Comment on: “Increased Risk of Postoperative Complications in Elderly Hip Fracture Patients With Cognitive Impairment: Evidence From a Japanese Nationwide Database”

Mori et al. [1] performed a nationwide retrospective cohort analysis to examine the association between cognitive impairment and postoperative outcomes in older adults undergoing surgical treatment for hip fracture. The results showed that cognitive impairment was significantly associated with a higher risk of several postoperative medical complications, including venous thromboembolism (odds ratio [OR] 1.168), urinary tract infection (OR 1.619), and pneumonia (OR 1.583). By contrast, in-hospital mortality rates were comparable between patients with and without cognitive impairment (2.0% vs. 1.9%). Patients with cognitive impairment also experienced slightly longer hospital stays (36.2 ± 29.9 days vs. 34.6 ± 28.3 days) and were less likely to receive anti-osteoporotic medications during hospitalization. Overall, these findings indicate that cognitive impairment is a clinically meaningful marker of increased susceptibility to postoperative complications following hip fracture surgery in older adults, underscoring the need for tailored perioperative management strategies in this vulnerable population. Nonetheless, several issues warrant further investigation and clarification. First, previous studies [2, 3] have indicated that medications commonly prescribed for the management of cognitive impairment, such as antipsychotic and antidepressant agents, are associated with an increased risk of adverse outcomes following fracture surgery. For example, Papola et al. [2] demonstrated that antipsychotic use was associated with higher risks of pneumonia, myocardial infarction, stroke, and mortality. Similarly, Morris et al. [3] reported an increased risk of mortality among patients using antidepressants. However, the present study did not provide information regarding treatments for cognitive impairment. In this context, the observed increase in postoperative complication risk may be attributable, at least in part, to medications used to manage cognitive impairment rather than to cognitive impairment itself. Therefore, the potential confounding effect of cognitive impairment–related medications warrants further consideration when interpreting the study's conclusions. Second, intraoperative blood loss and the type and dosage of anesthetic agents are key perioperative factors that influence postoperative outcomes in elderly patients with hip fracture. Intraoperative blood loss is directly associated with the risk of postoperative infection, cardiopulmonary complications, transfusion requirements, and prolonged hospital stay. Meanwhile, the choice and dosing of anesthetic agents (e.g., opioid vs. non-opioid regimens) can substantially affect the incidence of postoperative delirium, the severity of respiratory depression, susceptibility to infection, and hemodynamic stability. Because these variables were not included or adjusted for in the present analysis [1], their potential confounding effects cannot be excluded. This limitation may have resulted in either an overestimation or underestimation of the association between cognitive impairment and postoperative complications, thereby reducing the robustness of the study's conclusions. Third, nutritional status, as reflected by indicators such as serum albumin and hemoglobin levels [4, 5], is a key prognostic factor influencing postoperative infection risk and delayed wound healing in elderly patients with hip fracture. Patients with cognitive impairment are more likely to have inadequate nutritional intake due to swallowing dysfunction and reduced appetite, resulting in a substantially higher prevalence of malnutrition compared with cognitively intact older adults. Because the present study [1] did not incorporate or adjust for these nutrition-related parameters, residual confounding due to malnutrition cannot be excluded. This issue may have resulted in either an overestimation or underestimation of the strength of the association between cognitive impairment and postoperative complications. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.