Predicting 30-day mortality after hip fracture: the G4A calibrated prognostic tool

Introduction: Proximal femoral fracture is common with a high mortality (7% mortality at 30 days). Accurate determination of mortality risk allows better consenting, clinical management and expectation management. Our study aim was to develop a prognostic tool to predict 30-day mortality after proximal femoral fracture, among patients treated within a dedicated hip fracture unit. Materials and methods: We collected data from our hospital concerning 2210 patients with 2287 proximal femoral fractures. The clinical parameters of 97 patients who died within 30 days of surgery were analysed. We used logistic regression to determine if the parameters’ relationship with 30-day mortality was statistically significant or not. The statistically significant parameters were used to create a prognostic model for predicting 30-day mortality. Results: The 5 independent predictors of 30-day mortality were gender, age, admission source, preoperative Abbreviated Mental Test Score (AMTS) and American Society of Anesthesiologists Score (ASA). The highest risk was for males >85 years, admitted from institutional care, with low preoperative mental test score and high ASA grade. Using these predictors, we formulated the G4A score. The Hosmer-Lemeshow ‘goodness of fit’ test showed good concordance between observed and predicted mortality rates. Conclusions: We recommend the use of the G4A score to predict 30-day mortality after surgery for proximal femoral fracture, particularly within dedicated hip fracture units. Further research is needed to establish whether the findings of this study are applicable on a national scale.

PENURUNAN INDEKS MASSA TUBUH (IMT) BERHUBUNGAN STATUS KOGNISI BURUK PADA LANSIA

Salah satu masalah yang dialami pada lansia adalah Terganggunya kapasitas intelektual yang berhubungan dengan fungsi kognitif pada lansia. Faktor nutrisi adalah faktor yang dapat menentukan keadaan kognitif lansia dan untuk mencegah potensi penurunan kognitif pada lansia. Tujuan penelitian ini untuk mengetahui adanya hubungan antara indeks massa tubuh dengan status kognisi pada lansia. Penelitian ini merupakan penelitian analitik dengan rancangan penelitian studi cross-sectional. Penelitian dilaksanakan di Panti Sosial Tresna Werda Wana Seraya, Denpasar. Penghitungan Indeks Massa Tubuh (IMT) yang dilakukan pada lansia dengan pengukuran berat badan dan tinggi badan berdasarkan tinggi lutut dan Status kognisi ditentukan dengan menggunakan kuisioner abbreviated mental test (AMT). Data yang diperoleh di analisis secara univariat dan bivariat dengan uji korelasi Rank Spearman. Terdapat 22 responden termasuk dalam penelitian ini dengan rerata umur 76,5±4,56 tahun. Prevalensi penurunan fungsi kognitif lansia diperoleh 77,3%. Dari 17 lansia dengan penurunan fungsi kognitif, sebanyak 58,8% mengalami gizi kurang, 35,3% mengalami gizi baik dan 5,9% mengalami gizi lebih. Berdasarkan uji korelasi diperoleh hubungan yang cukup kuat antara indeks massa tubuh dengan status kognisi (r = 0,436; p=0,043). Dengan demikian, dapat disimpulkan bahwa terdapat hubungan yang cukup kuat antara IMT dengan status kognitif pada lansia.

Investigation of the effect of anesthesia implementation with bispectral index on postoperative neurocognitive functions and delirium in open heart surgery

Background: Neurological complications of coronary artery bypass surgery are still the major causes of mortality and morbidity despite all advances in this field. Aims and Objectives: We investigated the effect of bispectral index (BIS) monitoring of the patient consciousness on the postoperative neurocognitive functions in our study. Materials and Methods: A total of 40 patients in the age range from 25 to 75 years were included in our study, who were electively operated for isolated coronary artery bypass grafting (CABG) surgery in the period from January 2014 to June 2014. The patients were assigned to two groups based on whether BIS monitoring was performed or not. The patients were consecutively allocated to either group when they were found eligible to be included based on the exclusion criteria. Administration of the anesthesia was monitored with BIS in the respective group (Group 1). All patient follow-up parameters were compared in both groups. Neurocognitive function tests (the clock drawing test and standardized mini mental test) were administered to the patients in the preoperative and postoperative period(1 st day and day before discharge). The results were compared. Results: There were no significant findings in the demographic features and the routine follow-up parameters between the two groups. The time of extubation, intensive care unit (ICU) follow-up parameters, and the length of stay in the ICU were not significantly different between the groups; however, the length of stay at the hospital was significantly longer in the group of patients, who were not monitored with BIS (p<0.05). The mean arterial blood pressure was statistically significantly higher in group 1 (BIS monitoring) at all phases of the operation and during the postoperative follow-ups. A significant acidosis was present in the arterial blood pressure tests of the patients in group 1 during their stay at the ICU. The Po2 values following cross-clamping and extubation were significantly higher in group 1. In the group monitored with BIS, the results of the neurocognitive tests, which were the clock drawing test and the standardized mini mental test, were both clinically and statistically superior (p<0.05). Conclusıons: BIS monitoring provides favorable contributions for the follow-up of the patients undergoing CABG surgery and it is helpful in estimating the consciousness state of the patients after the surgery.

