A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery

Kinins' Contribution to Postoperative Pain in an Experimental Animal Model and Its Implications

Postoperative pain causes discomfort and disability, besides high medical costs. The search for better treatments for this pain is essential to improve recovery and reduce morbidity and risk of chronic postoperative pain. Kinins and their receptors contribute to different painful conditions and are among the main painful inflammatory mediators. We investigated the kinin's role in a postoperative pain model in mice and reviewed data associating kinins with this painful condition. The postoperative pain model was induced by an incision in the mice's paw's skin and fascia with the underlying muscle's elevation. Kinin levels were evaluated by enzyme immunoassays in sham or operated animals. Kinin's role in surgical procedure-associated mechanical allodynia was investigated using systemic or local administration of antagonists of the kinin B₁ receptor (DALBk or SSR240612) or B₂ receptor (Icatibant or FR173657) and a kallikrein inhibitor (aprotinin). Kinin levels increased in mice's serum and plantar tissue after the surgical procedure. All kinin B₁ or B₂ receptor antagonists and aprotinin reduced incision-induced mechanical allodynia. Although controversial, kinins contribute mainly to the initial phase of postoperative pain. The kallikrein-kinin system can be targeted to relieve this pain, but more investigations are necessary, especially associations with other pharmacologic targets.

The Prognostic Performance of Frailty for Delirium and Functional Decline in Vascular Surgery Patients

BACKGROUND

Frailty in older vascular surgery patients is associated with increased mortality, hospital stay, and morbidity. The association of frailty with hospital-acquired geriatric syndromes such as delirium and functional decline has not been well studied.

OBJECTIVES

To investigate the association between frailty and hospital-acquired geriatric syndromes in older hospitalized vascular surgery patients, and to evaluate the prognostic performance of the frailty index (FI) and the Clinical Frailty Scale (CFS) for delirium and functional decline.

DESIGN

Prospective cohort study.

SETTING

Acute care academic hospital.

PARTICIPANTS

Patients aged 65 years or more admitted to a tertiary vascular surgery unit (N=150).

MEASUREMENTS

Frailty was assessed using the FI and CFS. The adjusted association of frailty status with delirium and functional decline was assessed using logistic regression analysis. The prognostic performance of FI and CFS was determined by assessing C-statistic and positive and negative predictive values (PPV and NPV).

RESULTS

Of 150 participants, FI identified 34 (23%) and CFS identified 45 (30%) as frail. Frailty was an independent predictor of delirium (FI adjusted odds ratio, odds ratio (OR) = 5.66, 95% confidence interval (CI) = 1.53-21.03; CFS adjusted OR = 4.07, 95% CI = 1.14-14.50), but not functional decline. FI and CFS showed acceptable prognostic performance for delirium (C-statistic 0.74), but not functional decline (C-statistic 0.63-0.64). For both outcomes, the FI and CFS had high NPV (86-96%), and low PPV (22-29%).

CONCLUSION

Frail older vascular surgery patients are more likely to develop hospital-acquired geriatric syndromes. The FI and CFS have acceptable prognostic performance for predicting delirium but not all individuals who are identified as frail develop delirium. Ongoing research is needed to identify interventions that improve outcomes in patients who screen positive for frailty.

[Considerations concerning the perioperative use of metamizole]

BACKGROUND

The non-opioid analgesic metamizole (dipyrone) is approved for the treatment of severe pain and is often used in the perioperative period. As it can cause agranulocytosis, a severe adverse event, its perioperative administration is controversially discussed.

OBJECTIVE

Is there enough evidence for a high risk of metamizol-induced agranulocytosis (MIA)? What are the consequences of its perioperative use with respect to the risk profiles of alternative analgesics?

MATERIAL AND METHODS

Rapid review of the literature on the risk of MIA and adverse effects of non-opioid analgesics.

RESULTS

The incidence of MIA is estimated to be one case per million inhabitants per year. The risk seems low compared to other drugs associated with a risk of agranulocytosis, such as antithyroid drugs and ticlopidine. The risk profile of metamizole concerning hepatotoxicity, nephrotoxicity, bleeding and cardiovascular adverse effects is favorable compared to other non-opioid analgesics. None of the non-opioid analgesics are licensed to be administered intraoperatively.

CONCLUSION

The perioperative use of metamizole is possible after a thorough evaluation of the indications as it provides good analgesia with a generally favorable side effect profile and is administered intravenously. The risk of agranulocytosis is small but needs to be mentioned during patient informed consent in order to optimize early recognition. Intraoperative administration aims at reducing the expected severe postoperative pain. A documentation and justification for the evaluation of the indications are recommended.

The Pelvic Girdle Pain deadlock: 2. Topics that, so far, have remained out of focus

INTRODUCTION

In our preceding paper, we concluded that Pelvic Girdle Pain (PGP) should be taken seriously. Still, we do not know its causes. Literature reviews on treatment fail to reveal a consistent pattern, and there are patients who do not respond well to treatment. We designated the lack of progress in research and in the clinic as 'deadlock', and proposed a 'deconstruction' of PGP, that is to say, taking PGP apart into its relevant dimensions.

PURPOSE

We examine the proposition that PGP may emerge as local inflammation. Inflammation would be a new dimension to be taken into account, between biomechanics and psychology. To explore the consequences of this idea, we present four different topics that, so far, have remained out of focus. One: The importance of microtrauma. Two: Ways to counteract chronification. Three: The importance of sickness behaviour when systemic inflammation turns into neuroinflammation of the brain. And Four: The mainly emotional and cognitive nature of chronic pain, and how aberrant neuroinflammation may render chronic pain intractable. For intractable pain, sleep and stress management are promising treatment options.

IMPLICATIONS

The authors hope that the present paper helps to stimulate the flexible creativity that is required to deal with the biological and psychological impact of PGP. Measuring inflammatory mediators in PGP should be a research priority. It should be understood that the boundaries between biology and psychology are becoming blurred. Clinicians must frequently monitor pain, disability, and mood, and be ready to switch treatment whenever the patient does not improve.

