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

Patient-reported outcome measure use among older adults after emergency department care: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care.

METHODS

With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments.

RESULTS

Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality.

CONCLUSIONS

PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.

Associations between the use of common nonsteroidal anti-inflammatory drugs, genetic susceptibility and dementia in participants with chronic pain: A prospective study based on 194,758 participants from the UK Biobank

OBJECTIVE

To investigate the potential relationship between common nonsteroidal anti-inflammatory drugs (NSAIDs), genetic susceptibility and all-cause dementia (ACD), Alzheimer's disease (AD), and vascular dementia (VD) among individuals experiencing chronic pain.

METHODS

This study was based on 194,758 chronic pain participants form UK biobank with a median follow-up of 13.7 years. Participants were categorized into different NSAIDs painkiller regimen groups: No NSAIDs group, Aspirin group, Ibuprofen group, Paracetamol group, and 2-3 NSAIDs group. Cox proportional risk models were used to examine the correlation between regular NSAIDs usage and the risk of ACD, AD, and VD. In addition, we further performed subgroup analyses and sensitivity analyses.

RESULTS

1) Compared to the No NSAIDs group, the aspirin group (HR = 1.12, 95% CI:1.01-1.24, P < 0.05), the paracetamol group (HR = 1.15, 95% CI:1.05-1.27, P < 0.01), and the 2-3 NSAIDs group (HR = 1.2, 95% CI:1.08-1.33, P < 0.05) showed a higher risk of ACD. Furthermore, the 2-3 NSAIDs group was also associated with a higher risk of VD (HR = 1.39, 95% CI: 1.08-1.33, P < 0.05). 2) At high dementia GRS participants with chronic pain, the paracetamol group (HR = 1.2, 95% CI: 1.03-1.43, P < 0.05) and the NSAIDs group (HR = 1.3, 95% CI: 1.07-1.59, P < 0.05) were associated with a higher risk of ACD compared to the no painkiller group. 3) There was no significant association between ibuprofen use and higher risk of dementia.

CONCLUSION

In individuals with chronic pain, the use of aspirin and paracetamol was associated with a higher risk of ACD, whereas the use of ibuprofen was not significantly associated with a higher risk of ACD.

Pain after a motor vehicle crash: The role of socio-demographics, crash characteristics and peri-traumatic stress symptoms

BACKGROUND

The vast majority of individuals who come to the emergency department (ED) for care after a motor vehicle collision (MVC) are diagnosed with musculoskeletal strain only and are discharged to home. A significant subset of this population will still develop persistent pain and posttraumatic psychological sequelae may play an important role in pain persistence.

METHODS

We conducted a multisite longitudinal cohort study of adverse post-traumatic neuropsychiatric sequelae among patients seeking ED treatment in the aftermath of a traumatic life experience. We report on a sub-group of patients (n = 666) presenting after an MVC, the most common type of trauma and we examine associations of socio-demographic and MVC characteristics, and persistent pain 8 weeks after MVC. We also examine the degree to which these associations are related to peritraumatic psychological symptoms and 2-week acute stress reactions using an applied approach.

RESULTS

Eight-week prevalence of persistent moderate or severe pain was high (67.4%) and positively associated with patient sex (female), older age, low socioeconomic status (education and income) and pain severity in the ED. Peritraumatic stress symptoms (distress and dissociation) appear to exert some influence on both acute pain and the transition from acute to persistent pain.

DISCUSSION AND CONCLUSIONS

The early aftermath of an MVC may be an important time period for intervening to prevent and reduce persistent pain. Substantial variation in mediating pathways across predictors also suggests potential diverse and complex underlying biological and psychological pathogenic processes are at work in the early weeks following trauma.

SIGNIFICANCE

The first several days after trauma may dictate recovery trajectories. Persistent pain, pain lasting beyond the expected time of recovery, is associated with pain early in the recovery period, but also mediated through other pathways. Future work is needed to understand the complex neurobiological processes in involved in the development of persistent and acute post-traumatic pain.

