A case-control study examining inconsistencies in pain management following fractured neck of femur: an inferior analgesia for the cognitively impaired

McDermott, John H; Nichols, Donald R.; Lovell, M.E.

doi:10.1136/emermed-2013-203007

Cited by 26 publications

(35 citation statements)

References 32 publications

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“…In the present study, while the presence of cognitive impairment was not associated with a lower probability of receiving a pain intervention, it was associated with a reduced probability of receiving any analgesic. A similar trend was found by McDermott et al who studied pain management in the prehospital and ED setting for patients with a fractured neck of femur. In their study, patients with dementia were less likely to be offered an analgesic before arrival to the ED (55% vs 92%, P < 0.001), and less likely to receive strong opioids during their ED admission (37% vs 69%, P < 0.001).…”

Section: Discussionsupporting

confidence: 78%

“…Pain was found to be inadequately and inappropriately assessed in elderly patients with cognitive impairment as they were less likely to have their pain assessed with a standardised assessment tool. A study by McDermott et al reported a similar finding, but only considered the presence of a pain score at the time of admission to the ED.…”

Section: Discussionmentioning

confidence: 75%

“…Patients with a cognitive impairment are even less likely to have their pain assessed. A study from the UK reported that 75% of cognitively intact patients, compared with only 45% of patients with a cognitive impairment, had a pain score recorded on admission to the ED . No study has quantified this disparity for the entire ED admission…”

Section: Introductionmentioning

confidence: 99%

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Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross‐sectional study

Jones

Sim

Parsons

et al. 2019

Emerg Medicine Australasia

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Section: Discussionsupporting

confidence: 78%

Section: Discussionmentioning

confidence: 75%

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Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross‐sectional study

Jones

Sim

Parsons

et al. 2019

Emerg Medicine Australasia

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“…Even though these fractures vary within age groups, our analyses were adjusted for multiple confounders, including age. Another explanation for non-treatment, among a subgroup of the old patients may be their inability to express pain and analgesic requirements because of cognitive impairments [11]. This seems to be somewhat supported by our results, indicating that patients living in institutions were less likely to receive fentanyl compared with patients living in their own homes.…”

Section: Discussionsupporting

confidence: 70%

Prehospital intravenous fentanyl to patients with hip fracture: an observational cohort study of risk factors for analgesic non-treatment

Friesgaard

Christensen

Kirkegaard

et al. 2017

Scand J Trauma Resusc Emerg Med

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BackgroundPatients with proximal femoral neck fracture have a high short-term mortality, a high risk of postoperative complications, and impaired quality of life. One of the challenges related to the prehospital treatment of these patients is to administer systemic opioids fast and properly. Effective analgesic prehospital treatment ought be initiated rapidly in order to alleviate the stress that follows acute pain, to facilitate transportation, and to improve quality of care. The objectives of this study were to explore the prevalence of prehospital administration of intravenous fentanyl to patients with proximal femoral neck fracture in the ambulances and to assess risk factors for analgesic non-treatment.MethodsThis was a register-based observational cohort study of patients with proximal femoral neck fracture from the North Denmark Region transported by ambulance. The patients were identified via the Danish Interdisciplinary Hip Fracture Registry over a 3-year period from 1 July 2011 to 30 June 2014. This hospital registry contains data on several patient characteristics used for the risk factor analysis. Data on prehospital treatment (intravenous fentanyl) and patient monitoring were registered in an electronic prehospital patient record. A modified Poisson regression with robust standard errors was carried out with intravenous fentanyl as the primary binary outcome and the following explanatory variables: age, sex, Charlson Comorbidity Index score, housing, body mass index, type of fracture, fracture displacement, prior consultation with general practitioner, dispatch triage level, and time with ambulance personnel.ResultsIn total, 2,140 patients with proximal femoral neck fracture were transported by ambulance, of which 584 (27.3%, 95% CI: 25.4-29.2) were treated with intravenous fentanyl. Risk factors for non-treatment were: older age, male sex (RR 0.77, 95% CI: 0.64-0.91), institutional housing (RR 0.72, 95% CI: 0.56-0.92), medial fracture (RR 0.74, 95% CI: 0.60-0.92), short time with ambulance personnel, Charlson Comorbidity Index score > 1, year of fracture (2011), low levels of urgency at dispatch, and if seen by general practitioners prior to transport.DiscussionEducation of ambulance personnel in assessing and treating patients with hip fracture seems to be required. Also, future studies should consider alternative or supportive pain treatment options with suitable analgesic effects and side effects.ConclusionsFew patients with proximal femoral neck fracture were treated with intravenous fentanyl, and several risk factors were associated with prehospital analgesic non-treatment. Future prospective studies should explore covariates of socioeconomic, cultural, and psychological origin to provide further insight into the multifactorial causes of non-treatment of acute pain.

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“…In addition, in the NAC groups, the indication of analgesics was not documented in up to 20%, whereas in the AC group, an indication was missing in less than 10%, which presumably is a direct consequence and reflection of the difficulties in assessing the localisation and intensity of pain in NAC patients. Data regarding the use of different types of pain medication in patients with reduced or missing ability to self-report pain are inconsistent: cognitively impaired patients were found to receive less analgesicsopioids in particularin some studies [56,57] but not others [58]. In patients suffering from dementia, physicians are frequently reluctant to prescribe opioids due to the higher rates of complications and side-effects [59].…”

Section: Discussionmentioning

confidence: 99%

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

Schuster¹,

Hoyer²,

Ebert

et al. 2020

BMC Neurol

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Background: Pain is a common and burdensome complication in patients with acute stroke. We assessed the impact of impaired communication in stroke patients on pain assessment and treatment. Methods: We included 909 (507 male, mean age 71.8 years) patients admitted to our stroke unit from 01/2015 to 12/2015 in the analysis. Patients were assigned to four groups: able to communicate (AC), not able to communicate prior to index stroke (P-NAC), due to focal symptoms of index stroke (S-NAC), due to a reduced level of consciousness (C-NAC). Pain prevalence, documentation of pain and use of analgesics were evaluated. C-NAC patients were excluded from analyses regarding analgesic treatment due to relevant differences in patient characteristics. Results: 746 patients (82.1%) were classified as AC, 25 (2.8%) as P-NAC, 90 (9.9%) as S-NAC and 48 (5.3%) as C-NAC. Pain was documented on the Numeric Rating Scale and in form of free text by nurses and physicians. Nurses documented pain more frequently than physicians (p < 0.001). Pain prevalence was 47.0% (n.s. between groups). The use of analgesic medication increased from 48.7% in the AC group, to 76.0% in the P-NAC group, and 77.8% in the S-NAC group (p < 0.001). Opioid use was significantly more frequent in NAC patients (p < 0.001). The response to the treatment was poorly documented with significantly lowest rates in S-NAC patients (p < 0.001). Conclusions: Our study suggests that post-stroke pain in patients with inability to communicate is not attended enough, not systematically assessed and therefore not sufficiently treated.

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A case-control study examining inconsistencies in pain management following fractured neck of femur: an inferior analgesia for the cognitively impaired

Abstract: JHM and DRN have contributed equally to this study.

Cited by 26 publications

References 32 publications

Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross‐sectional study

Influence of cognitive impairment on pain assessment and management in the emergency department: A retrospective cross‐sectional study

Prehospital intravenous fentanyl to patients with hip fracture: an observational cohort study of risk factors for analgesic non-treatment

Use of analgesics in acute stroke patients with inability to self-report pain: a retrospective cohort study

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