Effectiveness of Multimodal Pain Therapy on Reducing Opioid Use in Surgical Geriatric Hip Fracture Patients

BACKGROUND

There is a need for appropriate pain control in the geriatric hip fracture population to prevent diminished function, increased mortality, and opioid dependence. Multimodal pain therapy is one method for reducing pain postoperatively while also decreasing opioid use in the geriatric hip fracture patient. This study aimed to determine whether multimodal pain therapy could decrease opioid use without increasing pain scores in surgical geriatric hip fracture patients.

METHODS

This was a before-and-after cohort study. The hospital implemented multimodal pain control order sets with a standardized pain regimen and performed retrospective chart review pre- and postorder set implementation for analysis.

RESULTS

A total of 248 patients were enrolled in the study: 131 in the preorder set group and 117 in the postorder set group. The mean postoperative oral morphine equivalent (OME) was significantly lower in the postorder set group than in the preorder set group (45.1 mg vs. 63.4 mg, respectively, p = .03). Compared with the preorder set group, total OME and postoperative OME were decreased by 22.6% (95% confidence interval [CI] -44.9, -3.8), 1-tailed p < .01, and 53.6% (95% CI -103.4, -16.1), 1-tailed p <.01 respectively, in the postorder set group. There was not a statistically significant difference in mean pain scores at 6, 24, and 48 hr postoperatively (p = .53, .10, and .99), respectively.

CONCLUSION

Implementing a multimodal approach to pain management may help reduce opioid use and may be a critical maneuver in averting the national opioid epidemic.

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial

BACKGROUND

Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).

METHODS

Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.

DISCUSSION

This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.

Nerve Block Use after Hip Fracture Versus Elective Hip or Knee Arthroplasty: Retrospective Analysis

OBJECTIVES

Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt.

DESIGN

Retrospective cohort study of claims data from one large national private US insurer.

SETTING

US acute care hospitals.

PARTICIPANTS

A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016.

MEASUREMENTS

Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims.

RESULTS

Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9-3.1) received a nerve block for pain control, and the percentage receiving a block increased from .4% in 2004-2006 (95% CI = .3%-.6%) to 4.6% in 2013-2016 (95% CI = 4.4%-4.8%; P < .001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] = .88; 95% CI = .80-.98; P = .02) and among patients aged 75 to 84 vs 64 years or younger (OR = .86; 95% CI = .74-1.00; P = .02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement.

CONCLUSION

Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835-840, 2020.

Effectiveness of interventions on the appropriate use of opioids for noncancer pain among hospital inpatients: A systematic review

AIMS

To summarise the effectiveness of interventions on appropriate opioid use for noncancer pain among hospital inpatients.

METHODS

Two reviewers independently searched 6 databases up to March 2018 original research articles reporting on quantitative outcomes of interventions on appropriate opioid use among hospital inpatients. Appropriate opioid use was measured by changes in prescribing, such as the lowest effective opioid dose and duration, or clinical outcomes such as adequate pain control. Quality and intervention complexity assessments were performed by 2 independent reviewers. The full methodological approach was published on PROSPERO (ID: CRD42019145947).

RESULTS

Of 398 full-text articles assessed for eligibility, 37 articles were included in the review. Most articles had a moderate or high risk of bias (27 of 37 studies). Thirty-one articles primarily addressed appropriate opioid use and 6 articles targeted opioid safety as a secondary outcome. A multifaceted approach was the most common primary intervention (16 studies) and adequate pain control was the main outcome measured (14 studies). Health provider education, reinforced by hard-copy material and feedback, was associated with a 13.0 to 29.5% increase in the proportion of opioid prescriptions written in concordance with local guidelines and reduced pain scores ranging from 7.0 to 34.5%. Interventions to improve opioid safety in patient-controlled analgesia reduced medication errors by up to 89.1%.

CONCLUSION

Interventions involving academic detailing and education, especially when reinforced by feedback, show positive effects on appropriate opioid use among hospital inpatients. Future studies investigating the impact of administrative interventions on opioid use and related outcomes are warranted.

Multidimensional investigation of chronic pain experience and physical functioning following hip fracture surgery: clinical implications

Introduction

Older adults experience significant chronic pain after hip fracture, resulting in decreased physical functioning. However, pain investigation in this population is mostly limited to self-reported pain intensity. Detailed pain assessment may identify intervention targets other than pain relief. The aim of this study is to investigate multiple dimensions of pain experience (intensity, sensory, affective, evaluative and miscellaneous dimensions) and to correlate them to lower limb functionality and limitations in daily living activities.

Methods

We conducted a cross-sectional study of 50 older adults (77.1 ± 8.1 years old) who underwent hip fracture surgery in the past 4 months. We used the Numeric Rating Scale (NRS), the McGill Pain Questionnaire (MPQ) and an algometer to assess pain intensity, pain quality and pressure pain threshold, respectively. Lower limb functionality and limitation in basic (activities of daily living (ADL)) and instrumental activities of daily living (IADL) were assessed using the Short Physical Performance Battery (SPPB) and the Brazilian OARS Multidimensional Functional Assessment Questionnaire.

Results

Participants described pain as brief, momentary and transient, especially during weight-bearing activities. Although the pain intensity measured by the NRS was reported as moderate to severe (7.5 ± 1.6 points), it was not correlated with physical functioning. However, we observed a moderate negative correlation between pressure pain threshold, ADL and IADL disability (r = -0.41, p < 0.01). Among pain qualities, the sensory category was moderately negatively correlated to SPPB (r = -0.41, p < 0.01), and the evaluative category was moderately correlated to ADL and IADL disability (r = 0.43, p < 0.01).

Conclusion

Pain can be present 4 months after hip fracture surgery, particularly during weight-bearing activities, and it is associated with poor lower limb functionality, as well as ADL and IADL disability. Older adults may benefit from pain assessments that go beyond pain intensity measurements after hip fracture, as this helps clinicians optimise pain management and overall functional recovery.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.

