术前认知功能障碍对老年髋部骨折患者预后的影响

Impact of preoperative cognitive dysfunction on the prognosis of hip fractures in the elderly

目的探索术前认知功能障碍与老年髋部骨折术后病死率和功能结局的相关性。方法本研究采用事后分析的方法,分析前瞻性收集2018年11月—2019年11月北京积水潭医院≥65岁老年髋部骨折患者1092例,依据术前简易智力状况检查量表(MMSE)得分将患者分为认知功能障碍组(认知障碍组)和认知功能正常组(认知正常组)。所有患者进行术后3~4年的电话随访,平均随访时间3.5年,记录死亡事件及发生时间,通过统计欧洲五维健康量表(EQ-5D)和Parker行动能力评分量表评估患者生活质量和活动能力结局。采用组间比较、多因素Cox回归生存分析、生存曲线的方法比较两组患者资料差异并分析认知障碍的影响。结果本研究最终纳入老年髋部骨折患者871名,其中认知障碍组374例,男性107例,女性267例;年龄65~98岁,平均79.9岁;认知正常组497例,男性151例,女性346例;年龄65~101岁,平均79.4岁。认知障碍组病死率25.7%(96/374)明显高于认知正常组的18.9%(94/497)(P=0.017)。认知正常组平均生存时间(1193.5±15.4)d高于认知障碍组(1138.3±20.2)d。即使校正潜在协变量(年龄、性别、高血压、糖尿病、脑卒中、冠心病、手术方式和住院时长)后,认知功能障碍与术后3~4年死亡风险关联依然差异有统计学意义(HR 1.386,95%CI 1.039~1.849,P=0.027)。功能结局方面,认知障碍组的Parker评分及EQ-5D评分低于认知正常组(P<0.01)。结论术前合并认知功能障碍的老年髋部骨折患者3~4年内的病死率明显增高,生活质量和活动能力更差。

Objective To explore the correlation between preoperative cognitive dysfunction and postoperative mortality and functional outcomes in the elderly with hip fractures.Methods A post hoc analysis was used to analyze 1092 prospectively collected geriatric hip fractures(over 65 years of age),who were admitted to Beijing Jishuitan Hospital from Nov.2018 to Nov.2019.Patients were divided into a cognitively impaired group and a cognitively normal group based on the score of the preoperative Mini Mental State Examination(MMSE).All patients were followed up by telephone for 3-4(mean 3.5)years,to evaluate death events and exact time,patients’quality of life and mobility outcomes by the EuroQol Five Dimensions Questionnaire(EQ-5D)and Parker Mobility Rating Scale.Intergroup comparisons,multifactorial Cox regression survival analysis,and survival curves were used to compare the differences between the two groups and to analyze the effect of cognitive impairment.Results Altogether 871 elderly hip fracture patients were finally included in this study,including 374(107 males and 267 females aged of 65-98 years,mean 79.9 years)in the cognitively impaired group,and 497(151 males and 346 females aged 65-101 years,mean 79.4 years)in the cognitively normal group.The mortality rate in the cognitively impaired group was 25.7%(96/374),which was significantly higher than that in the cognitively normal group(18.9%,94/497,P=0.017);moreover,the mean survival time(days)in the cognitively impaired group(1138.3±20.2)was shorter than that in the cognitively normal group(1193.5±15.4).Even after correcting potential covariates of age,sex,hypertension,diabetes,stroke,coronary artery disease,surgical approach,and length of hospitalization,the association between cognitive dysfunction and the risk of death at 3-4 years postoperatively remained statistically significant(HR 1.386,95%CI 1.039-1.849,P=0.027).Regarding functional outcomes,both the Parker score(Z=2.802,P=0.005)and the EQ-5D score(Z=2.725,P=0.006)were lower in the cognitively impaired group than in the cogni-tively normal group,suggesting that the patients with comorbid cognitive dysfunction had poorer long-term mobility and quality of life.Conclusion Elderly hip fracture patients with preoperative comorbid cognitive dysfunction have significantly higher mortality and worse quality of life and mobility at 3-4 years.