Acute confusion states, pain, health, functional status and quality of care among patients with hip fracture during hospital stay

Understanding the association between pain and delirium in older hospital inpatients: systematic review and meta-analysis

OBJECTIVE

Delirium and pain are common in older adults admitted to hospital. The relationship between these is unclear, but clinically important. We aimed to systematically review the association between pain (at rest, movement, pain severity) and delirium in this population.

METHODS

PubMed, EMBASE, CINAHL, PsycINFO, Cochrane and Web of Science were searched (January 1982-November 2022) for Medical Subject Heading terms and synonyms ('Pain', 'Analgesic', 'Delirium'). Study eligibility: (1) validated pain measure as exposure, (2) validated delirium tool as an outcome; participant eligibility: (1) medical or surgical (planned/unplanned) inpatients, (2) admission length ≥ 48 h and (3) median cohort age over 65 years. Study quality was assessed with the Newcastle Ottawa Scale. We collected/calculated odds ratios (ORs) for categorical data and standard mean differences (SMDs) for continuous data and conducted multi-level random-intercepts meta-regression models. This review was prospectively registered with PROSPERO [18/5/2020] (CRD42020181346).

RESULTS

Thirty studies were selected: 14 reported categorical data; 16 reported continuous data. Delirium prevalence ranged from 2.2 to 55%. In the multi-level analysis, pain at rest (OR 2.14; 95% confidence interval [CI] 1.39-3.30), movement (OR 1.30; 95% CI 0.66-2.56), pain categorised as 'severe' (OR 3.42; 95% CI 2.09-5.59) and increased pain severity when measured continuously (SMD 0.33; 95% CI 0.08-0.59) were associated with an increased delirium risk. There was substantial heterogeneity in both categorical (I2 = 0%-77%) and continuous analyses (I2 = 85%).

CONCLUSION

An increase in pain was associated with a higher risk of developing delirium. Adequate pain management with appropriate analgesia may reduce incidence and severity of delirium.

Experiences of suffering among elderly hip-fracture patients during the preoperative period: patients' and nurse's perspective

BACKGROUND

In Norway, 6000 patients were operated on due to hip fracture in 2016. Hip fracture results in increased suffering and often in a dramatic change in an older person's life. The experience of suffering in patients with hip fracture, or nursing staff's perception of it in the preoperative period, is sparsely studied. The perspective of the study was based on caring sciences.

AIM

The aim of this study was to gain a deeper understanding of subjective experiences of suffering among elderly hip-fracture patients during the preoperative period, seen from the patients' and nurses' perspective.

METHODOLOGICAL APPROACH

A Q-methodological approach was used. Forty statements (Q-sample), based on interviews and theory, were ranked in a forced-choice distribution curve from 'mostly agree' to 'mostly disagree', followed by postinterviews. Nine patients and five nurses participated. A by-person factor analysis in the form of principal component analysis with varimax and hand rotation was conducted.

RESULTS

Three factors, also called viewpoints, emerged as follows: (i) 'Feeling safe through presence, trust and hope'; (ii) 'Feeling safe occurs when the patient is seen, met and informed'; and (iii) 'Feeling alone and angry at oneself'. A polarisation between participants occurred, since the youngest patients (median age 73), the oldest patients (median age 90) and the nurses were represented in each specific factor.

CONCLUSION

There exist differences between how the nursing staff, the youngest and the oldest elderly patients experienced the preoperative period and what can enhance or alleviate their suffering. Where the youngest elderly communicated safety through trust and relatives' presence, the oldest elderly communicated insecurity in relation to staff and experienced severe pain and loneliness. Nursing staff and one patient emphasised the importance of seeing the patient in the first meeting to establish a feeling of security.

A systematic review of the use of music interventions to improve outcomes for patients undergoing hip or knee surgery

AIM

To examine the effectiveness of music as an adjunct treatment for pain, anxiety, and/or postoperative delirium, for patients undergoing hip or knee surgery.

BACKGROUND

Patients undergoing hip or knee surgery are known to experience pain and anxiety before and after surgery and be prone to postoperative delirium.

DESIGN

Quantitative systematic review.

DATA SOURCES

CENTRAL, Embase, Ovid MEDLINE, CINAHL, and PsycINFO databases were systematically searched without time limits (to June 2018).