Effect of infraorbital nerve block on postoperative pain and 30-day morbidity at the donor site in buccal mucosal graft urethroplasty

Background and Aims

Buccal mucosa harvest for substitution urethroplasty can be painful, and may be associated with long-term complications such as perioral numbness, persistent difficulty with mouth opening, and change in salivary function. This study was designed to evaluate the efficacy of infraorbital nerve block (IOB) in relieving postoperative pain at the donor site of the buccal mucosal graft (BMG) and its associated morbidity at 30 days.

Material and Methods

Thirty adults scheduled for BMG urethroplasty were enrolled in this study and were randomized to receive either no block group I (control) and IOB group II intraorally with 1 mL of 0.5% bupivacaine. Pain was assessed by visual analog scale, intraoral morbidity, and patient satisfaction in the immediate postoperative period. All patients were reviewed after 1 month for morbidity such as perioral numbness, pain on mastication, and tightness on mouth opening. Statistical analysis was done using Mann-Whitney's U and Chi-square tests.

Results

Median time to pain-free oral intake for liquids (group I: 2-5 days, group II: 1 day, P < 0.001) and solids (group I: 4 days, group II: 2 days, P < 0.001) was earlier in group II. At the follow-up after 1 month, one patient in group II and three patients in group I showed perioral numbness (P = 0.026), and five patients had pain on mastication in group I (P = 0.016).

Conclusion

IOB is associated with postoperative analgesia and facilitation of early food intake, mitigating the morbidity of the donor site and provides satisfaction.

Prevention and Treatment of Chronic Postsurgical Pain: A Narrative Review

Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain

OBJECTIVES

Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes.

RESULTS

Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups.

CONCLUSION

In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.

Contributions of Nociresponsive Area 3a to Normal and Abnormal Somatosensory Perception

Traditionally, cytoarchitectonic area 3a of primary somatosensory cortex (SI) has been regarded as a proprioceptive relay to motor cortex. However, neuronal spike-train recordings and optical intrinsic signal imaging, obtained from nonhuman sensorimotor cortex, show that neuronal activity in some of the cortical columns in area 3a can be readily triggered by a C-nociceptor afferent drive. These findings indicate that area 3a is a critical link in cerebral cortical encoding of secondary/slow pain. Also, area 3a contributes to abnormal pain processing in the presence of activity-dependent reversal of gamma-aminobutyric acid A receptor-mediated inhibition. Accordingly, abnormal processing within area 3a may contribute mechanistically to generation of clinical pain conditions. PERSPECTIVE: Optical imaging and neurophysiological mapping of area 3a of SI has revealed substantial driving from unmyelinated cutaneous nociceptors, complementing input to areas 3b and 1 of SI from myelinated nociceptors and non-nociceptors. These and related findings force a reconsideration of mechanisms for SI processing of pain.

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.

The effects of oral pregabalin on post-Lichtenstein herniorrhaphic pain: a randomized clinical trial

Background Pregabalin is a gamma-aminobutyric acid analog which seems to be effective in different neuropathic pains, as well as in incisional and inflammatory injuries. This study evaluated the effectiveness and safety of pregabalin on pain relief post herniorrhaphy. Methods In this randomized clinical trial, 60 men were chosen for unilateral inguinal herniorrhaphy under spinal anesthesia. The participants were randomly divided into two groups. The investigation (pregabalin) group received 300 mg of oral pregabalin 2 h before and 150 mg of pregabalin 12 and 24 h after surgery in addition to routine postoperative medication and 1 mg/kg of pethidine as needed. The control (placebo) group received placebo capsules similar to the investigation group, as well as routine medication and 1 mg/kg of pethidine as needed. All surgeries were done with the same technique. Post-surgery pain was evaluated in the walking and lying positions with a visual analog scale at 12 and 24 h and at 3 and 7 days after the surgery. Pethidine consumption and adverse effects of pregabalin were also assessed. Results The investigation group had less pain and lower visual analog scale scores at 12 and 24 h and also at 3 days after surgery and consumed less pethidine compared to the control group (p<0.05). Conclusions Pregabalin reduces pain and opioid consumption in the first 3 days after surgery. The adverse effects of pregabalin are limited to the first 12 h after surgery. Pregabalin can be suggested for pain relief, but it should be used with caution in the elderly.

Baseline and pre-operative 1-year mortality risk factors in a cohort of 509 hip fracture patients consecutively admitted to a co-managed orthogeriatric unit (FONDA Cohort)

INTRODUCTION

The aim of this study was to determine the patient characteristics that predict 1-year mortality after a hip fracture (HF).

METHODS

All patients admitted consecutively with fragility HF during 1 year in a co-managed orthogeriatric unit of a university hospital (FONDA cohort) were assesed. Baseline and admission demographic, clinical, functional, analytical and body-composition variables were collected in the first 72 h after admission. A protocol designed to minimize the consequences of the HF was applied. One year after the fracture patients or their carers were contacted by telephone to ascertain their vital status.

RESULTS

A total of 509 patients with a mean age of 85.6 years were included. One-year mortality was 23.2%. The final multivariate model included 8 independent mortality risk factors: age >85 years, baseline functional impairment in basic activities of daily living, low body mass index, cognitive impairment, heart disease, low hand-grip strength, anaemia at admission, and secondary hyperparathyroidism associated with vitamin D deficiency. The association of several of these factors greatly increased mortality risk, with an OR (95% confidence interval [CI]) of 5.372 (3.227-8.806) in patients with 4 to 5 factors, and an OR (95% CI) of 11.097 (6.432-19.144) in those with 6 or more factors.

CONCLUSIONS

In addition to previously known factors (such as age, impairment in basic activities of daily living, cognitive impairment, malnutrition and anaemia at admission), other factors, such as muscle strength and hyperparathyroidism associated with vitamin D deficiency, are associated with greater 1-year mortality after a HF.

Assessing and Managing Acute Pain: A Call to Action

: Acute pain, which is usually sudden in onset and time limited, serves a biological protective function, warning the body of impending danger. However, while acute pain often resolves over time with normal healing, unrelieved acute pain can disrupt activities of daily living and transition to chronic pain. This article describes the effects of unrelieved acute pain on patients and clinical outcomes. The authors call on nurses to assess and manage acute pain in accordance with evidence-based guidelines, expert consensus reports, and position statements from professional nursing organizations in order to minimize the likelihood of its becoming chronic.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial

OBJECTIVES

To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture.

DESIGN

Multisite randomized controlled trial from April 2009 to March 2013.

SETTING

Three New York hospitals.

PARTICIPANTS

Individuals with hip fracture (N = 161).

INTERVENTION

Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82).

MEASUREMENTS

Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects.

RESULTS

Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents.

CONCLUSION

Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Expert panel consensus recommendations for postoperative pain management in the Gulf region

Postoperative pain is a considerable issue in the Gulf region; however, at present there is a lack of comprehensive guidelines addressing postoperative pain management in the region. Therefore, an expert panel of pain specialists convened to address this issue and a set of key recommendations has been developed pertinent to the practice of postoperative pain management in the Gulf region (Bahrain, Iraq, Kuwait, Oman, Qatar, Saudi Arabia, the United Arab Emirates and Yemen). These recommendations take into consideration the unique variation in cultural, religious and societal beliefs found in the region, as well as varying accessibility to pain medications, thereby aiming to serve as evidence-based guidance on the best practice management of postoperative pain in the Gulf region.

The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study

BACKGROUND

Considering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC.

OBJECTIVES

This study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices.

METHODS

A mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012.

RESULTS

Implementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC.

CONCLUSIONS

The findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.

New approach for treatment of prolonged postoperative pain: APS Out-Patient Clinic

Background and aims

Persistent postoperative pain (PPP) is a significant clinical problem. Several patient-related risk factors for PPP have been identified, including a previous chronic pain problem, young age, female gender and psychological vulnerability. Intra- and postoperative risk factors include surgical complications such as infections, haematoma, nerve damage and repeated surgery. As the length of hospital stay has been shortened, some patients may be discharged despite ongoing pain and insufficient analgesic medication. The challenge is to identify patients at high risk of developing PPP and to create a targeted care pathway to ensure effective and safe pain treatment especially in the subacute postoperative phase at home. This observational study describes the first two years of the Acute Pain Service Out-Patient Clinic (APS-OPC) at the Helsinki University Hospital.

Methods

Patient characteristics, known risk factors, and details of treatment of PPP for the first 200 patients referred to our APS-OPC were retrospectively collected from the medical records. The APS-OPC clinic functions in close collaboration with the Multidisciplinary Pain Clinic (MPC), and the number of patients in need of physiotherapist, psychologist or psychiatrist counselling was recorded, as well as the number of patients referred to the MPC for further PPP management.

Results

Patients were referred to the APS-OPC from different surgical specialities, the two most common being thoracic and orthopaedic surgery. Seventy per cent of the patients (139/200) presented symptoms indicating neuropathic postsurgical pain. The patients had, on average, five risk factors for PPP. The median time from surgery to the first contact to the APS-OPC was two months, and the median duration of follow-up was 2.8 months (0–16 months). The median number of contacts with APS-OPC was 3 (range 1–14). Every fourth patient needed only one contact to the APS-OPC. Nineteen per cent of the patients had an appointment with the physiotherapist and 20% with a psychologist or psychiatrist. At discharge after surgery, 54% of the patients were using weak opioids, 32% strong opioids and 71% gabapentinoids; at discharge from the APS-OPC, these numbers were 20%, 6% and 43%, respectively. Twenty-two per cent of the patients were referred to the MPC for further pain management.

Conclusions

The APS-OPC provides a fluent fast-track method of ensuring effective multimodal analgesia in the subacute recovery phase after surgery. Even strong opioids can be safely used after discharge and then tapered off in close supervision of the APS-OPC anaesthesiologist. As the APS-OPC was implemented in close collaboration with the MPC, the multidisciplinary resources are easily available during the course of the APS-OPC treatment.

Implications

The first two years of the APS-OPC have shown that a significant number of surgical patients benefit from continuing active pain management after discharge from hospital. This fast-track service provides physician-supervised titration of analgesics to improve pain relief in the subacute phase. An important task of the APS-OPC is to ensure that strong opioids are not inappropriately continued after recovery. Another goal of the APS-OPC is to identify patients in need of multidisciplinary pain management services to prevent chronification.

Ketofol for monitored anesthesia care in shoulder arthroscopy and labral repair: a case report

A 21-year-old male (body mass index: 28.3) with a history of asthma and reactive airway disease since childhood underwent left shoulder arthroscopy and labral repair surgery under monitored anesthesia care. Because the procedure was performed in the beach chair position, access to the patient’s airway was limited throughout. To avoid general anesthesia and to limit potential complications associated with monitored anesthesia care, a ketofol admixture was used. This case demonstrates that, in conjunction with regional anesthesia, ketofol may be an acceptable alternative to propofol for maintenance in outpatient orthopedic procedures.

Pain, Genes, and Function in the Post-Hip Fracture Period

Post-hip fracture generalized pain can lead to a progressive decline in function and greater disability. The purpose of this study was to explore the factors that influence pain among older adults post-hip fracture, including genetic variability, and evaluate whether pain directly or indirectly influenced upper and lower extremity function. This was a secondary data analysis using data from the first 200 participants in a Baltimore Hip Study (BHS), BHS-7. Assessments were done at 2 months post-hip fracture and included age, sex, marital status, education, cognitive status, comorbidities, body mass index (BMI), upper and lower extremity function, single nucleotide polymorphisms (SNPs) from 10 candidate genes, and total areas of pain and pain intensity. Model testing was done using the AMOS statistical program. The full sample included 172 participants with an average age of 81. Fifty percent were female and the majority was Caucasian (93%). Model testing was done on 144 individuals who completed 2 month surveys. Across all models, age, cognition, and BMI were significantly associated with total areas of pain. Thirty SNPs from five genes (BDNF, FKBP5, NTRK2, NTRK3, and OXTR) were associated with areas of pain and/or pain intensity. Together, age, cognition, BMI, and the SNP from one of the five genes explained 25% of total areas of pain and 15% of pain intensity. Only age and cognition were significantly associated with lower extremity function, and only cognition was significantly associated with upper extremity function. The full model was partially supported in this study. Our genetic findings related to pain expand prior reports related to BDNF and NTRK2.

