Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture

Postoperative evaluation of special needs and healthy patients with endodontic treatment under general anesthesia: a retrospective research

BACKGROUND

This retrospective clinical study was undertaken to comparatively evaluate the number of restorative treatments, endodontic treatments, and tooth extractions performed for patients under general anesthesia due to dental anxiety or special needs between 2015 and 2022 and to examine the pain, bleeding, nausea, and vomiting data of those patients.

METHODS

In total, 1165 patients underwent dental treatment under general anesthesia in the faculty hospital. Those under the age of 15 and with no endodontic procedure planned (n = 918) were excluded, followed by those with incomplete data (n = 25) and those without endodontic treatment (n = 25). Patients who underwent at least one endodontic treatment were finally included in the study (n = 184). Patients were divided into two groups: healthy and with special needs. Dental treatments were recorded as endodontic, restorative, and teeth extractions. Endodontic treatments were classified according to the tooth type (premolar, molar, and incisors). The composite restorations were classified as anterior, occlusal (O), occluso-distal (OD) or occluso-mesial (OM), and mesio-occluso-distal (MOD) restorations and patients' post-treatment pain, nausea, vomiting, and bleeding were recorded. The data were analyzed statistically.

RESULTS

Among the 184 patients included in the study, 70 (38%) were healthy, and 114 (62%) had special needs. Postoperative bleeding was observed more in patients with special needs (χ2 = 4.189, p < 0.05), whereas pain was observed more in healthy patients (U = 2922.00, p < 0.05). While the number of anterior, O, and MOD restorations was higher in patients with special needs, the number of OD or OM restorations was higher in healthy patients (χ2 = 74.877, p < 0.05).

CONCLUSIONS

Patients with special needs undergo a greater number of restorative treatments compared to control patients, which may be associated with the inadequate oral hygiene care of such patients. However, restorative treatment is mostly indicated for such patients in our faculty hospital, which may indicate that a conservative approach is taken. Additionally, the finding that postoperative bleeding was more severe in this group of patients compared to the control group in this study may emphasize the need to consider more possible complications after general anesthesia in these patients.

Hip Fractures in Patients with Dementia: An Emerging Orthopedic Concern

Hip fractures are a very common injury in the elderly population associated with an increased mortality rate. Currently, more and more elderly patients are diagnosed with dementia. Demented patients are more prone to falls and hip fractures compared to the general population because of conditions related to their disease such as instability, osteoporosis, poor muscle control and weakness. The coexistence of dementia and hip fractures is a difficult situation for both the patients and the treating physicians because of postoperative complications in this frail subgroup of patients and their inability to stand up and walk. To enhance the literature, we reviewed published studies of hip fracture patients suffering from dementia to discuss why they have more frequent hip fractures, to review their associated in-hospital complications, and to emphasize on their postoperative management to be able to reach the pre-injury activity level and optimal quality of life.

Clinical Effects and Safety of Auricular Acupressure as an Adjunct Therapy on Postoperative Pain among Patients with Hip Fracture: A Meta-Analysis

Objectives

To evaluate the short-term outcome of treatment by auricular acupressure (AA) on postoperative pain among hip fracture (HF) patients.

Methods

A systematic search for randomized controlled trials on this topic was conducted through May 2022 by searching multiple English and Chinese databases. The methodological quality of the included trails was assessed by the Cochrane Handbook tool, and relevant data were extracted and statistically analyzed by RevMan 5.4.1 software. The quality of the evidence supporting each outcome was evaluated by GRADEpro GDT.

Results

Fourteen trials with a total of 1390 participants were included in this study. Compared with conventional treatment (CT) alone, the combination of AA and CT had a significantly greater effect on the visual analog scale at 12 h (MD -0.53, 95% CI -0.77 to -0.30), 24 h (MD -0.59, 95% CI -0.92 to -0.25), 36 h (MD -0.07, 95% CI -0.13 to -0.02), 48 h (MD -0.52, 95% CI -0.97 to -0.08), and 72 h (MD -0.72, 95% CI -1.02 to -0.42), amount of analgesics used (MD -12.35, 95% CI -14.21 to -10.48), Harris Hip Score (MD 6.58, 95% CI 3.60 to 9.56), effective rate (OR 6.37, 95% CI 2.68 to 15.15), and adverse events (OR 0.35, 95% CI 0.17 to 0.71).

Conclusions

Compared with CT alone, the combination of AA and CRT had a significantly greater effect on postoperative pain in HF patients. However, trails with a rigorous methodology, including standard protocols for AA and multiethnic subjects, are still needed.

[Postoperative pain experience after proximal femur fracture in dementia]

BACKGROUND

The present study aimed to assess the postoperative pain experience in cognitive deficit patients with special reference to sensory or affective pain quality.

METHODS

Nineteen patients with normal cognition up to cognitive impairments according to the DemTect screening-tool were studied regarding their postoperative pain experience after proximal femur fracture. The numerical rating scale (NRS), the cognitive DemTect questionnaire, the pain sensation questionnaire (SES), and a quantitative sensory test (QST) were used as examination instruments.

RESULTS

The mean ± SD age of the patients was 83.8 ± 10.0 years. Of the 19 patients, 6 (31.6%) had normal cognitive abilities. In 4 patients (21.1%) there were indications of mild cognitive impairments, and in 9 patients (47.4%) the suspicions of the presence of dementia arose. The mean postoperative pain intensity (NRS) was 4.0 (1.6). With comparable analgesic therapy, the reported pain intensities did not differ between the three patient groups with different cognitive impairments and the first three postoperative treatment days. There were no statistically significant differences between the groups for the sensory or affective total scores of the pain sensation scale. The QST parameters deep pain (PPT), superficial mechanical pain after needle stimulation (MPT), and the superficial sensitivity to light touch stimuli (MDT) showed a significantly increased sensitivity of the operated side. For the sensation of vibration (VDT) no differences between operated and healthy extremities could be proven.

DISCUSSION

The postoperative pain experience does not differ between patients with normal and limited cognition. The quantitative sensory testing showed mechanical hyperalgesia in the operated area. The study points to the importance of adequate postoperative pain management even in those with dementia.

Long-term follow-up of intracerebroventricular injection of streptozotocin-inducing pain sensitization

Age is known to be the major risk factor for both pain sensation and sporadic Alzheimer's disease (sAD). Pain management in AD is a critical health condition. However, assessing pain in sAD patients is challenging. The intracerebroventricularly injected streptozotocin (icv-STZ) rat model of sAD has been brought to the fore as a hopefully suitable model that could mimic some features of sAD. However, the exact mechanism by which this agent may induce AD-like pathology is largely unknown. In some studies, analgesic drugs have been suggested as possible prevention of AD and icv-STZ-induced AD-like pathology. Therefore, this study used formalin and tail-flick tests to investigate whether different doses of icv-STZ injections could affect acute and inflammatory pain sensation and edema volume over time. Behavioral responses were observed at four testing time points (1, 2.5, 3.5, and 6 months postinjection). The results indicate that icv-STZ was able to significantly decrease the animals' formalin pain threshold in both a time- and dose-dependent manner. Formalin-induced acute and chronic pain scores of animals treated with streptozotocin 3 mg/kg (STZ3) increased dramatically 2.5 months after injection and persisted thereafter. The augmentation in pain score induced by streptozotocin 1 mg/kg (STZ1) was observed from 3.5 months after STZ injection. However, the effect of streptozotocin 0.5 mg/kg (STZ0.5) was NS until 6 months after injection. However, formalin-induced paw edema occurred with a longer delay and was not detectable in STZ0.5-treated animals. In addition, only STZ3-treated animals significantly reduced the thermal pain threshold of animals 6 months after injection. These observations indicate that icv-STZ can sensitize central and/or peripheral receptors to pain. The effect of STZ is dose- and time-dependent. AD-like pathology induced by icv-STZ could be partially activated via pain processing pathways. Therefore, anti-inflammatory agents could alleviate AD-like symptoms via pain treatments.

