Impact of Competing Risk of Mortality on Association of Cognitive Impairment With Risk of Hip Fracture in Older Women

for the Study of Osteoporotic Fractures (SOF) Research Group

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


Previous studies examining the association of cognitive impairment and dementia with fracture outcomes in older adults have usually used standard approaches that did not take into account the competing risk of mortality. However, ignoring mortality may not provide accurate estimates of risk of fracture because dementia in older adults strongly predicts death, making mortality a competing risk. A total of 1491 women (mean age 87.6 years) participating in the prospective Study of Osteoporotic Fractures (SOF) Year 20 exam were cognitively assessed and followed to ascertain vital status (deaths verified by death certificates) and hip fractures (confirmed by radiographic reports). Cognitive status was categorized as normal, mild cognitive impairment (MCI), or dementia, based on a standardized evaluation. Absolute probability of hip fracture by category of cognitive function was estimated using traditional Kaplan-Meier method and cumulative incidence function accounting for competing mortality risk. Risk of hip fracture by cognitive function category was determined using conventional Cox proportional hazards regression and subdistribution hazards models with death as a competing risk. During an average follow-up of 5.6 years, 139 (9.3%) women experienced a hip fracture and 990 (66.4%) died before experiencing this outcome. Among women with dementia, the risk of hip fracture was 11.7% (95% confidence interval [CI] 7.3–17.2) at 5 years and 18.6% (95% CI 9.1–30.9) at 10 years using traditional survival analysis versus 7.9% (95% CI 5.1–11.6) at 5 years and 8.8% (95% CI 5.8–12.8) at 9.8 years using a competing risk approach. Results were similar for women with MCI. Women with MCI and dementia have a higher risk of hip fractures than women with normal cognition. However, not taking into account the competing risk of mortality significantly overestimates the risk of hip fracture in women in the ninth and tenth decades of life with cognitive impairment.

Original languageEnglish (US)
Pages (from-to)1595-1602
Number of pages8
JournalJournal of Bone and Mineral Research
Issue number9
StatePublished - Sep 2018

Bibliographical note

Funding Information:
The Study of Osteoporotic Fractures (SOF) is supported by National Institutes of Health funding. The National Institute on Aging (NIA) provides support under the following grant numbers: R01 AG005407, R01 AR35582, R01 AR35583, R01 AR35584, R01 AG005394, R01 AG027574, and R01 AG027576.

Publisher Copyright:
© 2018 American Society for Bone and Mineral Research




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