JFOA Journal

Abstract

Objectives: We hypothesis that dementia impact treatment strategy in cases hospitalized for advanced Peripheral Arterial Disease (PAD), Hip Fracture (HF) and Vertebral Bone Fracture (VF) in Germany. Patients and Methods: Detailed lists of cases hospitalized with the principal diagnosis PAD, HF and VF in the year 2019 were provided by the Federal Statistical Office. In addition, cases were separated by the additional diagnosis dementia and surgical treatment procedures. Results: In 2019, there were 166,244 cases hospitalized for HF, 69,888 with VF and 74,910 with PAD. The rate of cases with the additional diagnosis dementia were 18.2%, 7.7% and 7.1%. In HF cases most frequent surgical treatment was hip arthroplasty in both, cases with (37%) and cases without dementia (34%). In VF cases conservative treatment was the dominant treatment strategy with 70% in those without and 81% in those with dementia. In PAD cases conservative treatment was the dominant treatment strategy with 74% in those without and 67% in those with dementia. Mayor amputation (7% vs 14%) was performed more frequently in those with dementia, but not minor amputation (19% vs 19%). Conclusion: Our analysis supports the hypothesis, that dementia impacts treatment decisions in older patients suffering from HF, VF and PAD in Germany in different ways. In cases with dementia more cases with VB were treated conservatively and in case of HF more cases surgically. In cases with advanced PAD more major amputation were performed. 

Keywords: Dementia; Peripheral arterial disease; Hip fracture; Vertebral bone fracture

Introduction

Dementia is a condition characterized by cognitive decline affecting memory and at least one of the other neurocognitive domains, including personality, praxis, abstract thinking, language, executive functions, complex attention, social skills, and visuospatial skills. In addition to the deterioration noted, the severity must be such that daily functioning is impaired [1,2]. It is often a progressive disorder, and those affected often have no insight into their deficits. Currently, there is no cure for any of the causes of dementia. As treatment, outcomes for diseases such as cancer improve and life expectancy increases, the incidence and prevalence of dementia is expected to continue to increase.

Typical conditions associated with dementia include hip fractures [4-9] and Peripheral Arterial Disease (PAD) [10-16]. Dementia increases the risk of Hip Fracture (HF) [17-19]. In a study comparing patients aged 65 to 90 years from 1072 primary care practices diagnosed with dementia with matched controls between 2010 and 2013, a total of 5.3% of patients and 0.7% of controls were found to have HF after 3 years [17]. A population-based retrospective cohort study of adults aged ≥ 65 years hospitalized with HF between 2007 and 2017 in New South Wales, Australia, reported that HF hospitalization rates were 2.5 times higher in adults with dementia compared with adults without dementia [18]. Data from the Korean National Health Insurance Service-National Sample Cohort, collected for the population ≥60 years of age from 2002 to 2013, found higher Odds Ratios (ORs) for dementia in the group with HF and Vertebral Fracture (VF) than in the group without fracture [20]. Data from the Honolulu-Asia Aging Study (HAAS), a prospective community-based study of 3734 JapaneseAmerican men aged 71 to 93 years at baseline in 1991 to 1993, showed that low ABI was associated with a twofold increased risk of dementia [21]. A recent systematic review evaluating published data on undiagnosed cognitive impairment in patients with PAD found that patients with PAD were more likely to have undiagnosed cognitive impairment than healthy controls [22]. We previously analyzed dementia rates associated with various surgical procedures in 2012 [23]. From 2008 to 2010, dementia was documented as an additional diagnosis in 6% of cases with a principal diagnosis of PAD, but in approximately 18% of cases that received a major amputation.

Different jurisdictions may have different laws regarding the powers of appointed surrogates/powers of attorney/representatives. Dementia does not automatically preclude mental capacity - it depends on what is being asked. For example, a person with dementia can decide for themselves what to have for lunch, but is not able to consent to complex surgery. Between these examples, there are others that are more nuanced and need to be assessed for each individual. In patients with very severe dementia, decisions are almost always made with the surrogate decision maker due to the patient’s incapacity. It is the physician’s responsibility to inquire about and understand the patient’s previously stated goals and values and then to guide and facilitate medical decisions so that the treatments offered are consistent with those goals and values [24,25].

We hypothesized that patients with dementia who are admitted to a hospital for acute treatment will be treated differently than patients without dementia. Therefore, we analyzed the surgical treatment of patients with Hip Fractures (HF), Vertebral Fractures (VF), or Advanced Peripheral Arterial Disease (PAVD) separately for the additional diagnosis of dementia. These three entities were selected because they are common in older people with dementia.

Patients and Methods

Nationwide hospitalization data

The Diagnosis-Related Groups Statistic (DRG) is an annual complete survey of all hospital cases in Germany that were accounted for by case rates. The microdata can be requested via the RDC starting from the survey year 2005. All hospitals in Germany annually transfer their individual hospitalization data, including one primary diagnosis, up to 89 secondary diagnoses coded by ICD-10 (International Classification of Diseases, 10th edition), and up to 100 medical procedures according to a national classification of operations and procedures to the Institute for the Hospital Renumeration System (InEK). After a plausibility control, the InEK forwards anonymized data to the Federal Bureau of Statistics. Principles of the analysis of this hospitalization file have been published several times previously [26,27]. In brief, we ask the Federal Bureau of Statistics to identify all hospitalizations of the year 2019 that have a principal diagnosis of PAD with ulcer or gangrene, HF and VF by calendar year, sex and 5-year age group. In addition, we ask for all cases for surgical treatment procedures. Finally, we received a defined data set from the Federal Bureau of Statistics including this information from all fully reimbursed inpatient cases (Tables 1-3). For this analysis we include all cases 50 years and older.

Table 1: ICD and OPS codes used for definition of cases with fracture of the femur neck and number of included cases. (ORIF: Open Reduction and Internal Fixation, CRIF: Closed Reduction and Internal Fixation).

Table 2: ICD and OPS codes used for definition of cases with fracture of the vertebra and number of included cases.

Table 3: ICD and OPS codes used for definition of cases with advanced PAD and number of included cases.

According to the occupational regulations for the North Rhine-Westphalian physicians’ retrospective epidemiological research projects are specifically excluded from the necessity of an ethics vote. Specific linking of cases and procedures is possible but not allowed for legal reasons. Thus, institutional review board approval and patients informed consent are not necessary.

Our statistical analysis is just descriptive. Calculations were done using Microsoft^® Access 2003.

Results

In 2019, there were 166,244 cases hospitalized with the principal diagnosis HF, 69,888 with VF and 74,910 with PAD. The rate of cases with the additional diagnosis dementia were 18.2%,

7.7% and 7.1% (Figure 1).

In cases hospitalized for HF most frequent surgical treatment was hip arthroplasty in both, cases with (37%) and cases without dementia (34%). Open Reduction and Internal Fixation (ORIF) was performed in 11% and 12% and Closed Reduction and Internal Fixation (CRIF) in 38% and 36% (Figure 1). All together, these procedures sum up to 86% in cases with and to 82% in cases without dementia.

In cases hospitalized with VF conservative treatment was the dominant treatment strategy with 70% in those without and 81% in those with dementia. Kyphoplasty (23% vs. 15%) and vertebroplasty (5% vs. 2%) were performed more frequently in patients without dementia (Figure 1).

Figure 1: Comparison of rates of different treatment strategies in patients with and without dementia hospitalized for HF (top), VF (middle) or advanced PAD (bottom).

In cases hospitalized with advanced PAD conservative treatment was the dominant treatment strategy with 74% in those without and 67% in those with dementia. Mayor amputation (7% vs 14%) was performed more frequently in those with dementia, but not minor amputation (19% vs 19%).