Effect of Ultrasound-Guided Fascia Iliac Compartment Block with Nalbuphine and Ropivacaine on Preoperative Pain in Older Patients with Hip Fractures: A Multicenter, Triple-Blinded, Randomized, Controlled Trial

INTRODUCTION

Pain management for older patients with hip fractures is challenging. This study aimed to investigate the effect of ultrasound-guided fascia iliac compartment block (UGFICB) using different doses of nalbuphine in combination with ropivacaine on preoperative analgesia in older patients with hip fractures.

METHODS

In this multicenter randomized controlled trial, 280 elderly patients with hip fracture were randomly allocated into four UGFICB groups (n = 70 in each group): a ropivacaine group (30 mL 0.1% ropivacaine + 0.9% normal saline) and three ropivacaine plus nalbuphine groups (5, 10, and 20 mg nalbuphine, respectively). The primary outcomes were the duration of analgesia at rest and on passive movement. Secondary outcomes included sensory block area, side effects, and vital signs. The doses of rescue analgesia with parecoxib sodium were also analyzed.

RESULTS

The addition of nalbuphine dose-dependently increased the duration of analgesia at rest and on passive movement (P < 0.05) and expanded the area of sensory block (P < 0.05). Compared with the ropivacaine group, the pain scores at rest and on movement at 6 and 8 h after the block were lower in three ropivacaine plus nalbuphine groups (P < 0.05), without between-group differences at 2, 4, and 12 h. The four groups had comparable side effects (nausea and vomiting) and vital signs (P > 0.05).

CONCLUSIONS

UGFICB with 5, 10, and 20 mg nalbuphine added to ropivacaine prolonged the analgesia duration, increased sensory block area, reduced pain, and decreased the doses of rescue parecoxib sodium for older patients after hip fracture, without obvious side effects. Among these three doses, nalbuphine 20 mg in combination with ropivacaine provided the longest duration of analgesia and the largest sensory block area.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2000029934).

Use of Intravenous Paracetamol Preoperatively Favors Lower Risk of Delirium and Functional Recovery in Elderly Patients with Hip Fracture: A Propensity Score-Matched Analysis

We aimed to investigate whether the use of intravenous paracetamol (IVP) preoperatively in intertrochanteric fracture (IF) patients aged 65 years or over receiving intramedullary fixation had significantly benefits on the pain score at discharge, delirium incidence, length of hospital stay (LOS), functional outcomes, and mortality. A retrospective analysis of all surgically treated patients presenting with IF was conducted at a single Level I trauma center in China between Jan. 2016 and Jan. 2020. The data concerning patients' demographics, injury-related data, surgery-related data, operation-related data, in-hospital data, and postoperative outcomes were extracted. To minimize potential confounding and selection bias, the propensity score matching (PSM) method was performed via the caliper matching method by using a 1 : 1 ratio. After PSM, McNemar's chi-square tests were used to examine the association of using IVP with outcome analyses. The Spearman correlations of IVP using, pain scores, and the factors which may influence them were also computed. After screening 2963 consecutive patients, 2166 were included finally, including 1576 in the non-IVP group and 590 in the IVP group. After PSM, 531 remained in each group. The pain scores at discharge were significantly between the two groups before and after matching (all p < 0.001). The differences of delirium rate and functional outcomes became significant after propensity score-based matching (p=0.001 and 0.033, respectively), although they were not significant before matching. No significant difference was observed in other operation-related data, LOS, and crude mortality rates at 30-day, 90-day, and 12-month before and after PSM. In conclusion, this study highlights the need for preoperative IVP use to optimize pain control, postoperative functional recovery, and minimize pain-related comorbidities such as delirium in elderly patients with hip fracture.

Postoperative Pain Treatment in Patients with Dementia: A Retrospective Observational Study

BACKGROUND

Inadequate postoperative analgesia has been noted in patients with dementia, but this topic has only been studied in hip fractures. This study aimed to examine whether the duration of postoperative analgesia associated with three surgical procedures was shorter in patients with dementia than in those without dementia.

METHODS

This retrospective observational study was based on a nationwide discharge database of acute care hospitals in Japan and included patients aged ≥ 65 years diagnosed with lung cancer, rectal cancer, or hip fracture, who underwent surgery in 366 hospitals between April 2013 and September 2018. The primary outcome was the incidence of injectable analgesic use during the postoperative hospital stay. The number of person-days of opioid, non-steroidal anti-inflammatory drug, or acetaminophen use was calculated for patients with and without dementia after each surgery using generalized estimating equations to obtain the age-adjusted incidence per 100 person-days.

RESULTS

Among the 32,379 patients included, 4828 (14.9%) had dementia. The duration of opioid administration per 100 person-days was 14% shorter in patients with dementia than in those without dementia after open rectal cancer surgery (incidence rate ratio [IRR] 0.86; 95% confidence interval [CI] 0.74-1.00) and 20% shorter in patients with dementia after open lung cancer surgery (IRR 0.80; 95% CI 0.70-0.91). In patients who underwent thoracoscopic lung cancer surgery, laparoscopic rectal cancer surgery, or hip replacement surgery, the duration of opioid administration was shorter in patients with dementia than in those without dementia, but the difference was not statistically significant.

CONCLUSIONS

The length of postoperative opioid administration after lung and rectal cancer surgery was reduced in patients with dementia, suggesting that the duration of postoperative analgesia in patients with dementia may be insufficient. More careful pain assessment and management of postoperative analgesia in these patients may be necessary.

Discontinuation of Long-Term Opioid Therapy in Patients With Versus Without Dementia

INTRODUCTION

Discontinuation of long-term opioid therapy has increased in recent years, but whether this trend extends to patients with Alzheimer disease and related dementia remains unclear.

METHODS

Medicare data from 2011 to 2018 were analyzed to compare the trends in the use and discontinuation of long-term opioid therapy between patients with and without Alzheimer disease and related dementia who had chronic noncancer pain. Outcome measures were annual proportions of (1) patients who received long-term opioid therapy and (2) long-term opioid therapy users who subsequently discontinued opioids for ≥30, 60, or 90 days during 12-month follow-up. All analyses were performed in 2021.

RESULTS

The use of long-term opioid therapy decreased from 2011 to 2017 in both patients with and without Alzheimer disease and related dementia. In long-term opioid therapy users, discontinuation of opioids for ≥30, 60, and 90 days increased by 8% (95% CI=1.04, 1.12, p<0.001), 13% (95% CI=1.06, 1.20, p<0.001), and 18% (95% CI=1.10, 1.28, p<0.001), respectively, between 2011 and 2017 among patients with Alzheimer disease and related dementia, whereas the proportion was largely declining or unchanged among patients without the condition. Differences in long-term opioid therapy discontinuation by Alzheimer disease status widened over time (p<0.01 for interaction).

CONCLUSIONS

Discontinuation of long-term opioid therapy was consistently higher in patients with than in patients without Alzheimer disease and related dementia, with the gap between the 2 groups widening over time. The reasons for these differences and the risk-benefit of increased long-term opioid therapy discontinuation among patients with Alzheimer disease and related dementia warrant further investigation.

Management of preoperative pain in elderly patients with moderate to severe cognitive deficits and hip fracture: a retrospective, monocentric study in an orthogeriatric unit

Background

Patients with cognitive deficits are 3 times more likely to suffer a hip fracture than geriatric patients of the same age group without cognitive deficits. The persistence of perioperative pain following hip fracture is a risk factor for the occurrence of delirium, poor functional prognosis, and the development of secondary chronic pain. Patients with cognitive deficits receive 20 to 60% less analgesics than those without cognitive deficits. Our retrospective descriptive monocentric study was performed in an orthogeriatric unit on a cohort of elderly patients hospitalized for hip fracture. The aim of the study was to compare the quantity of strong opioids delivered in a morphine sulfate equivalent daily during the preoperative period after a hip fracture between cognitively intact patients and those with cognitive deficits.

Results

Our total population of 69 patients had a median age of 90 years old, and 46% of these patients had moderate or severe cognitive deficits. During the preoperative period, the same quantity of strong opioids was administered to both groups of patients (13.1 mg/d versus 10.8 mg/d (p = 0.38)). Patients with moderate to severe cognitive deficits more often experienced delirium during their hospitalization (p < 0.01) and received more psychotropic drugs in the first 3 postoperative days (p = 0.025).

Conclusions

We reported that with standardized pain management in an orthogeriatric unit, patients aged 75 years and older received the same daily average quantity of strong opioids during the preoperative period regardless of the presence of cognitive deficits.

Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials

Background

With continuous increase of the aging population, the number of geriatric patients with fragility hip fractures is rising sharply, and timely surgery remains the mainstay of treatment. However, adequate and effective pain control is the precondition of satisfactory efficacy. This systematic review aimed to summarize the use of fascia iliaca compartment block (FICB) as an analgesic strategy for perioperative pain management in geriatric patients with hip fractures.

Methods

PubMed and Embase databases were searched for English published randomized controlled trials (RCTs) reporting application of FICB for pain control of the older adults with hip fractures between January 1^st, 2000, and May 31^st, 2020. The modified Jadad scale was used to evaluate quality of the RCTs included. Primary outcomes of the eligible RCTs were presented and discussed.

Results

A total of 27 RCTs with 2478 cases were included finally. The present outcomes suggested, after admission or in the emergency department (ED), FICB can provide patients with equal or even better pain relief compared with the conventional analgesia methods, which can also reduce additional analgesic consumptions. While, before positioning for spinal anesthesia (SA), FICB is able to offer superior pain control, facilitating SA performance, after surgery FICB can effectively alleviate pain with decreased use of additional analgesics, promoting earlier mobilization and preventing complications.

Conclusions

FICB is a safe, reliable, and easy-to-conduct technique, which is able to provide adequate pain relief during perioperative management of geriatric patients with hip fractures.

Factors Affecting Persistent Postoperative Pain in Patients with Hip Fractures

Osteoporotic fractures are common among older people, and hip fractures (HF) can be devastating. Surgery is indicated for most cases of HF, and chronic persistent postoperative pain is likely to occur. This study investigated the multifaceted factors related to persistent pain occurring during the acute phase and subacute phase of recovery after HF surgery. We conducted a prospective 8-week study of older HF patients after surgery. We evaluated pain intensity, depression symptoms, the fear of falling, pain catastrophizing, cognition and attention, the ability to perform activities of daily living, and the physical performance at 2 weeks (acute phase) and at 4 weeks (subacute phase) after surgery. Patients were divided into the light group (Verbal Rating Scale (VRS) score ≤1) and severe group (VRS score ≥2) according to pain intensity at 8 weeks (recovery phase) after surgery. Factors affecting persistent postoperative pain during recovery were examined using logistic regression analysis. Seventy-two patients were analyzed: 50 in the light group and 22 in the severe group. In the severe group, pain with movement and Pain Catastrophizing Scale scores were higher than those of the light group at 2 weeks and at 4 weeks after surgery. The regression analysis showed that pain with movement at 2 weeks and at 4 weeks after surgery and pain catastrophizing at 4 weeks after surgery were related to persistent postoperative pain. HF patients may have persistent pain if they continue to experience pain and catastrophize their pain during the acute phase and subacute phase after surgery.

Mild to Moderate Cognitive Impairment Does Not Affect the Ability to Self-Report Important Symptoms in Patients With Cancer: A Prospective Longitudinal Multinational Study (EPCCS)

CONTEXT

Patients with advanced cancer commonly suffer from both distressing symptoms and cognitive impairment, but the effect of cognitive impairment on the reliability and validity of symptom self-report is unknown.

OBJECTIVES

To evaluate the reliability and validity of symptom self-report in cancer outpatients with and without mild to moderate cognitive impairment.

METHODS

This was an analysis of the longitudinal European Palliative Care Cancer Symptom study of adults with incurable cancer in specialized palliative care (30 centers across 12 countries). Patients who could not comply with the study because of severe cognitive impairment were excluded. Cognitive status on the Mini-Mental State Examination short version and nine symptoms (pain, tiredness, drowsiness, nausea, appetite, breathlessness, depression, anxiety, and well-being) using the revised Edmonton Symptom Assessment System were self-reported at baseline and one-month follow-up. Reliability was analyzed using intraclass correlation coefficients and validity using regression of each symptom with health-related quality of life (HrQoL) measured with European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 15 for Palliative Care.

RESULTS

A total of 1047 patients were included: mean age of 62.9 years; 54.4% women; main cancer types were of digestive organs (26.6%), breast (21.6%), and lungs (21.2%). Cognitive impairment was present in 181 (17.3%) at baseline and associated with worse self-reported tiredness, drowsiness, appetite, and depression. Reliability (intraclass correlation coefficient) and validity (associations with HrQoL) were similar between people with/without cognitive impairment across the nine symptoms, except breathlessness, which showed a weaker relation to HrQoL in patients with cognitive impairment. Findings were robust in sensitivity analyses and after controlling for potential confounders.

CONCLUSION

In advanced cancer, self-report of nine major symptoms was reliable and valid also in people with mild-to-moderate cognitive impairment.

TRIAL REGISTRATION

ClinicalTrials.gov database (NCT01362816).

Hip fracture clearance: How much optimisation is necessary?

Patients with hip fractures are typically elderly individuals with several co-morbidities. Upon admission to the hospital, they often present with acute pain, electrolyte disturbances, anaemia, coagulopathy, and delirium. Long waiting times for surgery are associated with increased morbidity and mortality. The balance between the number of clinical tests and optimisation, which may (i.e., fewer complications and better survival) or may not (i.e., more complications and increased mortality due to unnecessary surgical delay) benefit the patient, has been a preoperative challenge. This summary will review existing clinical guidelines and relevant selected studies to evaluate the extent of preoperative optimisation needed prior to hip fracture surgery.

Age and postoperative opioid prescriptions: a population-based cohort study of opioid-naïve adults

PURPOSE

Opioids are commonly prescribed for acute pain after surgery. However, it is unclear whether these prescriptions are usually modified to account for patient age and, in particular, opioid-related risks among older adults. We therefore sought to describe postoperative opioid prescriptions filled by opioid-naïve adults undergoing four common surgical procedures.

METHODS

This retrospective cohort study used individually linked surgery and prescription opioid dispensing data from Ontario, Canada to create a population-based sample of 135 659 opioid-naïve adults who underwent one of four surgical procedures (laparoscopic cholecystectomy, laparoscopic appendectomy, knee meniscectomy, or breast excision) between 2013 and 2017. Patient age, in years, was categorized as 18 to 64, 65 to 69, 70 to 74, and 75 and over. Postoperative opioid prescriptions were identified as those filled on or within 6 days of surgical discharge date. For those who filled a prescription, we assessed the total morphine milligram equivalent (MME) dose, types of opioids, and any subsequent opioid prescriptions filled within 30 days of surgical discharge date. Results were presented stratified by surgical procedure.

RESULTS

For three of the four surgical procedures we assessed, the proportion of patients who filled a postoperative opioid prescription decreased with age (P < 0.001 for trend), and there was a small shift in the type of opioid (more codeine or tramadol and less oxycodone; P < 0.001 for trend). However, the total MME dose of the initial prescription(s) filled showed minimal age-related trends.

CONCLUSIONS

The proportion of opioid-naïve patients filling postoperative opioid prescriptions decreases with age. However, postoperative opioid prescription dosage is not typically different in older adults.

Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery

BACKGROUND

Hip fracture is a major injury that causes significant problems for affected individuals and their family and carers. Over 40% of people with hip fracture have dementia or cognitive impairment. The outcomes of these individuals after surgery are poorer than for those without dementia. It is unclear which care and rehabilitation interventions achieve the best outcomes for these people. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

(a) To assess the effectiveness of models of care including enhanced rehabilitation strategies designed specifically for people with dementia following hip fracture surgery compared to usual care. (b) To assess for people with dementia the effectiveness of models of care including enhanced rehabilitation strategies that are designed for all older people, regardless of cognitive status, following hip fracture surgery, compared to usual care.

SEARCH METHODS

We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group Specialised Register, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 16 October 2019.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating the effectiveness of any model of enhanced care and rehabilitation for people with dementia after hip fracture surgery compared to usual care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion and extracted data. We assessed risk of bias of the included trials. We synthesised data only if we considered the trials to be sufficiently homogeneous in terms of participants, interventions, and outcomes. We used the GRADE approach to rate the overall certainty of evidence for each outcome.

MAIN RESULTS

We included seven trials with a total of 555 participants. Three trials compared models of enhanced care in the inpatient setting with conventional care. Two trials compared an enhanced care model provided in inpatient settings and at home after discharge with conventional care. Two trials compared geriatrician-led care in-hospital to conventional care led by the orthopaedic team. None of the interventions were designed specifically for people with dementia, therefore the data included in the review were from subgroups of people with dementia or cognitive impairment participating in randomised controlled trials investigating models of care for all older people following hip fracture. The end of follow-up in the trials ranged from the point of acute hospital discharge to 24 months after discharge. We considered all trials to be at high risk of bias in more than one domain. As subgroups of larger trials, the analyses lacked power to detect differences between the intervention groups. Furthermore, there were some important differences in baseline characteristics of participants between the experimental and control groups. Using the GRADE approach, we downgraded the certainty of the evidence for all outcomes to low or very low. The effect estimates for almost all comparisons were very imprecise, and the overall certainty for most results was very low. There were no data from any study for our primary outcome of health-related quality of life. There was only very low certainty for our other primary outcome, activities of daily living and functional performance, therefore we were unable to draw any conclusions with confidence. There was low-certainty that enhanced care and rehabilitation in-hospital may reduce rates of postoperative delirium (odds ratio 0.04, 95% confidence interval (CI) 0.01 to 0.22, 2 trials, n = 141) and very low-certainty associating it with lower rates of some other complications. There was also low-certainty that, compared to orthopaedic-led management, geriatrician-led management may lead to shorter hospital stays (mean difference 4.00 days, 95% CI 3.61 to 4.39, 1 trial, n = 162).

AUTHORS' CONCLUSIONS

We found limited evidence that some of the models of enhanced rehabilitation and care used in the included trials may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia who have been treated for hip fracture. However, the certainty of these results is low. Data were available from only a small number of trials, and the certainty for all other results is very low. Determining the optimal strategies to improve outcomes for this growing population of patients should be a research priority.

["Emergency anesthesia" in geriatric patients]

BACKGROUND

The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term.

OBJECTIVES

Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented.

METHODS

Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews.

CONCLUSION

Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

A Comprehensive Review of Analgesia and Pain Modalities in Hip Fracture Pathogenesis

PURPOSE OF REVIEW

Hip fracture is common in the elderly population, painful and costly. The present investigation was undertaken to review epidemiology, socio-economic and medical implications, relevant anatomy, and anesthetic and pain modalities of hip fracture.

RECENT FINDINGS

A literature search of PubMed, Ovid Medline, and Cochrane databases was conducted in December 2018 to identify relevant published clinical trials, review articles, and meta-analyses studies related to anesthetic and pain modalities of hip fracture. The acute pain management in these situations is often challenging. Common issues associated with morbidity and mortality include patients' physiological decrease in function, medical comorbidities, and cognitive impairment, which all can confound and complicate pain assessment and treatment. Perioperative multidisciplinary and multimodal approaches require medical, surgical, and anesthesiology teams employing adequate preoperative optimization. Reduction in pain and disability utilizing opioid and non-opioid therapies, regional anesthesia, patient-tailored anesthetic approach, and delirium prevention strategies seems to ensure best outcomes.

Cancer Pain Management Considerations in Older Adults

OBJECTIVE

To address the pharmacokinetics and pharmacodynamics of aging and its impact on the complexities of pain management in older adults with cancer. To describe assessment and nursing strategies for individualized care and side effect management DATA SOURCES: Peer-reviewed articles.

CONCLUSION

Cancer pain is a complex problem in older adults because of the variations in aging and alterations in pharmacokinetics and pharmacodynamics. Pain management must be based on thorough assessment, incorporating the unique factors of each patient. Ongoing follow-up is critical to ensure adequate pain control with optimization of functional status.

IMPLICATIONS FOR NURSING PRACTICE

Awareness of physiological changes of aging is important in caring for older adults. Oncology nurses can play a key role in the assessment of older adults with cancer and education of patients and caregivers regarding pain medications, side-effects, and oral adherence.

Baseline and 1-year follow-up differences between hip-fracture patients admitted from nursing homes and the community. A cohort study on 509 consecutive patients (FONDA Cohort)

OBJECTIVE

To determine the clinical and functional differences at hospital admission and at 1 year after a hip fracture (HF) in nursing homes (NH) and community-dwelling (CD) patients.

METHODS

All patients with HF admitted to the orthogeriatric unit at a university hospital between January 2013 and February 2014 were prospectively included. Clinical and functional variables, and mortality were recorded during the hospital admission. The patients were contacted by telephone at 1 year to determine their vital condition and functional status.

RESULTS

A total of 509 patients were included, 116 (22.8%) of whom came from NH. Compared with the CD patients, the NH patients had higher surgical risk (ASA ≥3: 83.6% vs. 66.4%, P<.001), poorer theoretical vital prognosis (Nottingham Profile ≥5: 98.3% vs. 56.6%, P<.001), higher rate of previous functional status (median Barthel index: 55 [IQR, 36-80] vs. 90 [IQR, 75-100], P<.001), poorer mental status (Pfeiffer's SPMSQ>2: 74.1% vs. 40.2%, P<.001), and a higher rate of sarcopenia (24.3% vs. 15.2%, P<.05). There were no differences in in-hospital or at 1-year mortality. At 1 year, NH patients recovered their previous walking capacity at a lower rate (38.5% vs. 56.2%, P<.001).