Cognitive screening assessment in Thai older adults: a prospective study of the reliability and validity of the Abbreviated Mental Test

PurposeThe purpose of this paper is to examine the reliability and validity of the Abbreviated Mental Test (AMT) and the agreement with the Mini-Mental State Examination (MMSE).Design/methodology/approachThis cross-sectional study included 446 older adults who were recruited by cluster sampling from 200,481 adults aged more than 60 years. For each participant, the AMT was administered by village health volunteers and, on a separate day, by a trained professional who also administered the MMSE. Descriptive statistics, Bland and Altman levels of agreement, and Receiver Operator Curves (ROCs) were used to analyze data.FindingsAdministration of the AMT by village health volunteers during the annual health screening found cognitive impairment in only 1.12% of the sample. When the AMT was given to these same individuals by trained professionals, the rate of cognitive impairment was almost 24 times greater. Two items in the Thai AMT may require modification due to markedly elevated failure rates. At the cut score of 8, the sensitivity and specificity of the AMT relative to the MMSE were moderate (78.83 and 66.67%, respectively). The degree of agreement between AMT and MMSE was 0.49 (p < 0.001) and the correlation between the difference scores and the mean is exceptionally low (0.048).Originality/valueReliable and valid cognitive screening assessment requires the administrator to be well trained and the tools to be appropriate for the population. Although AMT is short and easy for a nonprofessional to administer, some items were not suitable due to construct validity and contextual issues.

The Abbreviated Mental Test Score; Is There a Need for a Contemporaneous Update?

Introduction: Designed in 1972 the Abbreviated Mental Test Score (AMTS) is widely used to assess a cognition on hospital admission. The Nottingham Hip Fracture Score uses this in predicting morbidity/mortality in neck of femur fracture. The consequences of misappropriating cognitive impairment could have lasting implications. Questions about the monarchy or World War One and Two may be inappropriate for today’s diverse society. Materials and Methods: 100 patients were questioned during routine fracture clinic appointments. Patients were asked: In what year did WWII start? Who is the current monarch? Please state a memorable event in your lifetime that you would not expect another person of the same age to forget. Two-tailed Z-tests were performed between the observed proportions and those from the original AMTS validation study. Results: Only 47% (n = 47) were able to correctly answer the year in which WW2 started. A statistically significant difference when compared to the upper and lower limits from the original study (z = -4.191, p < .001.). Significance was not seen in the second question, with 97% (n-97) identifying the monarch correctly. 51% (n = 51) of participants suggested the terrorist attack on the World Trade Centre in New York as an alternative memorable event. Discussion: Some hospitals now use the 4 “A”s Test (4-AT) as a screening tool for delirium. Without amendments to the Nottingham Hip Fracture Score, AMTS use is likely to continue in orthogeriatric patients. Over time there will be a need for the AMTS to be reviewed so that it remains a true assessment of cognition. Its limitations regarding language and culture is widely acknowledged and several validated variants have been published in the literaure. Conclusions: We highlight a potential future issue with the AMTS and raise considerations for the development of an alternative question to better meet the needs of the orthogeriatric population.

Underestimation of Cognitive Impairment in Older Inpatients by the Abbreviated Mental Test Score versus the Montreal Cognitive Assessment: Cross-Sectional Observational Study