REVIEW METHODS

A systematic search yielded 10 randomized controlled trials and quasi-experimental designs. Studies were appraised using the Cochrane Risk of Bias Tool. Data were extracted using the Effective Practice and Organization of Care data extraction tool.

RESULTS

Mixed results were found for the effect of music on anxiety, pain, and postoperative delirium in patients undergoing hip or knee surgery. Six of 10 included studies provided evidence that music can improve anxiety, pain, or postoperative delirium outcomes for patients undergoing hip or knee surgery. Music effectively reduced anxiety in one of three studies. Three of seven studies reported benefits of music for reducing postoperative pain. Positive effects of music on postoperative delirium were reported in all three studies that evaluated this outcome. Within group improvements were observed in many of the studies.

CONCLUSION

Music has the potential to improve outcomes of anxiety, pain, and postoperative delirium, for patients undergoing hip or knee surgery. The low number of studies found indicates results should be treated with caution. Further studies are required to provide strong evidence generalizable to a broader population.

Initial testing of a behavioural pain assessment tool within trauma units

Pain is common in trauma patients who may be older and also may have cognitive impairment leading to reduced communication about their pain. A number of observational pain assessment tools are available and have been found to have limited clinical usefulness. The Bolton Pain Assessment Tool (BPAT) was developed following a trial of three established tools and includes a section to involve family and/or close carers in the pain assessment process. The aim of this paper is to present the findings of initial testing of BPAT. BPAT was used and evaluated by clinical staff in four trauma units in the UK. Forty-six staff evaluations were completed and 98% indicated it was easy to use; it took between one and two minutes to complete by 69.5% and led to pain management interventions by 93.5% of the respondents. It was rated highly by the clinical staff, but the involvement of families and close carers in the assessment process was different at each unit, with one unit not involving the family/close carer. There remains the need for a simple and practical way of assessing pain. This initial testing of the clinical feasibility of BPAT suggests that it is easy to use and helps to identify pain, but further testing of its reliability and validity is required.

Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial

The aim of the present study was to determine whether celecoxib is able to ameliorate pain intensity, provide a narcotic-sparing effect, achieve early ambulation and improve rehabilitation following total hip arthroplasty (THA) in elderly patients. Peri- and post-operative oral celecoxib was administered to verify the efficacy of celecoxib for acute pain management in a multimodal analgesic strategy. All 64 eligible patients were randomly allocated to either the celecoxib group, who took an oral 400 mg capsule of celecoxib peri-operatively and 200 mg per 12 h post-operatively for the first 5 days, or the control group, who were orally treated with a placebo capsule having the same appearance. A multimodal analgesic technique was used in which oral celecoxib or placebo capsule was combined with intravenous patient-controlled analgesia (PCA) morphine pump for peri- and post-operative pain management. Pain assessments were recorded at 6, 12, 24, 48 and 72 h, and 7 and 14 days after THA using the visual analog scale (VAS). PCA morphine consumption; 6, 12, 24 and 48-h post-operative Harris hip score (HHS); time interval until initial ambulation; rates of urinary retention and post-operative nausea and vomiting (PONV) within 72 h; and intra- and post-operative blood loss were also documented. The celecoxib and control groups comprised 34 and 30 patients, respectively. Baseline demographics were comparable between the two groups. The post-operative VAS in the celecoxib group was significantly lower than that in the control group at 12, 24, 48 and 72 h after THA. The post-operative HHS had no significant difference between the two groups, while the time interval until initial ambulation in the celecoxib group (4.5±1.2 days) was significantly less than that in the control group (5.83±2.04 days; P<0.05). Morphine consumption was significantly decreased in the celecoxib group when compared with the control group at 6, 12, 24 and 24 h. Although the 72-h post-operative rates of urinary retention and PONV were lower in the celecoxib group than in the control group, there were no significant differences in these rates between the two groups. The intra- or post-operative blood loss was not significantly different between groups. In conclusion, pre-and post-operative oral celecoxib in a multimodal analgesic strategy can achieve favorable pain relief, reduce opioid consumption, and provide earlier ambulation and improved rehabilitation when compared with PCA morphine alone following THA in elderly patients.