CONCLUSIONS

Among the patients with HF treated in an orthogeriatric unit, NH patients had higher, surgical risk, functional and mental impairment, and a higher rate of sarcopenia than CD patients. At 1 year of follow-up, NH patients did not have higher mortality, but they recovered their previous capacity for walking less frequently.

Local Anesthetic Wound Infiltration after Osteosynthesis of Extracapsular Hip Fracture Does Not Reduce Pain or Opioid Requirements: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial in 49 Patients

Background and purpose

Local infiltration analgesia (LIA) supports early mobilization after hip and knee arthroplasty. Inspired by this, we studied the effectiveness of wound infiltration with the long acting local anesthetic ropivacaine in an effort to decrease the need for postoperative opioids after osteosynthesis of extracapsular hip fracture.

Methods

Forty-nine patients undergoing osteosynthesis with a sliding hip screw were randomized into two groups in a double-blind study (ClinicalTrials.gov:NCT01119209). The patients received intraoperative infiltration followed by 6 postoperative injections through a wound catheter in eight-hour intervals. 23 patients received ropivacaine and 26 received saline. The intervention period was 2 days, and the observation period was 5 days. In both groups, there were no restrictions on the total daily dose of opioids. Pain was assessed at specific postoperative time points, and the daily opioid usage was registered.

Results

Intraoperative infiltration with 200 mg ropivacaine and postoperative repeated infiltration with 100 mg ropivacaine did not result in statistically significant difference between the groups regarding postoperative opioid consumption or pain.

Interpretation

Ropivacaine as single component in postoperative treatment of pain after hip fracture is not effective. In our setup, wound infiltration with ropivacaine is not statistically significantly better than placebo.

Assessment and Early Management of Pain in Hip Fractures: The Impact of Paracetamol

Introduction

As the number of patients sustaining hip fractures increases, interventions aimed at improving patient comfort and reducing complication burden acquire increased importance. Frailty, cognitive impairment, and difficulty in assessing pain control characterize this population. In order to inform future care, a review of pain assessment and the use of preoperative intravenous paracetamol (IVP) is presented.

Materials and Methods

Systematic review of preoperative IVP administration in patients presenting with a hip fracture.

Results

Intravenous paracetamol is effective in the early management of pain control in the hip fracture population. There is a considerable decrease in use of breakthrough pain medications when compared with other pain relief modalities. Additionally, IVP reduces the incidence of opioid-induced complications, reduces length of stay, and lowers mean pain scores. Another significant finding of this study is the poor administration of all analgesics to patients with hip fracture with up to 72% receiving no prehospital analgesia.

Discussion

The potential benefits of IVP as routine in the early management of hip fracture-related pain are clear. Studies of direct comparison between analgesia regimes to inform optimum bundles of analgesic care are sparse. This study highlights the need for properly constructed pathway-driven comparator studies of contemporary analgesia regimes, with IVP as a central feature to optimize pain control and minimize analgesia-related morbidity in this vulnerable population.

How general practitioners would deprescribe in frail oldest-old with polypharmacy - the LESS study

BACKGROUND

Many oldest-old (> 80-years) with multimorbidity and polypharmacy are at high risk of inappropriate use of medication, but we know little about whether and how GPs would deprescribe, especially in the frail oldest-old. We aimed to determine whether, how, and why Swiss GPs deprescribe for this population.

METHODS

GPs took an online survey that presented case-vignettes of a frail oldest-old patient with and without history of cardiovascular disease (CVD) and asked if they would deprescribe any of seven medications. We calculated percentages of GPs willing to deprescribe at least one medication in the case with CVD and compared these with the case without CVD using paired t-tests. We also included open-ended questions to capture reasons for deprescribing and asked which factors could influence their decision to deprescribe by asking for their agreement on a 5-point-Likert-scale.

RESULTS

Of the 282 GPs we invited, 157 (56%) responded: 73% were men; mean age was 56. In the case-vignette without CVD, 98% of GPs deprescribed at least one medication (usually cardiovascular preventive medications) stating it had no indication nor benefit. They would lower the dose or prescribe pain medication as needed to reduce side effects. Their response was much the same when the patient had a history of CVD. GPs reported they were influenced by 'risk' and 'benefit' of medications, 'quality of life', and 'life expectancy', and prioritized the patient's wishes and priorities when deprescribing.

CONCLUSION

Swiss GPs were willing to deprescribe cardiovascular preventive medication when it lacked indication but tended to retain pain medication. Developing tools for GPs to assist them in balancing the risks and benefits of medication in the context of patient values may improve deprescribing activities in practice.

Pain: The Neglect Issue in Old People's Life

BACKGROUND

As the elderly population increases dramatically, the chronic age-related disease should be noted. In the elderly, chronic pain is a common health problem.

METHODS

This search was performed in 3 databases (PubMed, Google Scholar, Embase). We have reviewed articles related to pain management in the elderly.

RESULT

The prevalence of pain in people aged above 60 is twice that in younger people. Pain is estimated to be 45-85 per cent in the elderly. Pain is not a part of the ageing process, but many older people can experience it. Perception of pain can be affected by environmental, emotional, cultural and cognitive factors. Pain in the elderly often remains untreated and misdiagnosed.

CONCLUSION

Pain management in elderly needs different approach because of unreported pain in this population, and usually they have multiple problems and comorbidities that complicate evaluation and treatment.

Risk factors for mortality in elderly patients with hip fractures: a meta-analysis of 18 studies

BACKGROUND

Hip fracture is common and associated with poor outcomes in elderly patients. This meta-analysis aims to investigate the risk factors that might increase the mortality rate in elderly patients with hip fracture.

METHODS

PubMed, Embase, and Web of Science were systematically searched for observational studies regarding the prognostic factors of mortality in elderly patients with hip fracture. A fixed-effects or random-effects model was used to calculate pooled hazard ratio (HR) and 95% confidence intervals (95% CIs).

RESULTS

Eighteen cohort studies, involving 223,875 patients, were included in this meta-analysis. The most prominent factors associated with mortality were higher age (HR 1.51, 95% CI 1.37, 1.67; P < 0.001), male gender (HR 1.91, 95% CI 1.67, 2.19; P < 0.001), cognitive impairment (HR 2.06, 95% CI 1.25, 3.40; P = 0.005), delirium (HR 2.14, 95% CI 1.50, 3.05; P < 0.001), dementia (HR 2.72, 95% CI 1.41, 5.26; P = 0.003), depression (HR 1.71, 95% CI 1.43, 2.05; P < 0.001), living with caregiver (HR 1.61, 95% CI 1.43, 1.82; P < 0.001), cardiovascular disease (HR 2.10, 95% CI 1.14, 3.86; P = 0.018), renal disease (HR 1.66, 95% CI 1.52, 1.82; P < 0.001), and malignancy (HR 1.75, 95% CI 1.30, 2.37; P = 0.031), whereas respiratory disease (HR 1.49, 95% CI 0.99, 2.24; P = 0.056), diabetes (HR 1.15, 95% CI 0.96, 1.37; P = 0.121), and smoking (HR 1.54, 95% CI 0.64, 3.71; P = 0.337) did not increase the risk of mortality.

CONCLUSION

The current study investigated several factors that might increase the risk of mortality in elderly patients with hip fracture. Further studies are needed to evaluate the effectiveness of specific interventions to reduce the risk of mortality.

Osteoporotic Pelvic Fractures

BACKGROUND

The estimated incidence of osteoporotic pelvic fractures among persons over age 60 in Germany is 224 per 100 000 persons per year, and rising. A number of surgical treatment options are available, but clinical long-term data are lacking.

