Patients with dementia might be at greater risk for undertreatment
of pain.
(Morrison, R. S., & Siu, A. L. (2000). A
comparison of pain and its treatment in advanced dementia and cognitively
intact patients with hip fracture. Journal of pain and Symptom management,
19(4), 240-248.)
Under treatment of pain in elderly has been examined and demonstrated. Elderly surgical patients receive less analgesic than younger patients. Patients with dementia might be at greater risk for undertreatment of pain.
Purpose of the study:
To compare
analgesic prescribing in hip fracture patients with normal cognitive function
to hip fracture patients with advanced dementia, and to examine the adequacy of
analgesic prescribing in cognitively intact group as an approximation for those
unable to report their pain.
Inclusion criteria
- Patients aged 70 years or older admitted
to the hospital with a diagnosis with hip fracture (femoral neck or
intertrochanteric fracture) during Sep 1, 1996 to march 1, 1998. -
Patients scoring 18 or greater out of 24 of the Mini-Mental State Exam were
eligible for enrollment in the cognitively intact group.
- Patients with a history of dementia and a
Reisberg Global Deterioration Scale stage 6 or 7 (severe to very severe
dementia) were enrolled in the dementia group.
- Patients who had a concomitant diagnosis
of cancer, multiple internal injuries, a previous fracture in the affected hip.
- Non English speaking.
- Patients with delirium on admission and
those with delirium as documented by the Confusion Assessment Method (CAM) on 2
consecutive days following admission.
- Patients with mild cognitive impairment.
Setting: a
Tools: Confusion
Assessment Method (CAM), 5-point pain rating scale (0-no pain to 4-very
severe), and pain management index (PMI).
PMI is used as an indicator of the adequacy of
analgesic prescribing. PMI is constructed by subtracting the patient’s self
report of pain (0-no pain, 1-mild pain, 2-moderate pain, 3-severe pain) from
the strongest analgesic prescribed (0-none, 1-nonopioid, 2-weak opioid,
3-strong opioid). Subjects with a PMI score less than zero have been prescribed
inadequate analgesia for their level of pain.
Procedure
Informed consent was obtained from all
cognitively intact adults and from surrogate decision makers of subjects with
dementia.
Patient interview
- cognitively intact patients daily rated the
severity of their average pain on the pain rating scale over the preceding 24
hours and rated the severity of their worst episode of pain, while in bed or
sitting in a chair, over the previous 24 hours. Patients also were evaluated
for the presence of delirium using the
Charts were reviewed daily for information about
analgesic agents; name, dose, and frequency of administration (standing or as
needed). Aspirin administered as a 325 mg standing dose once per day was not
considered as analgesic. Medications were classified according to WHO Analgesic
Ladder as nonopioids (NSAIDs), weak opioids or strong opioids. No patient received
parenteral NSAIDs in this study. Doses of all oipoids, except oxycodone, were
converted into parenteral morphine sulfate equivalents using published
equianalgesic dosing guideline. For oxycodone, an equianalgesic ratio of 1 mg
of oxycodone to 1.5 mg of morphine sulfate (based on recent published data) was
used.
Cognitively
intact subjects who reported moderate to severe pain were used to determine the
PMI scores. PMI scores were calculated for subjects who could be assessed
preoperatively and for the first three postop days in all subjects of this
group. An average of the worst pain scores reported for each of these three
days and the strongest analgesic prescribed were used to compute the PMI
scores.
Cognitively
intact group received significant higher dose of parenteral morphine sulfate
than the dementia group during preoperative period (2.6 mg in cognitive group
versus 1.2 mg in dementia group), and through postoperative day 3 (4.1 mg
versus 1.5 mg).
Some patients from both groups did not have a
standing order (ATC) for an analgesic agent (opioids or nonopioids) for their
entire hospitalization (83% in cognitive group and 76% in dementia group=not
sig different between group).
For pain severity in cognitively intact group, 75% (31 of 38) reported their worst pain as severe to very severe and 43% (16 of 38) reported their average level of pain as severe to very severe during pre-op period. For 3 post-op days, 81% (46 of 57) reported at least one episode of severe pain and 42% reported their average level of pain to be severe to very severe.
PMI scores- 37 of 38 patients, who pain scores are
available for pre-op period, experienced at least one episode of moderate to
severe pain, and 22 of these 37 patients (59%) had a PMI score of less than 0.
For post-op period, 52 of 58 patients (90%) had a mean worst pain score that
was moderate to very severe, and 26 of these 52 patients had a PMI score of
less than 0.
Pain was substantially untreated or undertreated in geriatric hip
fracture patients especially in patients with dementia.