (12.6 vs. 4.3%, p < 0.001) and the interaction was bordering significance (interaction, p = 0.066). Zol prolonged survival only in patients with normal cognitive status [HR 0.56 (95% CI 0.40-0.80)] and not in those with CI [HR 0.90 (95% CI 0.59-1.38)].While these results require confirmation, the findings support the use of bisphosphonates in patients with osteoporotic fracture and CI expected to live for more than 6 months.

SUBMITTER: Prieto-Alhambra D

PROVIDER: S-EPMC3867338 | biostudies-literature | 2014 Jan

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Fracture prevention in patients with cognitive impairment presenting with a hip fracture: secondary analysis of data from the HORIZON Recurrent Fracture Trial.

Prieto-Alhambra D D Judge A A Arden N K NK Cooper C C Lyles K W KW Javaid M K MK

Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA 20130628 1

<h4>Unlabelled</h4>Patients with cognitive impairment (CI) often do not receive secondary fracture prevention. Use of zoledronic acid led to a similar reduction in re-fracture risk but the survival benefit was limited to those without CI.<h4>Introduction</h4>We tested whether the effects of zoledronic acid (Zol) on re-fracture and mortality differed in patients presenting with a hip fracture by cognitive status.<h4>Methods</h4>We used data from the Health Outcomes and Reduced Incidence with Zole ...[more]

PMID: 23812596

Similar Datasets

Project description:Fragility fractures of the hip have a major impact on the lives of patients and their families. This study highlights significant geographical variation in secondary fracture prevention with even the highest performing regions failing the majority of patients despite robust evidence supporting the benefits of diagnosis and treatment.IntroductionThe purpose of the study is to describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999-2013 in the UK.MethodsWe used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to 5 years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI).ResultsThirteen thousand sixty-nine patients (76 % female) diagnosed with a hip fracture during 1999-2013 were identified. Eleven per cent had any anti-osteoporosis drug prescription in the 6 months prior to the index hip fracture. In the 0-4 months following a hip fracture, 5 % of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51 % in 2011 and then decreasing to 39 % in 2013. The independent predictors (OR (95 % CI)) of treatment initiation included gender (male 0.42 (0.36-0.49)), BMI (0.98 per kg/m2 increase (0.97-1.00)) and geographic region (1.29 (0.89-1.87) North East vs. 0.56 (0.43-0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally, an additional 3214 hip fracture patients would be initiated on therapy every year.ConclusionsSignificant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture.

Project description:BackgroundHip fractures are common fall-related injuries, with rehabilitation and recovery often complicated by cognitive impairment. Understanding what interventions exist, and in what settings, for people with hip fracture and co-occurring cognitive impairment is important in order to provide more evidence on rehabilitation and related outcomes for this population.ObjectiveTo examine the extent, nature, and range of literature on rehabilitation interventions for adults with hip fracture and cognitive impairment.MethodsArticles were required to: include an adult population with hip fracture and cognitive impairment, include a rehabilitation intervention, and be published between January 1, 2000 and November 19, 2021. Articles were excluded if they were opinion pieces, study protocols, conference abstracts, or if they did not describe the rehabilitation intervention. Relevant articles were searched on the following electronic databases: MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. All articles were double-screened by two reviewers and disagreements were resolved through consensus. Data were extracted and synthesized using descriptive approaches.ResultsSeventeen articles were included in this scoping review. We identified a variety of interventions targeting this population; about half were specific to physical rehabilitation, with the other half incorporating components that addressed multiple aspects of the care journey. Interventions had varying outcomes and no studies qualitatively explored patient or family experiences. All intervations were initiated in hospital, with less than half including cross-sectoral components. About half of the articles described modifying or tailoring the intervention to the participants' needs, but there was limited information on how to adapt rehabilitation interventions for individuals with cognitive impairment.ConclusionsMore work is need to better understand patient, family, and provider experiences with rehabilitation interventions, how to tailor interventions for those with cognitive impairment, and how to successfully implement sustainable interventions across sectors.