METHODS

This review is based on pertinent publications and guidelines retrieved by a selective literature search, and on the authors' clinical experience.

RESULTS

Patients often report one or more relatively trivial traumatic incidents leading up to the fracture. They complain of pain in the hip, groin, or lower lumbar region, or of low back pain and sciatica. A new classification scheme entitled Fragility Fractures of the Pelvis (FFP) takes the morphology of the fracture into account and can be used as an aid to therapeutic decision-making (evidence level IV). The goal of treatment is early mobilization with adequate pain relief. Isolated anterior pelvic ring fractures (FFP I) and nondisplaced posterior pelvic ring fractures (FFP II) are usually stable and can be treated conservatively. Type III and IV injuries are unstable and should generally be treated surgically.

CONCLUSION

Retrospective analyses have shown that osteoporotic pelvic fractures are associated with decreased mobility and independence and with a one-year mortality ranging from 9.5% to 27%. Prospective therapeutic trials are urgently needed.

Palliative care in dementia: issues and evidence

Palliative care is an approach that stands well with the aims of person-centred dementia care. There is no doubt that the standards of care for many people with advanced dementia are poor. There is a lack of good-quality evidence, however, to support any particular approach for palliative care in dementia. Still, there are a number of areas in relation to caring for people with severe dementia where a palliative approach might be beneficial. In general, the relevant decisions have to be made on an individual basis but within a palliative framework. Advance care planning is likely to be crucial in encouraging this process. There is certainly a moral imperative behind the idea that care at the end of life for people with dementia should be improved.

Prevalence of pain and pharmacological pain treatment among old people in nursing homes in 2007 and 2013

PURPOSE

Many elderly people living in nursing homes experience pain and take analgesic medication. The aim of this study was to analyze the prevalence of pain and pharmacological pain treatment among people living in nursing homes in Sweden, in two large, comparable, samples from 2007 to 2013.

METHODS

Cross-sectional surveys were performed in 2007 and 2013, including all residents in nursing homes in the county of Västerbotten, Sweden. A total of 4933 residents (2814 and 2119 respectively) with a mean age of 84.6 and 85.0 years participated. Of these, 71.1 and 72.4% respectively were cognitively impaired. The survey was completed by the staff members who knew the residents best.

RESULTS

The prescription of opioids became significantly more common while the use of tramadol decreased significantly. The staff reported that 63.4% in 2007 and 62.3% in 2013 had experienced pain. Of those in pain, 20.2% in 2007 and 16.8% in 2013 received no treatment and 73.4 and 75.0% respectively of those with pain, but no pharmacological treatment, were incorrectly described by the staff as being treated for pain.

CONCLUSIONS

There has been a change in the pharmacological analgesic treatment between 2007 and 2013 with less prescribing of tramadol and a greater proportion taking opioids. Nevertheless, undertreatment of pain still occurs and in many cases, staff members believed that the residents were prescribed analgesic treatment when this was not the case.

Physiological and Behavioral Responses to Calibrated Noxious Stimuli Among Individuals with Cerebral Palsy and Intellectual Disability

Objective

As individuals with intellectual disability (ID) due to cerebral palsy (CP) are at high risk of experiencing pain, measuring their pain is crucial for adequate treatment. While verbal reports are the gold standard in pain measurements, they may not be sufficient in ID. The aim was to detect behavioral/autonomic responses that may indicate the presence and intensity of pain in individuals with CP and ID, using calibrated stimuli, here for the first time.

Subjects

Thirteen adults with CP and ID (CPID), 15 healthy controls (HC), and 5 adults with CP with no ID (CPNID).

Methods

Subjects received pressure stimuli of various intensities. Self-reports (using a pyramid scale), facial expressions (retrospectively analyzed with Facial Action Coding System = FACS), and autonomic function (heart rate, heart rate variability, pulse, galvanic skin response) were analyzed.

Results

Self-reports and facial expressions but not the autonomic function exhibited stimulus-response relationship to pressure stimulation among all groups. The CPID group had increased pain ratings and facial expressions compared with controls. In addition, the increase in facial expressions along the increase in noxious stimulation was larger than in controls. Freezing in response to pain was frequent in CPID.

Conclusions

1) Individuals with CP and ID have increased responses to pain; 2) facial expressions and self-reports, but not autonomic variables can reliably indicate their pain intensity; 3) the pyramid scale is suitable for self-report in this population. Although facial expressions may replace verbal reports, increased facial expressions at rest among these individuals may mask pain, especially at lower intensities.

Postoperative Treatment of Pain after Hip Fracture in Elderly Patients with Dementia

BACKGROUND/AIMS

Prior studies have shown that patients with dementia are at risk of receiving insufficient treatment for pain after a hip fracture. We therefore hypothesized that elderly hip fracture patients with dementia received less postoperative pain treatment than those without dementia.

METHOD

All patients (age ≥65 years) who had been operated on for a hip fracture in the Copenhagen University Hospital region in 2009 were included. Data about analgesic use for the first 72 h after surgery were acquired from the hospitals' electronic medication system and linked with information about dementia, comorbidity, and prior drug use.

RESULTS

A total of 1,507 patients were included, of which 296 (19.6%) suffered from dementia. Both groups were equally likely to receive paracetamol and opioids. Patients with dementia received lower doses of oral morphine equivalents during the first [dementia vs. no dementia: 29.0 (26.4-31.8) vs. 34.7 (33.1-36.4) mg, p = 0.001] and second [27.8 (25.4-30.5) vs. 31.2 (29.9-32.4) mg, p = 0.019] but not on the third postoperative day (p = 0.10).

CONCLUSION

The lower doses of opioids may reflect uncertainty about how to treat pain patients with dementia. Further guidance is needed, as inadequate treatment of pain may have adverse consequences.

Pain Assessment of Elderly Patients with Cognitive Impairment in the Emergency Department: Implications for Pain Management-A Narrative Review of Current Practices

Elderly people are susceptible to both falls and cognitive impairment making them a particularly vulnerable group of patients when it comes to pain assessment and management in the emergency department (ED). Pain assessment is often difficult in patients who present to the ED with a cognitive impairment as they are frequently unable to self-report their level of pain, which can have a negative impact on pain management. This paper aims to review how cognitive impairment influences pain assessment in elderly adults who present to the ED with an injury due to a fall. A literature search of EMBASE, ProQuest, PubMed, Science Direct, SciFinder and the Curtin University Library database was conducted using keyword searches to generate lists of articles which were then screened for relevance by title and then abstract to give a final list of articles for full-text review. Further articles were identified by snowballing from the reference lists of the full-text articles. The literature reports that ED staff commonly use visual or verbal analogue scales to assess pain, but resort to their own intuition or physiological parameters rather than using standardised observational pain assessment tools when self-report of pain is not attainable due to cognitive impairment. While studies have found that the use of pain assessment tools improves the recognition and management of pain, pain scores are often not recorded for elderly patients with a cognitive impairment in the ED, leading to poorer pain management in this patient group in terms of time to analgesic administration and the use of strong opioids. All healthcare professionals involved in the care of such patients, including pharmacists, need to be aware of this and strive to ensure analgesic use is guided by appropriate and accurate pain assessment in the ED.

Pain Assessment in Noncommunicative Adult Palliative Care Patients

Palliative care patients who have pain are often unable to self-report their pain, placing them at increased risk for underrecognized and undertreated pain. Use of appropriate pain assessment tools significantly enhances the likelihood of effective pain management and improved pain-related outcomes. This paper reviews selected tools and provides palliative care clinicians with a practical approach to selecting a pain assessment tool for noncommunicative adult patients.