I've got to be independent': views of older people on recovery following road traffic injury in New South Wales, Australia

BACKGROUND

Mild to moderate road traffic injury (RTI) in people of working age is associated with limited recovery. Less is known about RTI recovery in older age. This study explored the perspectives and factors associated with recovery and health-related quality of life following mild to moderate RTI in older age in New South Wales, Australia.

METHODS

A qualitative study using content analysis was undertaken. Participants aged 65 or more years were purposively selected from a larger inception cohort study of health outcomes following mild to moderate RTI conducted in New South Wales, Australia. Semi-structured interviews were undertaken at approximately 12 or 24 months post-injury. Content analysis was used to code and analyse the data, with methodological rigour obtained by double-coding and discussing findings to reach consensus. Results were reported using the consolidated criteria for reporting qualitative research (COREQ).

RESULTS

Nineteen participants were invited to participate in the study of which 12 completed interviews. Data saturation was reached at the twelfth interview. Recovery experiences were diverse. Five main themes were identified: recovery is regaining independence; injury and disability in older age; the burden of non-obvious disability; the importance of support; and positive personal approaches. Key facilitators of recovery were: regaining independence; support from family and friends; and positive personal approaches. Key barriers were: threats to independence; passive coping behaviours; non-obvious disabilities (chronic pain, psychological impacts); and reluctance to raise ongoing issues with General Practitioners. Threats to independence, especially not driving and self-care, appeared to have a more profound effect on recovery than physical functioning.

CONCLUSION

Older people view injury as a threat to independent functioning. This is somewhat different to what younger people report. Regaining independence is key to older people's recovery and health-related quality of life following RTI, and should be a key consideration for health professionals, services and supports working with this unique cohort. Greater efforts to help older people regain their independence following RTI are needed and can be facilitated by health professionals and appropriate service provision.

TRIAL REGISTRATION

Australia New Zealand clinical trial registry identification number ACTRN12613000889752 .

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.

Comorbidities, anticoagulants, and geriatric-specific physiology for the field triage of injured older adults

BACKGROUND

Comorbid conditions and anticoagulants have been considered as field triage criteria to raise the sensitivity for identifying seriously injured older adults, but research is sparse. We evaluated the utility of comorbidities, anticoagulant use, and geriatric-specific physiologic measures to improve the sensitivity of the field triage guidelines for high-risk older adults in the out-of-hospital setting.

METHODS

This was a cohort study of injured adults 65 years or older transported by 44 emergency medical services agencies to 51 trauma and nontrauma hospitals in seven Oregon and Washington counties from January 1, 2011, to December 31, 2011. Out-of-hospital predictors included current field triage criteria, 13 comorbidities, preinjury anticoagulant use, and previously developed geriatric specific physiologic measures. The primary outcome (high-risk patients) was Injury Severity Score of 16 or greater or need for major nonorthopedic surgical intervention. We used binary recursive partitioning to develop a clinical decision rule with a target sensitivity of 95% or greater.

RESULTS

There were 5,021 older adults, of which 320 (6.4%) had Injury Severity Score of 16 or greater or required major nonorthopedic surgery. Of the 2,639 patients with preinjury medication history available, 400 (15.2%) were taking an anticoagulant. Current field triage practices were 36.6% sensitive (95% confidence interval [CI], 31.2%-42.0%) and 90.1% specific (95% CI, 89.2%-91.0%) for high-risk patients. Recursive partitioning identified (in order): any current field triage criteria, Glasgow Coma Scale score of 14 or less, geriatric-specific vital signs, and comorbidity count of 2 or more. Anticoagulant use was not identified as a predictor variable. The new criteria were 90.3% sensitive (95% CI, 86.8%-93.7%) and 17.0% specific (95% CI, 15.8%-18.1%).

