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Design and Participants: This retrospective cross-sectional study compared outcomes of community-dwelling people living with dementia treated surgically vs nonsurgically for hip fracture. A population-based analysis of Medicare fee-for-service data was undertaken. Participants included community-dwelling beneficiaries with dementia and an inpatient claim for hip fracture in 2017 to 2018. The primary outcome was 30-, 90-, and 180-day mortality. Secondary outcomes consisted of selected post-acute care services. Inverse propensity-weighted regression was used.
Results: Participants (N=56,209; 59% surgical and 41% nonsurgical) were aged mean 86 years (SD=7.0) and were 73% women. Additionally, participants were 2.2% Alaska Native, American Indian, or Asian; 4.2% Hispanic; 4.0% non-Hispanic Black; and 89% non-Hispanic White. Among patients treated surgically, 73% had femoral head and neck fracture (FHNF) and 40% had moderate-to-severe dementia (MSD); among patients with both, 180-day mortality was 32% (surgical) vs 46% (nonsurgical). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI=0.49-0.62) and the adjusted OR was 0.59 (0.53-0.66). Among patients with mild dementia and FHNF, 180-day mortality was 27% (surgical) vs 35% (nonsurgical). For patients with mild dementia treated surgically vs nonsurgically for FHNF, the unadjusted OR of 180-day mortality was 0.67 (0.60-0.76) and the adjusted OR was 0.71 (0.63-0.79). For patients with FHNF, there was no difference in nursing home admission within 180 days when treated surgically vs nonsurgically.
Commentary: When weighing the risks and benefits of surgical repair for FHNF among older patients with dementia, it is important to consider not only the mortality risk but also the potential long-term custodial care needs. Patients treated surgically have shown lower odds of death and less frequent hospice referrals compared to those treated nonsurgically, although there is an increased risk of postoperative delirium. Yet, the risk of subsequent nursing home admission remains similar across groups. Further research comparing the quality of life between these groups is also needed to aid complex treatment decision making.
Bottom Line: In community-dwelling patients with dementia and FHNF, surgical treatment is associated with lower odds of death compared to nonsurgical treatment but does not reduce the risk of subsequent nursing home admission.
Reviewer: Alisha A. Morgan, DO MS FAAHPM, Mayo Clinic, Rochester, MN
References:
1. Yoon SH, Kim BR, Lee SY, Beom J, Choi JH, Lim JY. Influence of comorbidities on functional outcomes in patients with surgically treated fragility hip fractures: a retrospective cohort study. BMC Geriatr. 2021;21(1):283. doi:10.1186/s12877-021-02227-5.
2. Berry SD, Rothbaum RR, Kiel DP, Lee Y, Mitchell SL. Association of clinical outcomes with surgical repair of hip fracture vs nonsurgical management in nursing home residents with advanced dementia. JAMA Intern Med. 2018;178(6):774-780. doi:10.1001/jamainternmed.2018.0743.
3. Callahan CM, Arling G, Tu W, et al. Transitions in care for older adults with and without dementia. J Am Geriatr Soc. 2012;60(5):813-820. doi:10.1111/j.1532-5415.2012.03905.x.
Source: Adler RR, Xiang L, Shah SK, et al. Hip fracture treatment and outcomes among community-dwelling people living with dementia. JAMA Netw Open. 2024;7(5):e2413878. doi:10.1001/jamanetworkopen.2024.13878.
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