Osteoporosis International

, Volume 25, Issue 1, pp 77–83

Fracture prevention in patients with cognitive impairment presenting with a hip fracture: secondary analysis of data from the HORIZON Recurrent Fracture Trial

  • D. Prieto-Alhambra
  • A. Judge
  • N. K. Arden
  • C. Cooper
  • K. W. Lyles
  • M. K. Javaid
Original Article

DOI: 10.1007/s00198-013-2420-8

Cite this article as:
Prieto-Alhambra, D., Judge, A., Arden, N.K. et al. Osteoporos Int (2014) 25: 77. doi:10.1007/s00198-013-2420-8

Abstract

Summary

Patients with cognitive impairment (CI) often do not receive secondary fracture prevention. Use of zoledronic acid led to a similar reduction in re-fracture risk but the survival benefit was limited to those without CI.

Introduction

We tested whether the effects of zoledronic acid (Zol) on re-fracture and mortality differed in patients presenting with a hip fracture by cognitive status.

Methods

We used data from the Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly Recurrent Fracture Trial, of yearly intravenous 5 mg Zol vs. placebo in patients presenting with a hip fracture. Primary outcome was new fracture and secondary outcome mortality. Short Portable Mental Status Questionnaire (SPMSQ) with a cut-point of >2 was used to identify CI. Fine–Gray models for competing events were fitted to study the effect of Zol on re-fracture and Cox regression for death. A multiplicative term was introduced to study a potential interaction between treatment and cognitive status on outcomes.

Results

Baseline SPMSQ of 1,966/2,127 (92.4 %) patients was measured. Three hundred fifty (17.8 %) had CI, balanced between treatment arms. In the placebo arm, there was similar fracture incidence between those with and without CI (15.4 vs. 12.3 %, p = 0.26). There was no significant interaction for the effect of CI on Zol and re-fracture (p = 0.66). CI was associated with higher 1-year mortality (12.6 vs. 4.3 %, p < 0.001) and the interaction was bordering significance (interaction, p = 0.066). Zol prolonged survival only in patients with normal cognitive status [HR 0.56 (95 % CI 0.40–0.80)] and not in those with CI [HR 0.90 (95 % CI 0.59–1.38)].

Conclusions

While these results require confirmation, the findings support the use of bisphosphonates in patients with osteoporotic fracture and CI expected to live for more than 6 months.

Keywords

BoneDementiaEpidemiologyFracturesMortalityZoledronic acid

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2013

Authors and Affiliations

  • D. Prieto-Alhambra
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
  • A. Judge
    • 1
    • 6
  • N. K. Arden
    • 1
    • 6
  • C. Cooper
    • 1
    • 2
    • 6
  • K. W. Lyles
    • 7
    • 8
  • M. K. Javaid
    • 1
    • 6
    • 9
  1. 1.Oxford NIHR Musculoskeletal Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesUniversity of OxfordHeadingtonUK
  2. 2.Institut Catala de la SalutBarcelonaSpain
  3. 3.URFOA-IMIMParc de Salut MarBarcelonaSpain
  4. 4.Medicine DepartmentUniversitat Autonoma de BarcelonaBarcelonaSpain
  5. 5.IDIAP Jordi Gol (Primary Care Research Institute)BarcelonaSpain
  6. 6.MRC Lifecourse Epidemiology Unit, Southampton General HospitalUniversity of SouthamptonSouthamptonUK
  7. 7.Duke University and VA Medical CentersDurhamUSA
  8. 8.The Carolinas Center for Medical ExcellenceCaryUSA
  9. 9.The Botnar Research Centre Institute of Musculoskeletal SciencesNuffield Orthopaedic CentreOxfordUK