CONCLUSIONS

The current field triage guidelines have poor sensitivity for high-risk older adults. Adding comorbidity information and geriatric-specific physiologic measures improved sensitivity, with a decrement in specificity.

LEVEL OF EVIDENCE

Prognostic/Epidemiologic, level II.

Association between Patient-Reported Health Status and Physical Activity Six Months after Upper and Lower Limb Fractures in Working-Aged Adults

INTRODUCTION

Physical activity limitations are common following upper and lower limb fractures in adults of working age. There is a lack of research investigating the factors associated with these limitations, such as pain, mental health problems, and mobility impairments.

OBJECTIVES

To report health status (EQ-5D) 6 months after upper and lower limb fracture in adults of working age (ages 18-69 years), and to determine the association between sedentary behavior (sitting time) and physical activity (steps, moderate-intensity physical activity [MPA]) 2 weeks and 6 months post-fracture with health status 6 months post-fracture.

DESIGN

Prospective cohort study.

SETTING

Major (level I) trauma center.

PARTICIPANTS

Sixty-three adults 18-69 years of age with upper or lower limb fractures who were recruited consecutively.

MAIN OUTCOME MEASURES

Participants wore ActiGraph and activPAL accelerometers for 10 days, 2 weeks and 6 months post-fracture. At 6 months, participants completed the EQ-5D. We used linear mixed-effects multivariable regression analyses to explore associations between EQ-5D domains and sitting time, steps, or physical activity.

RESULTS

Participants with mobility problems (compared to participants without) were highly sedentary at 2 weeks (β = 0.86, P = .04), took fewer steps/d (Ratio of Geometric Means [RGM] = 0.62, P = .02) and engaged in less MPA (RGM = 0.32, P = .01). In addition, they engaged in less MPA at 6 months (RGM = 0.52, P = .02). Participants with self-care problems (compared with participants without) took fewer steps per day at 6 months (RGM = 0.78, P = .04), and engaged in less MPA at 2 weeks (RGM = 0.31, P = .01) and 6 months (RGM = 0.48, P = .02).

CONCLUSIONS

Adults with mobility and self-care problems 6 months post-fracture engaged in high levels of sedentary behavior and low levels of physical activity. These findings can guide clinicians on health problems to target in order to maximize recovery of physical activity following fracture.

Comparison of Injured Older Adults Included in vs Excluded From Trauma Registries With 1-Year Follow-up

Importance

Trauma registries are the primary data mechanism in trauma systems to evaluate and improve the care of injured patients. Research has suggested that trauma registries may miss high-risk older adults, who commonly experience morbidity and mortality after injury.

Objective

To compare injured older adults who were included in with those excluded from trauma registries, with a focus on patients with serious injuries, requiring major surgery, or dying after injury.

Design, Setting, and Participants

This cohort study included all injured adults 65 years and older transported by 44 emergency medical services agencies to 51 trauma and nontrauma centers in 7 counties in Oregon and Washington from January 1, 2011, to December 31, 2011, with follow-up through December 31, 2012. Record linkage was used to match emergency medical services records with state trauma registries, state discharge databases, state death registries, and Medicare claims. Data were analyzed from August to November 2018.

Exposures

Inclusion in vs exclusion from a trauma registry.

Main Outcomes and Measures

Mortality up to 12 months, including time to death and causes of death.

Results

Of 8161 included patients, 5579 (68.4%) were women, and the mean (SE) age was 82.2 (0.10) years. A total of 1720 older adults (21.1%) were matched to a trauma registry record. Seriously injured patients not captured by trauma registries ranged from 18% (7 of 38 patients with abdominal-pelvic Abbreviated Injury Scale score of 3 or greater) to 80.0% (1792 of 2241 patients with extremity Abbreviated Injury Scale score of 3 or greater), while 68 of 186 patients requiring major nonorthopedic surgery (36.6%) and 1809 of 2325 patients requiring orthopedic surgery (77.8%) were not included in trauma registries. Of patients with serious injuries or undergoing major surgery missed by trauma registries (range by injury and procedure type, 36.0% to 57.1%), 36.4% (39.3% when excluding serious extremity injuries and orthopedic procedures) were treated at trauma centers, particularly level III through V hospitals. When registry and nonregistry groups were tracked over 12 months, 93 of 188 in-hospital deaths (49.5%) and 1531 of 1887 total deaths (81.1%) occurred in the nonregistry cohort.