<b><i>Background/Aims:</i></b> Cognitive impairment is prevalent in older inpatients but may be unrecognized. Screening to identify cognitive deficits is therefore important to optimize care. The 10-point Abbreviated Mental Test Score (AMTS) is widely used in acute hospital settings but its reliability for mild versus more severe cognitive impairment is unknown. We therefore studied the AMTS versus the 30-point Montreal Cognitive Assessment (MoCA) in older (≥75 years) inpatients. <b><i>Methods:</i></b> The AMTS and MoCA were administered to consecutive hospitalized patients at ≥72 h after admission in a prospective observational study. MoCA testing time was recorded. Reliability of the AMTS for the reference standard defined as mild (MoCA &#x3c;26) or moderate/severe (MoCA &#x3c;18) cognitive impairment was assessed using the area under the receiver-operating curve (AUC). Sensitivity, specificity, positive and negative predictive values of low AMTS (&#x3c;8) for cognitive impairment were determined. <b><i>Results:</i></b> Among 205 patients (mean/SD age = 84.9/6.3 years, 96 (46.8%) male, 74 (36.1%) dementia/delirium), mean/SD AMTS was 7.2/2.3, and mean/SD MoCA was 16.1/6.2 with mean/SD testing time = 17.9/7.2 min. 96/205 (46.8%) had low AMTS whereas 174/185 (94%) had low MoCA: 74/185 (40.0%) had mild and 100 ( 54.0%) had moderate/severe impairment. Moderate/severe cognitive impairment was more prevalent in the low versus the normal AMTS group: 74/83 (90%) versus 25/102 (25%, <i>p</i> &#x3c; 0.0001). AUC of the AMTS for mild and moderate/severe impairment were 0.86 (95% CI = 0.80–0.93) and 0.88 (0.82–0.93), respectively. Specificity of AMTS &#x3c;8 for both mild and moderate/severe cognitive impairment was high (100%, 71.5–100, and 92.7%, 84.8–97.3) but sensitivity was lower (44.8%, 37.0–52.8, and 72.8%, 62.6–81.6, respectively). The negative predictive value of AMTS &#x3c;8 was therefore low for mild impairment (10.9%, 5.6–18.7) but much higher for moderate/severe impairment (75.2%, 65.7–83.3). All MoCA subtests discriminated between low and normal AMTS groups (all <i>p</i> &#x3c; 0.0001, except <i>p</i> = 0.002 for repetition) but deficits in delayed recall, verbal fluency and visuo-executive function were prevalent even in the normal AMTS group. <b><i>Conclusion:</i></b> The AMTS is highly specific but relatively insensitive for cognitive impairment: a quarter of those with normal AMTS had moderate/severe impairment on the MoCA with widespread deficits. The AMTS cannot therefore be used as a “rule-out” test, and more detailed cognitive assessment will be required in selected patients.

KEDUDUKAN EVALUASI DALAM PENDIDIKAN ISLAM

Sistem evaluasi yang disebutkan dalam Al-Qur’an adalah sifat universal. Yaitu dengan menggunakan teknik testing mental (mental test atau psikotest dalam sunnah Nabi system evaluasi bersifat makro adalah untuk mengetahui kemajuan belajar manusia termasuk nabi sendiri. Sebagiaman dalam kisah kedatangan Jibril AS untk menguji Nabi Muhammad saw. Dengan pertanyaan-pertanyaan yang menyangkut pengetahuan beliau tentang rukun Islam.Setiap jawaban Nabi atas pertanyaan yang diajukan selalu dibenarkan oleh malaikat Jibril AS. Peristiwa lain yaitu ketiak nabi diuji hafalan-ahafalan pada ayat-ayat al-qur’an yang tetap konsisten dan valid dalam ingatan beliau. Akan tetapi system evaluasi yang diterapkan pada dunia pendidikan menggunakan pendekatan berupa teknik penilaian yang diterapkan dalam sekolah-sekolah adalah yang bersifat kuantitatif.Penilaian kuantitatif dinyatakan dengan menggunakan angka-angka sedangkan yang kaulitatif dinyatakan dengan ungkapan-ungkapan.Aspek tingkah laku siswa dalam bidang kognitif dinilai secara kuantitaif.Aspek sikap/ afektif diniali secara kualitatif dan aspek keterampilan / psikomotorik dinilai secara kuantitatif dan kualitatif.

Effect of Obesity on Cognitive Functions in Elderly People

Aim: We aimed to evaluate effect of obesity on cognitive functions in 65 years and older patients. Methods: This study was conducted in the Recep Tayyip Erdogan University Family Medicine outpatient clinic between November 2018 and January 2019. 65 years and older 83 voluntary patients were included in our study. All participants evaluated by a survey for their socio-demographic characteristics, Standardized Mini Mental Examination Test and Rey Auditory and Verbal Learning Test. Statistical comparison was made between patients’ body mass indexes and their test scores. Results: Mini Mental Test total score was statistically higher in men. Besides that, working patients had higher Mini Mental Test total score compared to retired patients and housewives. As participants’ waist circumference and body mass index increase, their Mini Mental Test language scores were decreasing. Conclusions: We found that as body mass index increases, Mini Mental Test language scores were significantly decreasing. In literature there are studies that suggesting obesity is related to decline in cognitive functions, but there are also studies that suggesting obesity has protective effect for cognitive decline. More comprehensive prospective studies are required for clearer results. Keywords: geriatrics, obesity, cognitive dysfunction