Restricted activity and persistent pain following motor vehicle collision among older adults: a multicenter prospective cohort study

Background

Restricted physical activity commonly occurs following acute musculoskeletal pain in older adults and may influence long-term outcomes. We sought to examine the relationship between restricted physical activity after motor vehicle collision (MVC) and the development of persistent pain.

Methods

We examined data from a prospective study of adults ≥65 years of age presenting to the emergency department (ED) after MVC without life-threatening injuries. Restricted physical activity 6 weeks after MVC was defined in three different ways: 1) by a ≥25 point decrease in Physical Activity Scale in the Elderly (PASE) score, 2) by the answer “yes” to the question, “during the past two weeks, have you stayed in bed for at least half a day?”, and 3) by the answer “yes” to the question, “during the past two weeks, have you cut down on your usual activities as compared to before the accident?” We examined relationships between each definition of restricted activity and pain severity, pain interference, and functional capacity at 6 months with adjustment for confounders.

Results

Within the study sample (N = 164), adjusted average pain severity scores at 6 months did not differ between patients with and without restricted physical activity based on decreased PASE score (2.54 vs. 2.07, p = 0.32). In contrast, clinically and statistically important differences in adjusted average pain severity at 6 months were observed for patients who reported spending half a day in bed vs. those who did not (3.56 vs. 1.91, p < 0.01). In adjusted analyses, both decreased PASE score and cutting down on activity were associated with functional capacity at 6 months, but only decreased PASE score was associated with increased ADL difficulty at 6 months (0.70 vs. -0.01, p = 0.02).

Conclusions

Among older adults experiencing MVC, those reporting bed rest or reduced activity 6 weeks after the collision reported higher pain and pain interference scores at 6 months. More research is needed to determine if interventions to promote activity can improve outcomes after MVC in older adults.

Constipation Prophylaxis Is Rare for Adults Prescribed Outpatient Opioid Therapy From U.S. Emergency Departments

OBJECTIVES

Constipation is a common and potentially serious side effect of oral opioids. Accordingly, most clinical guidelines suggest routine use of laxatives to prevent opioid-induced constipation. The objective was to characterize emergency provider prescribing of laxatives to prevent constipation among adults initiating outpatient opioid treatment.

METHODS

National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2010 were analyzed. Among visits by individuals aged 18 years and older discharged from the emergency department (ED) with opioid prescriptions, the authors estimated the survey-weighted proportion of visits in which laxatives were also prescribed. A subgroup analysis was conducted for individuals aged 65 years and older, as the potential risks associated with opioid-induced constipation are greater among older individuals. To examine a group expected to be prescribed laxative medication and confirm that NHAMCS captures prescriptions for these medications, the authors estimated the proportion of visits by individuals discharged with prescriptions for laxatives among those who presented with constipation.

RESULTS

Among visits in 2010 by adults aged 18 years and older discharged from the ED with opioid prescriptions, 0.9% (95% confidence interval [CI] = 0.7% to 1.3%, estimated total n = 191,203 out of 21,075,050) received prescriptions for laxatives. Among the subset of visits by adults aged 65 years and older, 1.0% (95% CI = 0.5% to 2.0%, estimated total n = 18,681 out of 1,904,411) received prescriptions for laxatives. In comparison, among visits by individuals aged 18 years and older with constipation as a reason for visit, 42% received prescriptions for laxatives.

CONCLUSIONS

In this nationally representative sample, laxatives were not routinely prescribed to adults discharged from the ED with prescriptions for opioid pain medications. Routine prescribing of laxatives for ED visits may improve the safety and effectiveness of outpatient opioid pain management.

Nutzung von Conjoint-Analysen zur Messung von Therapiezielpräferenzen aus Patientenperspektive in der Behandlung psychischer Störungen

Hintergrund: Im Zuge der wachsenden Bedeutung von Ansätzen zur Patientenorientierung und -partizipation in der Gesundheitsversorgung gewinnt die Bestimmung subjektiver Therapiezielpräferenzen unterschiedlicher Akteure (Patienten, Behandler, Angehörige) zunehmend an Forschungsinteresse. Stated-Preference-Methods ermöglichen die systematische Untersuchung speziell patientenorientierter Fragestellungen. Ziele der Studie: Identifikation und Beschreibung (nach formalen, methodischen und inhaltlichen Merkmalen) von Studien mit Stated-Preference-Methods (Conjoint Measurements, Conjoint Analysis, Discrete Choice Experiments) in der Versorgung von Patienten mit psychischen Störungen mit dem Ziel, eine Bewertung zur Anwendbarkeit der Methode (Potential, Nutzen, Grenzen) in zukünftiger patientenorienterter Forschung abzuleiten. Methode: Systematische Literaturrecherche mit folgenden Studieneinschlusskriterien: Participants: Interventionen zur Behandlung von Patienten mit psychischer Störung; Intervention: psychotherapeutische, psychiatrische, hausärztliche Behandlungen (stationär, teil-stationär, ambulant); Comparison: Studien mit keiner (Ein-Gruppen-Design) oder mindestens einer Kontrollgruppe; Outcomes: conjoint-spezifische Angaben zu Nutzenwerten. Ergebnisse: Conjoint-Analysen werden in unterschiedlichen Forschungsdesigns und unter heterogenen Rahmenbedingungen (Stichprobe, Störungsbild, Setting, Intervention, Zieldimension) zur Messung von Therapiezielpräferenzen eingesetzt. Die Erstellung des Conjoint-Designs erfolgt in der Regel reduziert (orthogonal), mithilfe von Softwarepaketen, die Erhebung als Fragebogen. Schlussfolgerungen: Conjoint-Analysen ermöglichen differenzierte Aussagen über Therapiepräferenzstrukturen auf Basis relationaler Beurteilungsszenarien und stellen damit eine fundiertere Basis zur Verbesserung der Patientenorientierung in der Gesundheitsversorgung zur Verfügung. Die Befundlage belegt, dass sich die Methode zur Untersuchung patientenorientierter Fragestellungen (mehrheitlich zu Pharmakotherapie und Kombinationsbehandlung) in der Versorgung psychischer Störungen (depressive Störungen, ADHS, Schizophrenie, bipolare Störungen, Tabak- und Alkoholabhängigkeit und chronische Schmerzen) eignet. Allerdings ist der erfolgreiche Einsatz der Methodik an einige Voraussetzungen geknüpft (u. a. Unabhängigkeit der betrachteten Therapiezielaspekte, Designkomplexität). Forschungsbedarf besteht u. a. im Hinblick auf bisher nicht untersuchte Störungsbilder (u. a. somatoforme, Angst-, Ess-, Persönlichkeitsstörungen) und Interventionen (u. a. reine Psychotherapie, störungsspezifische Behandlungen).