Conclusions and Relevance

In their current form, trauma registries are ineffective in capturing, tracking, and evaluating injured older adults, although mortality following injury is frequently due to noninjury causes. High-risk injured older adults are not included in registries because of care in nontrauma hospitals, restrictive registry inclusion criteria, and being missed by registries in trauma centers.

Long-term outcomes among injured older adults transported by emergency medical services

INTRODUCTION/OBJECTIVE

Little is known about the long-term outcomes of injured older adults cared for in trauma systems. We sought to describe mortality and causes of death over time, and the independent association of injury severity, comorbidities, and other factors on 12-month mortality among injured older adults transported by emergency medical services (EMS).

MATERIALS AND METHODS

This was a population-based cohort study of injured adults ≥ 65 years in the United States transported by 44 EMS agencies to 51 hospitals from January 1, 2011 to December 31, 2011, with 12-month follow-up through December 31, 2012. The primary outcomes were time to death and causes of death. We used descriptive statistics and Cox proportional hazards models to generate adjusted hazard ratios (HR).

RESULTS

15,649 injured older adults were transported by EMS, frequently after a fall (84.5%). Serious injuries (Injury Severity Score [ISS] ≥ 16) occurred in 3.5%, with serious extremity injury (Abbreviated Injury Scale score ≥ 3) being most common (17.8%). Mortality rates were: 1.6% in-hospital, 5.1% at 30 days, 9.4% at 90 days and 20.3% at 1 year. The adjusted HR for patients in the highest comorbidity quartile was 2.20 (versus lowest quartile, 95% CI 1.97-2.46, p <  .001), while the HR for ISS ≥ 25 was 2.69 (versus ISS 0-8, 95% CI 1.60-4.51, p =  .001). Cardiovascular etiologies (53.3%) and dementia (32.7%) were the most common causes of death, with injury listed in 12.8% of death certificates.

CONCLUSIONS

Injury requiring EMS transport is a sentinel event among older adults, with death typically occurring months later, often due to cardiovascular causes and dementia. A heavy comorbidity burden had an adjusted mortality risk comparable to severe injury.

Social Support and Pain Outcomes After Trauma Exposure Among Older Adults: A Multicenter Longitudinal Study

OBJECTIVES

Certain forms of social support have been shown to improve pain-coping behaviors and pain outcomes in older adults with chronic pain, but little is known about the effect of social support on pain outcomes in older adults following trauma exposure.

METHODS

We analyzed data from a prospective longitudinal study of adults aged 65 years and older presenting to an emergency department after a motor vehicle collision (MVC) to characterize the relationship between perceived social support and MVC-related pain after trauma overall and by subgroups based on sex, depressive symptoms, and marital status.

RESULTS

In our sample (N=176), patients with low perceived social support had higher pain severity 6 weeks after MVC than patients with high perceived social support after adjustment for age, sex, race, and education (4.2 vs. 3.2, P=0.04). The protective effect of social support on pain severity at 6 weeks was more pronounced in men and in married individuals. Patients with low social support were less likely to receive an opioid prescription in the emergency department (15% vs. 32%, P=0.03), but there was no difference in opioid use at 6 weeks (22% vs. 20%, P=0.75).

DISCUSSION

Among older adults experiencing trauma, low perceived social support was associated with higher levels of pain at 6 weeks.