Drug-based pain management for people with dementia after hip or pelvic fractures: a systematic review

Background

Studies indicate that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent drug-based pain management is performed for people with dementia following a hip or pelvic fracture.

The aim of this systematic review was to identify and analyse studies that investigate drug-based pain management for people with dementia with a hip or pelvic fracture in all settings. Treatment could be surgical or conservative. We also analysed study designs, methods and variables, as well as which assessments were applied to measure pain management and mental status.

Method/design

The development of this systematic review protocol was guided by the PRISMA-P requirements, which were taken into consideration during the review procedures. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect were searched. Studies published up to January 2016 were included. The data extraction, content and quantitative descriptive analysis were carried out systematically, followed by a critical appraisal.

Results

Eight of the 13 included studies focusing on patient data showed that people with dementia received less drug-based pain management than people without cognitive impairment. Four studies based on surveys of healthcare professionals stated that cognitive impairment is a major barrier for effective pain management. There was heterogeneity regarding the assessment of the mental status and the pain assessment of the patients. The assessment of the drugs administered in all of the studies working with patient data was achieved through chart reviews.

Conclusion

People with dementia do not seem to receive the same amount of opioid analgesics after hip fracture as people without cognitive impairment. There is need to enhance pain assessment and management for these patients. Future research should pay more attention to the use of the appropriate items for assessing cognitive impairment and pain in people with dementia.

Trial registration

This systematic review was registered at Prospero (CRD42016037309); on 11 April 2016, and the systematic review protocol was published (Syst Rev. 5(1):1, 2016).

The Challenges of Anaesthesia and Pain Relief in Hip Fracture Care

The care of the older person with hip fracture is complicated by their comorbid condition, limited physiological reserve, cognitive impairment and frailty. Two aspects of hip fracture management that have received considerable attention are how best to manage the pain associated with it and the ideal mode of anaesthesia. Existing literature has reported on the suboptimal treatment of pain in this orthogeriatric cohort. With recent advancements in medical care, a number of options have emerged as alternatives to conservative systemic analgesia. Systemic analgesia, such as opioids, can lead to untoward side effects, especially in this particular group of patients. Hence, peripheral nerve blocks, epidural analgesia and regional anaesthesia have emerged as options in the delivery of adequate pain relief in hip fractures. Besides that, there is ongoing debate regarding the appropriate anaesthesia technique for surgical repair of the fractured hip. The benefits and risks related to either spinal anaesthesia or general anaesthesia have been subject to studies determining which method is associated with better short- and long-term outcomes. In this review, we aim to examine the evidence behind the different analgesia options available, compare spinal and general anaesthesia, and discuss the importance of the multidisciplinary orthogeriatric model of care in hip fracture and its potential role in other fragility fractures.

Risk Factors for Urinary Retention Following Surgical Repair of Hip Fracture in Female Patients

BACKGROUND/OBJECTIVES

Postoperative urinary retention (POUR) is a common event following surgical procedures. An increase in the number of elderly individuals who undergo hip fracture repair procedures is inevitable due to the aging of population. Postoperative urinary retention is associated with both early (infections, delirium) and late complications (urinary incontinence) of surgery. The objective of the current study is to direct attention to the less studied population of patients admitted to a geriatric rehabilitation ward following hip fracture repair who are at risk of POUR.

DESIGN

Prospective single-center cohort study.

SETTING

Academic tertiary hospital.

MEASUREMENT

Postvoid bladder volume by ultrasonography (US).

RESULTS

Postvoid bladder volume was measured by US in 88 consecutive female patients on the morning following their admission to the geriatric rehabilitation department. The mean age of the patients was 82.5 ± 6.5 years, and the frequency of POUR (defined as postvoid bladder volume ≥200 mL) was 37.5%. The POUR (n = 33) and non-POUR (n = 55) groups were similar with respect to most demographic and disease states. Multivariable stepwise logistic regression revealed a significant effect for opioid use (relative risk [RR] = 8.0, P < .001) and for treatment with anticholinergic medication (RR = 1.3, P = .046). There was an unexpectedly high proportion of patients with asymptomatic urinary retention (29 of the 33 patients, 88%).

CONCLUSION

The high incidence of asymptomatic POUR in elderly patients calls for the need for improved screening tools for early identification and treatment.

Gaps in Aging Research as it Applies to Rheumatologic Clinical Care

The incidence and prevalence of rheumatologic conditions are increasing and the rheumatology workforce must be aware of aging-specific issues. This article reviews specific barriers to understanding the biology of aging and aging-related mechanisms that may underlie development of rheumatologic diseases in older adults. It summarizes gaps in the assessment, outcomes measurement, and treatment of these diseases in this unique population. It also highlights potential solutions to these barriers and suggests possible ways to bridge the gap, from a research and education standpoint, so that clinicians can be better prepared to effectively manage older adults with rheumatologic conditions.

Evaluation of a Behavioral Assessment Tool for the Individual Unable to Self-report Pain

Assessment of pain intensity using a standard self-reported pain score is standard practice in most institutions. These instruments require the cognitive ability to process the pain intensity into a numeric or descriptive value. Many institutions are considering adopting an assessment tool for cognitive impairment. The purpose of this study is to evaluate a clinician-administered assessment tool, PAINAD, in patients with cognitive impairment. Opioid consumption and frequency of documented unknown pain were collected in 2 cognitive impaired groups. In the control group, a self-reporting pain intensity tool was used, and in a second group, the PAINAD was used. Opioid use was significantly higher ( P = .003) and the rates of reported unknown pain were significantly lower ( P < .01) in the group using the PAINAD instrument compared to the control group of patients with cognitive impairment. There were no noted differences in opioid-induced adverse reactions in either group.

An Exploration of Seniors' Ability to Report Pain

The purpose of this study was to evaluate the ability of a group of elderly residents to use self-report methods to measure their pain in an accurate fashion. Using a comparative descriptive design, completion rates of three pain assessment tools and the self-report skills of a sample of 130 long-term care residents with varying levels of cognitive impairment were evaluated. The majority of residents with mild to moderate cognitive impairment were able to complete at least one of the verbal pain assessment tools, with the Present Pain Intensity and Numerical Rating Scales being the preferred choices for use in clinical settings. However, the Faces Pain Scale appeared to be more challenging for residents to complete, suggesting that it requires further testing before it can be recommended for clinical use.

Cognitive Citizenship: Access to Hip Surgery for People with Dementia

Dementia and chronic hip disease are both more prevalent with advancing age. Given this, the number of people with both dementia and hip disease is likely to increase in an ageing population such as the UK. This article raises questions about how people with dementia and chronic hip disease are conceptualized in the context of evidence-based medicine, and whether this conceptualization may limit unfairly their access to surgical services. The published clinical research discourse at the interface of hip disease and dementia is taken as an ‘evidence-base’, and is evaluated in terms of its suitability for informing professional decisions about viability for surgery. The analysis suggests that the outcomes criteria used to determine patient viability serve to discriminate unfairly against people with dementia. If such discrimination exists, it necessarily militates against the promotion of health-related citizenship rights of the cognitively impaired, creating an evidence-based culture that encourages a problematic model of cognitive citizenship.