Functional decline in older adults

Functional disability is common in older adults. It is often episodic and is associated with a high risk of subsequent health decline. The severity of disability is determined by physical impairments caused by underlying medical conditions, and by external factors such as social support, financial support, and the environment. When multiple health conditions are present, they often result in greater disability than expected because the patient's ability to compensate for one problem may be affected by comorbid conditions. Evaluation of functional disability is most effective when the physician determines the course of the disability, associated symptoms, effects on specific activities, and coping mechanisms the patient uses to compensate for the functional problem. Underlying health conditions, impairments, and contextual factors (e.g., finances, social support) should be identified using validated screening tools. Interventions should focus on increasing the patient's capacity to cope with task demands and reducing the demands of the task itself. Interventions for functional decline in older adults are almost always multifactorial because they must address multiple conditions, impairments, and contextual factors.

Side effects from oral opioids in older adults during the first week of treatment for acute musculoskeletal pain

OBJECTIVES

The authors sought to describe the frequency of short-term side effects experienced by older adults initiating treatment with opioid-containing analgesics for acute musculoskeletal pain.

METHODS

This was a cross-sectional study of individuals age 65 years or older initiating analgesic treatment following emergency department (ED) visits for acute musculoskeletal pain. Patients were called by phone 4 to 7 days after their ED visits to assess the intensity of six common opioid-related side effects using a 0 to 10 scale and to assess medication discontinuation due to side effects. Propensity score matching was used to compare side effects among patients initiating treatment with any opioid-containing analgesics to side effects among those initiating treatment with only nonopioids.

RESULTS

Of 104 older patients initiating analgesic treatment following ED visits for musculoskeletal pain, 71 patients took opioid-containing analgesics, 15 took acetaminophen, and 18 took ibuprofen. Among the patients who took opioids, at least one side effect of moderate or severe intensity (score ≥ 4) was reported by 62%. Among patients with matching propensity scores, those taking opioids were more likely to have had moderate or severe side effects than those taking only nonopioids (62%, 95% confidence interval [CI] = 48% to 74% vs. 4%, 95% CI = 1% to 20%) and were also more likely to have discontinued treatment due to side effects (16%, 95% CI = 8% to 29% vs. 0%, 95% CI = 0% to 13%). The most common side effects due to opioids were tiredness, nausea, and constipation.

CONCLUSIONS

Among older adults initiating treatment with opioid-containing analgesics for musculoskeletal pain, side effects were common and sometimes resulted in medication discontinuation.

Scheduled analgesic regimen improves rehabilitation after hip fracture surgery

BACKGROUND

Postoperative pain often is the limiting factor in the rehabilitation of patients after hip fracture surgery.

QUESTIONS/PURPOSES

We compared an approach using scheduled analgesic dosing with as-needed analgesic dosing in patients after hip fracture surgery, to compare these approaches in terms of (1) resting and dynamic pain intensity, (2) postoperative patient mobility, and (3) functional end points.

METHODS

We conducted a prospective cohort study of 400 patients who underwent surgical treatment of hip fractures at our hospital. The groups were formed sequentially, such that the first 200 patients formed the intervention group (treated with scheduled analgesic intake for the first 3 weeks after surgery), and the next 200 patients were the control group (treated using a protocol of analgesic administration on request). Resting and dynamic pain intensity, mobility, and functional performance were compared between the two analgesic protocols.

RESULTS

As expected, analgesic consumption was lower in the control group (tramadol doses, 27 versus 63; paracetamol doses, 29 versus 63). Despite the large difference in the amounts of analgesics consumed, resting and dynamic pain intensity showed improvement in each group and there was no difference between groups in terms of postoperative pain. However, there was a positive correlation between functional outcomes and analgesic consumption in the control group. The intervention group achieved higher functional performance on discharge (elderly mobility scale, 11 versus 8; functional independence measure, 88 versus 79). On discharge, fewer patients in the intervention group were wheelchair ambulators (3 versus 32), meaning more patients in the intervention group were able to walk.

CONCLUSIONS

The study showed that a scheduled analgesic intake can improve the functional outcomes of patients with geriatric hip fractures after surgery.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the guidelines for authors for a complete description of levels of evidence.

Clinical and transitional care: considerations to optimize functional recovery following hip fracture

Between 30% and 40% of community-dwelling older adults in the United States fall at least once each year, and approximately 10% of these falls are associated with a major injury such as a hip fracture. Return to maximum level of functional status following surgery requires individualized rehabilitation programs and may involve multiple care transitions. Using an individual example, this article provides context for meeting rehabilitation goals during transitional care following hip fractures. Understanding recommended clinical management strategies during the acute perioperative period and the rationale for postsurgical rehabilitation decisions based on clinical assessment, program eligibility, and Medicare coverage will allow all health professionals to provide optimal guidance and maximize functional recovery for older adults with hip fractures.

Opioid use patterns and association with pain severity and mental health functioning in chronic pain patients

OBJECTIVE

The objective of this study was to explore the relationship between patterns of opioid use, pain severity, and pain-related mental health in chronic pain patients prescribed opioids.

DESIGN

The study was designed as a one-time patient interview with structured pain and opioid use assessments.

SETTING

The study was set in a tertiary care medical center in the United States Department of Veterans Affairs. PATIENTS.  Study participants were primary care patients with a pain condition for greater than 6 months who received at least one prescription for an opioid in the prior 12 months.

OUTCOME MEASURES

The Prescription Drug Use Questionnaire was used to assess patterns of opioid use. The Pain Outcomes Questionnaire was used to assess pain-related functioning.

RESULTS

Symptomatic use of opioid medication (e.g., taking an opioid in response to increased pain) was more common than scheduled (i.e., taking an opioid at regular times) or strategic use of opioid medication (e.g., taking an opioid specifically to engage in activities). Symptomatic use of opioids was associated with poorer pain-related mental health, after controlling for pain duration and pain-related physical functioning. Use of opioids in a scheduled pattern was associated with better pain-related mental health. Patients rarely reported that they used opioids strategically to facilitate functional activities.

CONCLUSIONS

The patterns in which patients use their opioid medications are associated with their psychological functioning. This is consistent with theory regarding the potential impact of reinforcing effects of opioid medication on functional outcomes. Interventions to encourage strategic or scheduled opioid use warrant investigation as methods to improve pain outcomes with opioids.

Hip fracture-related pain strongly influences functional performance of patients with an intertrochanteric fracture upon discharge from the hospital

OBJECTIVE

To examine whether functional performance upon hospital discharge is influenced by pain in the region of the hip fracture or related to the fracture type.

DESIGN

Prospective observational study.

SETTING

A 20-bed orthopedic hip fracture unit.

PATIENTS

Fifty-five cognitively intact patients (20 men and 35 women; ages 75.8 ± 10 years), 33 with a cervical hip fracture and 22 with an intertrochanteric hip fracture, all of whom were allowed to bear full weight after surgery.

METHODS

All patients were evaluated upon discharge from the hospital to their own homes at a mean of 10 ± 6 days after surgery.

MAIN OUTCOME MEASUREMENTS

The Timed Up & Go (TUG) test, supervised by a physical therapist, was used to evaluate functional performance, and a 5-point verbal ranking scale (0 = no pain to 4 = intolerable pain) was used to evaluate pain.

RESULTS

Patients took an average of 22.7 ± 11.7 seconds to perform the TUG. No significant differences were observed in baseline characteristics or pain medication given for patients with a cervical versus an intertrochanteric fracture (P ≥ .22), but patients with an intertrochanteric fracture presented more often with moderate to severe pain during testing (P < .001), with associated poorer performances on the TUG test (29.4 ± 12.8 seconds versus 18.3 ± 8.5 seconds). Univariate analysis showed that TUG scores were associated with age, prefracture function evaluated by the New Mobility Score, fracture type, day of TUG performance, and pain intensity. Multivariate linear regression analyses (fracture type not included) showed that only greater age (B = 0.34), low prefracture function (B = 7.9), and experiencing moderate to severe pain (B = 8.7) were independently associated with having a poorer TUG score.

CONCLUSIONS

Hip fracture-related pain primarily compromises the functional performance of patients with an intertrochanteric hip fracture upon discharge from hospital. Physical therapists should be involved in new and optimized fracture-type stratified pain management strategies.

Older US emergency department patients are less likely to receive pain medication than younger patients: results from a national survey

STUDY OBJECTIVE

The purpose of this study is to determine whether older adults presenting to the emergency department (ED) with pain are less likely to receive pain medication than younger adults.

METHODS

Pain-related visits to US EDs were identified with reason-for-visit codes from 7 years (2003 to 2009) of the National Hospital Ambulatory Medical Care Survey. The primary outcome was the administration of an analgesic. The percentage of patients receiving analgesics in 4 age groups was adjusted for measured covariates, including pain severity.

RESULTS

Pain-related visits accounted for 88,031 (46.9%) ED visits by patients aged 18 years or older during the 7-year period. There were 7,585 pain-related ED visits by patients aged 75 years or older, representing an estimated 3.65 million US ED visits annually. In comparing survey-weighted unadjusted estimates, pain-related visits by patients aged 75 years or older were less likely than visits by patients aged 35 to 54 years to result in administration of an analgesic (49% versus 68.3%) or an opioid (34.8% versus 49.3%). Absolute differences in rates of analgesic and opioid administration persisted after adjustment for sex, race/ethnicity, pain severity, and other factors and multiple imputation of missing pain severity data, with visits by patients aged 75 years and older being 19.6% (95% confidence interval 17.8% to 21.4%) less likely than visits by patients aged 35 to 54 years to receive an analgesic and 14.6% (95% confidence interval 12.8% to 16.4%) less likely to receive an opioid.

CONCLUSION

Patients aged 75 years and older with pain-related ED visits are less likely to receive pain medication than patients aged 35 to 54 years.

Motor vehicle collision-related emergency department visits by older adults in the United States

OBJECTIVES

Motor vehicle collisions (MVCs) are the second most common cause of nonfatal injury among U.S. adults age 65 years and older. However, the frequency of emergency department (ED) visits, disposition, pain locations, and pain severity for older adults experiencing MVCs have not previously been described. The authors sought to determine these characteristics using information from two nationally representative data sets.

METHODS

Data from the 2008 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) were used to estimate MVC-related ED visits and ED disposition for patients 65 years and older. NHAMCS data from 2004 through 2008 were used to further characterize MVC-related ED visits.

RESULTS

  In 2008, the NEDS contained 28,445,564 patient visits, of which 760,356 (2.7%) were due to MVCs. The NHAMCS contained 34,134 patient visits, of which 1,038 (3.0%) were due to MVCs. National estimates of MVC-related ED visits by patients 65 years and older in 2008 are 226,000 (95% confidence interval [CI]=210,000 to 240,000) for NEDS and 270,000 (95% CI=185,000 to 355,000) for NHAMCS. Most older adults with MVC-related ED visits were sent home from the ED (proportion discharged NEDS 78%, 95% CI=78% to 79%; NHAMCS 77%, 95% CI=66% to 86%). During the years 2004 through 2008, of MVC-related ED visits by older adults not resulting in hospital admission, moderate or severe pain was reported in 61% (95% CI=52% to 70%) of those with recorded pain scores. Older patients sent home after MVC-related ED visits were less likely than younger patients to receive analgesics (35%, 95% CI=26% to 43% vs. 47%, 95% CI=44% to 50%) during their ED evaluations or as discharge prescriptions (52%, 95% CI=41% to 62% vs. 65%, 95% CI=61% to 68%).