Project description:AimsPatients who present with fragility fractures are consistently under-evaluated and under-treated for underlying osteoporosis. This point-of-care represents a lost opportunity to prevent future fractures. This 2-arm study evaluated the success by an orthopaedic department in osteoporosis evaluation and initiating treatment.MethodsPatients over the age of 50 years with a fragility fracture of the hip were candidates for inclusion. Exclusion criteria included end-of-life care and moderate or severe dementia. Patients were prospectively randomized into 1 of 2 groups. The Letter group received a letter at the time of discharge encouraging their primary care physician to start medication for osteoporosis (Letter group). The intervention group had 4 interventions including printed information, a DEXA scan, a specific treatment recommendation, and monthly phone calls for 4 months (Intervention group). The primary outcome measure was whether the patient was on recommended treatment at 4 months from the fracture.ResultsThere were 200 patients in the study, 100 in the Letter, and 100 in the Intervention group. Sixteen patients were removed from the study since they either died (9) within 4 months of their fracture, were transferred for end-of-life care (7), and 4 dropped out. This left 180 patients for analysis. The Letter group had only 6 patients (6.2%) on recommended treatment compared with the Intervention group with 64 patients (77.1%). This was statistically significant (P < 0.0001).ConclusionOsteoporosis is a worldwide epidemic. Internationally, only about 20% of patients after a hip fracture are treated for their underlying weak bone. The most effective systems use a fracture liaison service (FLS) model. We present a 4-part intervention program that uses an FLS coordinator within the orthopaedic department. We encourage orthopaedic programs to adopt this or other models with the goal of taking the first step toward responsibility for bone health.An FLS program within an orthopaedic department can successfully initiate treatment for underlying osteoporosis.

Project description:IntroductionThe most successful programme for secondary fracture prevention is the FLS (fracture liaison service) model. Our orthopaedic department carried out a prospective randomised study to measure the effectiveness of a 4-step intervention programme. The findings in this study reveal important additional clinical benefits to having an orthopaedic-based FLS programme and evaluates the usefulness of fracture risk tools.MethodsWe carried out a prospective study to evaluate patients with a fragility fracture of the hip. There were 2 groups, intervention and control (each 100 patients). Of these, 20 were either removed from the study or dropped out, leaving 180 for analysis. In addition to routine preoperative blood tests, albumin and thyroid function levels were obtained and PTH (parathyroid hormone) levels when indicated.The intervention group (83 patients) had a dual-energy x-ray absorptiometry (DEXA) scan performed and fracture risk (FRAX) was calculated.Results12 patients (6.7%) had blood results which showed a potentially treatable cause for osteoporosis and 36 (20%) had blood results that changed their medical care.FRAX scores (180 patients) showed that the major osteoporotic fracture score correctly predicted the hip fracture in only 49%. The hip fracture score correctly predicted the hip fracture in 83%.DEXA scores (65 patients) showed osteoporosis in only 46% of hips and in only 26% of spines.An abnormal FRAX score or DEXA scan would have predicted a fragility fracture 93% of the time.ConclusionsIn addition to reducing secondary fractures, FLS programmes can provide fundamental benefits to the health of the patient. The intervention programme in this study identified patients with underlying treatable causes, correctable clinical conditions and patients with an unusually low bone density. When used together, FRAX and DEXA are more sensitive predictors for hip fracture risk than either are individually.Trial registry201497CTIL (https://clinicaltrials.gov/ct2/show/NCT02239523).

Project description:Previous studies examining the association of cognitive impairment and dementia with fracture outcomes in older adults have usually used standard approaches that did not take into account the competing risk of mortality. However, ignoring mortality may not provide accurate estimates of risk of fracture because dementia in older adults strongly predicts death, making mortality a competing risk. A total of 1491 women (mean age 87.6 years) participating in the prospective Study of Osteoporotic Fractures (SOF) Year 20 exam were cognitively assessed and followed to ascertain vital status (deaths verified by death certificates) and hip fractures (confirmed by radiographic reports). Cognitive status was categorized as normal, mild cognitive impairment (MCI), or dementia, based on a standardized evaluation. Absolute probability of hip fracture by category of cognitive function was estimated using traditional Kaplan-Meier method and cumulative incidence function accounting for competing mortality risk. Risk of hip fracture by cognitive function category was determined using conventional Cox proportional hazards regression and subdistribution hazards models with death as a competing risk. During an average follow-up of 5.6 years, 139 (9.3%) women experienced a hip fracture and 990 (66.4%) died before experiencing this outcome. Among women with dementia, the risk of hip fracture was 11.7% (95% confidence interval [CI] 7.3-17.2) at 5 years and 18.6% (95% CI 9.1-30.9) at 10 years using traditional survival analysis versus 7.9% (95% CI 5.1-11.6) at 5 years and 8.8% (95% CI 5.8-12.8) at 9.8 years using a competing risk approach. Results were similar for women with MCI. Women with MCI and dementia have a higher risk of hip fractures than women with normal cognition. However, not taking into account the competing risk of mortality significantly overestimates the risk of hip fracture in women in the ninth and tenth decades of life with cognitive impairment. © 2018 American Society for Bone and Mineral Research.

Dataset Information

Fracture prevention in patients with cognitive impairment presenting with a hip fracture: secondary analysis of data from the HORIZON Recurrent Fracture Trial.

Publications

Fracture prevention in patients with cognitive impairment presenting with a hip fracture: secondary analysis of data from the HORIZON Recurrent Fracture Trial.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets