In the case of a hip fracture, operating on a patient with dementia can be a difficult decision to make. Indeed, surgery exposes patients with dementia to a higher mortality rate than patients of the same age without cognitive impairments. For patients with dementia in institutional settings, survival is better for those who undergo surgery. But what about the patients with dementia who live at home? It is a big decision for all family members.
Based on recent medical study included patients aged over 65 years with dementia who were living at home and not placed in institutions and who had a hip fracture between 2017 and 2018. Fractures were categorized based on location and complexity. The type and severity (mild, moderate, or severe) of dementia were identified using the diagnostic code list in the International Statistical Classification of Diseases.
Among almost 57 000 patients with dementia who were admitted for a hip fracture (as of 73 % women with mean age, 86.4 years), 59 % underwent surgery and 41 % did not. Among surgically treated patients, 40.2% had moderate to severe dementia. At 180 days, mortality was 31.8% in the surgery group compared with 45.7% in the nonsurgery group. Among patients with mild dementia and a fracture of the head or neck of the femur, mortality at 6 months was 26.5% among surgical patients and 34.9% among nonsurgical patients. After the investigators adjusted for risk according to propensity score, the benefit of surgery remained significant at the examined timeframe, regardless of dementia severity. Among patients with dementia living at home with a fracture of hip bone, those who underwent surgery had a lower risk for death than those who did not, regardless of the severity of dementia.
It is noteworthy that less than two thirds of patients with dementia underwent surgery, which contradicts recommendations for almost routine surgery for patients with dementia. This observation raises questions about respecting patient wishes and advance directives when known, possible detrimental delays in referrals, and legal-medical issues. Needed to bear in mind that the treatment choices of surgeons can be influenced by the type of hip fracture. Fractures of the head and neck of the femur are typically treated with prosthetic arthroplasty, which simplifies postoperative care, compared with osteosynthesis. The latter procedure is more often used for extra-articular hip fractures but entails higher risks. While survival is an apparently more easily achievable goal through surgery, ethical considerations about other treatment objectives such as pain control, functional recovery, and treatment adequacy cannot be overlooked.