CONCLUSIONS

In 2008, adults age 65 years or older made more than 200,000 MVC-related ED visits. Approximately 80% of these visits were discharged home from the ED, but the majority of discharged patients reported moderate or severe pain. Further studies of pain and functional outcomes in this population are needed.

Consensus recommendations from the strategic planning summit for pain and palliative care pharmacy practice

Pain and symptoms related to palliative care (pain and palliative care [PPC]) are often undertreated. This is largely owing to the complexity in the provision of care and the potential discrepancy in education among the various health care professionals required to deliver care. Pharmacists are frequently involved in the care of PPC patients, although pharmacy education currently does not offer or require a strong curriculum commitment to this area of practice. The Strategic Planning Summit for the Advancement of Pain and Palliative Care Pharmacy was convened to address opportunities to improve the education of pharmacists and pharmacy students on PPC. Six working groups were charged with objectives to address barriers and opportunities in the areas of student and professional assessment, model curricula, postgraduate training, professional education, and credentialing. Consensus was reached among the working groups and presented to the Summit Advisory Board for adoption. These recommendations will provide guidance on improving the care provided to PPC patients by pharmacists through integrating education at all points along the professional education continuum.

Prevention of chronic pain after surgical nerve injury: amputation and thoracotomy

Although techniques for acute pain management have improved in recent years, a dramatic reduction in the incidence and severity of chronic pain following surgery has not occurred. Amputation and thoracotomy, although technically different, share the commonalities of unavoidable nerve injury and the frequent presence of persistent postsurgical neuropathic pain. The authors review the risk factors for the development of chronic pain following these surgeries and the current evidence that supports analgesic interventions. The inconclusive results from many preemptive analgesic studies may require us to reconceptualize the perioperative treatment period as a time of gradual neurologic remodeling.

Pain and interference of pain with function and mood in elderly adults involved in a motor vehicle collision: a pilot study

BACKGROUND/STUDY CONTEXT: Musculoskeletal pain after motor vehicle collision is a substantial public health problem. The number of elderly individuals experiencing motor vehicle collision is increasing. The authors conducted analyses of data collected as part of a prospective observational study of outcomes after motor vehicle collision to estimates rates of persistent pain, pain interference, and change in physical function in patients 65 or older.

METHODS

Adults presenting to one of four emergency departments following motor vehicle collision without severe or life-threatening injury were recruited. Outcomes were assessed using 1-month follow-up surveys.

RESULTS

The frequencies of persistent moderate or severe pain resulting from the motor vehicle collision were similar among elderly and nonelderly participants, both in the neck region (27% vs. 30%) and in any region (60% vs. 56%). For both elderly and nonelderly patients, persistent pain was associated with high levels of interference with physical activity and mood.

CONCLUSION

Further studies of this vulnerable and rapidly increasing injury population are needed.

Increased access to palliative care and hospice services: opportunities to improve value in health care

CONTEXT

A small proportion of patients with serious illness or multiple chronic conditions account for the majority of health care spending. Despite the high cost, evidence demonstrates that these patients receive health care of inadequate quality, characterized by fragmentation, overuse, medical errors, and poor quality of life.

METHODS

This article examines data demonstrating the impact of the U.S. health care system on clinical care outcomes and costs for the sickest and most vulnerable patients. It also defines palliative care and hospice, synthesizes studies of the outcomes of palliative care and hospice services, reviews variables predicting access to palliative care and hospice services, and identifies those policy priorities necessary to strengthen access to high-quality palliative care.

FINDINGS

Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Some data suggest that, compared with the usual care, palliative care prolongs life. By helping patients get the care they need to avoid unnecessary emergency department and hospital stays and shifting the locus of care to the home or community, palliative care and hospice reduce health care spending for America's sickest and most costly patient populations.

CONCLUSIONS

Policies focused on enhancing the palliative care workforce, investing in the field's science base, and increasing the availability of services in U.S. hospitals and nursing homes are needed to ensure equitable access to optimal care for seriously ill patients and those with multiple chronic conditions.

The Transition from Acute to Chronic Post Surgical Pain

All chronic pain was once acute, but not all acute pain becomes chronic. The transition of acute postoperative pain to chronic post surgical pain is a complex and poorly understood developmental process. The manuscript describes the various factors associated with the transition from acute to chronic pain. The preoperative, intraoperative and postoperative surgical, psychosocial, socio-environmental and patient-related factors and the mechanisms involved are discussed and preventive (or limitation) strategies are suggested. In future, the increasing understanding of genetic factors and the transitional mechanisms involved may reveal important clues to predict which patients will go on to develop chronic pain. This may assist the development of appropriate interventions affecting not only the individual concerned, but also ultimately the community at large.

Outcome measures to evaluate the effectiveness of pain management in older adults with cancer

PURPOSE/OBJECTIVES

To identify the most appropriate outcome measures to determine the effectiveness of pain management plans in older adults with cancer.

DATA SOURCES

PubMed literature searches, medical and nursing textbooks, and clinical experience.

DATA SYNTHESIS

Unrelieved chronic pain can have a significant impact on older adults' activity levels and their ability to function. Hence, effective pain management in older adults requires a comprehensive approach, including assessment of functional outcomes. Because the goals of pain management are broad, healthcare professionals should use an array of functional outcome measures along with pain intensity ratings to better assess the effectiveness of analgesic medications.

CONCLUSIONS

Particularly in older adults, evaluation of functional outcomes provides a better indication of the effectiveness of pain management strategies than pain intensity ratings. Appropriate outcome measures for older adults in the outpatient setting include pain relief, physical functioning, emotional functioning, patients' ratings of global improvement and satisfaction with treatment, and symptoms and adverse effects associated with analgesic medications.

IMPLICATIONS FOR NURSING

Healthcare providers should manage pain in older adults with cancer in an interdisciplinary environment with pharmacologic and nonpharmacologic interventions. The primary goals are decreasing pain and improving function and quality of life.