Assisting Older Clients With Pain Management in the Home

Older home health clients experience significant pain from a variety of age-related conditions. It is important for home health nurses to be knowledgeable about strategies for assessing and managing pain that are adapted to the unique needs of the older patient. A thorough pain assessment gathers key information guiding treatment decisions and follow-up evaluation of intervention effectiveness. Nonpharmacologic interventions, including comfort measures, cutaneous stimulation techniques, and cognitive-behavioral strategies, may help to relieve mild pain when used alone and moderate to severe pain when used in addition to analgesic medications. Assessment and treatment strategies can be tailored to meet the needs of the older clients, taking into account the clients’ cognitive ability and caregivers’ willingness to participate. Home health nurses, in their limited contact time, can educate both older clients and family caregivers in actively managing pain through frequent pain assessment and the use of nonpharmacologic interventions.

Local anaesthetic wound infiltration after internal fixation of femoral neck fractures: a randomized, double-blind clinical trial in 33 patients

Pain control may assist early mobilisation after internal fixation of femoral neck fractures. Systemic opioids have significant side effects in elderly patients. We present an evaluation of the effect of local anaesthetic infiltration in such cases , the objective being to decrease the need for postoperative opioids and to improve pain control for patients after surgery. 33 patients undergoing internal fixation with 2 parallel hook pins were randomized into 2 groups in a double blind study (ClinicalTrials.gov: NCT00529425). 33 patients received intraoperative infiltration followed by 6 postoperative injections through an intraarticular catheter in eight-hour intervals. 19 patients received ropivacaine and 14 received saline. The intervention period was 48 hours and the observation period was 5 days. In both groups there were no restrictions on the total daily dose of rescue analgesics. Pain was assessed at specific postoperative time-points and the daily consumption of opioid drugs needed for analgesia was registered. There was no significantly reduced consumption of standardized opioid rescue analgesics or pain in the study group receiving ropivacaine injections. Apart from a reduction in nausea in the study group on the second postoperative day, there were no significant differences in the occurrence of side effects between the groups. On day 2 the placebo group had less pain than the study group. Local anaesthetic infiltration after fixation of femoral neck fractures does not reduce opioid consumption or pain'.

Pain Assessment with Cognitively Impaired Older People in the Acute Hospital Setting

Research reveals that older people continue to experience much suffering from acute and chronic pain conditions.People with cognitive impairment receive less analgesia than their cognitively intact peers.Postoperative pain assessment with older people in the acute hospital setting remains a challenge.Context and culture have a significant impact of pain assessment practices.Due to a paucity of research exploring how pain assessment and management practices with cognitively impaired older people may be realised in the acute hospital setting, there is a need for further research to be conducted.

Pain relief management following proximal femoral fractures: Options, issues and controversies

The majority of proximal femoral fractures occur in the elderly population. Safe and adequate pain relief is an integral part of the overall management of hip fractures. Inherent difficulties in the assessment of pain in elderly need to be taken into account and unique considerations should be made regarding the effective analgesia due to different elderly physiology, and their response to trauma and subsequent surgery. The pain management should start as soon as possible and special emphasis should be paid to contemporary methods of regional anaesthesia whilst a multimodal approach should be adopted in the perioperative period. The present review summarises the contemporary treatment options and controversies pertaining to the management of pain in elderly patients with proximal femoral fractures.

Pain reporting in older adults: the influence of cognitive impairment - results from the Cambridge City >75 Cohort study

OBJECTIVES

Evidence suggests that while disabling back pain (BP), and rheumatic diseases associated with pain, continues to increase with age, the prevalence of non-disabling BP reaches a plateau, or even decreases, in the oldest old. This study aimed to determine whether this age-related pattern of non-disabling BP is a function of increasing cognitive impairment.

METHODS

Cross-sectional study of adults aged >77 years. Participants answered interviewer-administered questions on BP and cognitive function, assessed using the Mini-Mental State Examination, categorised into normal versus mild, moderate or severe impairment. The relationship between cognitive function and BP was examined using multinomial logistic regression, adjusted for age, sex and residence.

RESULTS

Of 1174 participants with BP data, 1126 (96%) completed cognitive assessments. The relationship between cognitive function and BP differed for disabling and non-disabling BP. Across categories of cognitive impairment, increasingly higher prevalence of disabling BP was reported, compared to those with normal cognition, although this was not statistically significant (odds ratio (OR) = 1.7; 95% confidence interval (CI) = 0.7-4.6). No association was found between cognitive function and non-disabling BP (OR = 0.8; 95% CI = 0.4-1.6).

CONCLUSION

This study found no association between the reporting of BP and level of cognitive impairment, suggesting that increasing cognitive impairment is an inadequate explanation for age-related decline in self-reported non-disabling BP. Future research should determine the reasons for the decline in non-disabling pain in older adults, although, meanwhile, it is important to ensure that this group receive appropriate pain assessment and pain management.

KEY POINTS

Prevalence of non-disabling back pain decreases in the oldest old.Some have proposed that this may be a function of cognitive impairment in older age, and an increasing inability to adequately report pain.Our findings do not support this hypothesis.

How do healthcare workers judge pain in older palliative care patients with delirium near the end of life?

Objective:

Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging, and there is currently no validated assessment tool for this task. The present retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain.

Method:

We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (N= 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome.

Results:

We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behavior. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting.

Significance of results:

These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.

Decision Factors Nurses Use to Assess Pain in Nursing Home Residents With Dementia

Nurses caring for older people with various psychiatric illnesses face many obstacles when treating pain. One setting with a high percentage of psychiatric conditions is long-term care where more than half of residents have some form of dementia, and behavioral symptoms of dementia (BSDs) may mimic behavioral displays of pain. Furthermore, two-thirds of nursing home residents have pain. Thus, many nursing home residents with dementia have pain that may be confounded by BSDs. Since many people with dementia are at risk for poor pain management, determining current methods in which nurses assess and manage pain in nursing home residents will aid in recognizing potential barriers to using current pain management guidelines and help develop strategies to enhance nurses' assessment and management of pain in this vulnerable population. The aim of this study was to explore nursing home nurses' cues and practices to identify and alleviate pain in nursing home residents with dementia. Nurses use the constructs of 'comfort' and 'quality of life' as key components in their overall pain assessment strategy in people with dementia. Indeed, the extensive process they use involving frequent reassessment and application of interventions is geared towards "appearance of comfort." Nurses reported difficulty in ascertaining whether a person with dementia was in pain, and they expressed further difficulty determining the intensity associated with resident pain. Nurses further reported that residents with dementia who are not well know by the staff were are greater risk of poor pain management. It was not unusual for nurses to discuss the importance of conflict resolution among family members as well as allowing for open expression of family's concerns. Nurses had to focus not only on the resident's comfort, but also the families' level of comfort with pain management, especially at the end-of-life. Findings support further use and development of discomfort behavior scales to help manage pain.

Pain intensity among institutionalized elderly: a comparison between numerical scales and verbal descriptors

AbstractOBJECTIVECorrelating two unidimensional scales for measurement of self-reported pain intensity for elderly and identifying a preference for one of the scales.METHODA study conducted with 101 elderly people living in Nursing Home who reported any pain and reached ( 13 the scores on the Mini-Mental State Examination. A Numeric Rating Scale - (NRS) of 11 points and a Verbal Descriptor Scale (VDS) of five points were compared in three evaluations: overall, at rest and during movement.RESULTSWomen were more representative (61.4%) and the average age was 77.0±9.1 years. NRS was completed by 94.8% of the elderly while VDS by 100%. The association between the mean scores of NRS with the categories of VDS was significant, indicating convergent validity and a similar metric between the scales.CONCLUSIONPain measurements among institutionalized elderly can be made by NRS and VDS; however, the preferred scale for the elderly was the VDS, regardless of gender.