Randomized controlled pilot study of an educational video plus telecare for the early outpatient management of musculoskeletal pain among older emergency department patients

Background

Musculoskeletal pain is a common reason for emergency department (ED) visits. Following discharge from the ED, patients, particularly older patients, often have difficulty controlling their pain and managing analgesic side effects. We conducted a pilot study of an educational video about pain management with and without follow-up telephone support for older adults presenting to the ED with musculoskeletal pain.

Methods

ED patients aged 50 years and older with musculoskeletal pain were randomized to: (1) usual care, (2) a brief educational video only, or (3) a brief educational video plus a protocol-guided follow-up telephone call from a physician 48–72 hours after discharge (telecare). The primary outcome was the change from the average pain severity before the ED visit to the average pain severity during the past week assessed one month after the ED visit. Pain was assessed using a 0–10 numerical rating scale.

Results

Of 75 patients randomized (mean age 64 years), 57 (76%) completed follow up at one month. Of the 18 patients lost to follow up, 12 (67%) had non-working phone numbers. Among patients randomized to the video (arms 2 and 3), 46/50 viewed the entire video; among the 25 patients randomized to the video plus telecare (arm 3), 23 were reached for telecare. Baseline pain scores for the usual care, video, and video plus telecare groups were 7.3, 7.1, and 7.5. At one month, pain scores were 5.8, 4.9, and 4.5, corresponding to average decreases in pain of -1.5, -2.2, and -3.0, respectively. In the pairwise comparison between intervention groups, the video plus telecare group had a 1.7-point (95% CI 1.2, 2.1) greater decrease in pain compared to usual care, and the video group had a 1.1-point (95% CI 0.6, 1.6) greater decrease in pain compared to usual care after adjustment for baseline pain, age, and gender. At one month, clinically important differences were also observed between the video plus telecare and usual care groups for analgesic side effects, ongoing opioid use, and physical function.

Conclusion

Results of this pilot trial suggest the potential value of an educational video plus telecare to improve outcomes for older adults presenting to the ED with musculoskeletal pain. Changes to the protocol are identified to increase retention for assessment of outcomes.

Trials registration

ClinicalTrials.gov, NCT02438384. Registered on 5 May 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2403-8) contains supplementary material, which is available to authorized users.

Post-Traumatic Stress Disorder among Older Adults Experiencing Motor Vehicle Collision: A Multicenter Prospective Cohort Study

OBJECTIVE

To characterize risk factors for and consequences of post-traumatic stress disorder (PTSD) among older adults evaluated in the emergency department (ED) following motor vehicle collision (MVC).

DESIGN

Prospective multicenter longitudinal study (2011-2015).

SETTING

9 EDs across the United States.

PARTICIPANTS

Adults aged 65 years and older who presented to an ED after MVC without severe injuries.

MEASUREMENTS

PTSD symptoms were assessed 6 months after the ED visit using the Impact of Event Scale-Revised.

RESULTS

Of 223 patients, clinically significant PTSD symptoms at 6 months were observed in 21% (95% CI 16%-26%). PTSD symptoms were more common in patients who did not have a college degree, had depressive symptoms prior to the MVC, perceived the MVC as life-threatening, had severe ED pain, and expected their physical or emotional recovery time to be greater than 30 days. Three factors (ED pain severity [0-10 scale], perceived life-threatening MVC [0-10 scale], and pre-MVC depressive symptoms [yes to either of two questions]), predicted 6-month PTSD symptoms with an area under the curve of 0.76. Compared to patients without PTSD symptoms, those with PTSD symptoms were at higher risk for persistent pain (72% versus 30%), functional decline (67% versus 42%), and new disability (49% versus 18%).

CONCLUSIONS

Among older adults treated in the ED following MVC, clinically significant PTSD symptoms at 6 months were present in 21% of patients and were associated with adverse health outcomes. Increased risk for PTSD development can be identified with moderate accuracy using information readily available in the ED.