A Prospective Review of Hip Fracture Subtypes, Surgical Procedure, Cognitive Status, and Analgesia Use Across 4 Australian Hospitals

Abstract

Objectives: To correlate analgesia use among patients with hip fracture requiring surgery with hip fracture subtype, cognitive status, and type of surgery in the postacute period. Design and Participants: Prospective review of patients with hip fractures requiring surgical intervention. A total of 415 patients (mean age: 81.2 + 9.1 years, 74.3% women) presented with 195 subcapital fractures (39 undisplaced, 156 displaced) and 220 trochanteric fractures (136 stable, 84 unstable) requiring surgery. Setting: Inpatient orthopedic units in 4 Australian hospitals. Measurements: The primary outcome measures were mean analgesia usage (oral morphine equivalent) for 4 defined time intervals and total amount 36 hours following surgery. Results: Patients with subtrochanteric fractures required more analgesia compared with displaced-subcapital, undisplacedsubcapital, basicervical, stable-pertrochanteric, and unstable-pertrochanteric fractures in the 24 to 36 hours following operation (24.7 vs 11.3 vs 8.8 vs 12.1 vs 7.6 vs 9.7, P ¼ .001). Total analgesia requirements were higher in patients treated with an intramedullary nail, increasing by 1.3-to 3.3-fold in the 36 hours postsurgery. Patients with cognitive impairment utilized markedly less analgesia at all time periods measured. At 24 to 36 hours, higher levels of analgesia were noted in patients with higher premorbid level of mobility (P ¼ .015) and activities of daily living function (P ¼ .007). Conclusion: Important differences in utilization of analgesia following hip fracture across readily defined clinical groups exist. Proactive pain management for those with cognitive impairment, certain hip fracture subtypes, and surgical procedures may enable early functional mobility and other activities.

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

“…Seven of the eight studies found the differences to be statistically significant, and one study found no significant differences but did note a tendency [ 33 ]. These eight studies are as follows: Adunsky et al [ 10 ] stated that PwD received only 53% of the amount of opioid analgesics that were administered to cognitively intact patients ( P < 0.001); Feldt et al [ 33 ] came to the conclusion that, even though the prescription of pain medication did not differ significantly, PwD received fewer opioid analgesics ( P = 0.02 in the first and P = 0.07 in the second 48 h post-operatively); Grall [ 34 ] pointed out that people without dementia received almost 50% more pain medication compared to their counterparts with dementia following acute hip fracture ( p = 0.018); Jensen-Dahm et al [ 22 ] came to the result that PwD received lower doses of oral morphine equivalents during the first ( P = 0.001) and second postoperative day ( P = 0.019), lower doses of acetaminophen during the first 3 days post-operatively ( P < 0.0001), and were also more likely to receive opioids pro re nata (PRN) ( P = 0.0005); the study by McDermott et al [ 26 ] outlined that PwD received a weaker level of analgesia both in the outpatient and in the emergency setting ( P < 0.001); Morrison and Siu [ 12 ] found that the advanced dementia patients in their study received one-third of the amount of morphine sulphate equivalents that the cognitively intact patients did ( P < 0.02), and that 76% of the PwD did not have a standing order for their analgesic agent for their entire hospitalisation ( P = 0.44); in the study by Mak et al [ 31 ]. PwD used distinctly less analgesia during all the time periods measured ( P < 0.001) and Titler et al [ 32 ] concluded that PwD received significantly fewer mean parenteral morphine equivalents of opioids than those without dementia ( P < 0.001).…”

“… Dementia as a risk factor for undertreatment of pain, considerable delays in analgesic administration, and treatment with inappropriate analgesics. Mak et al 2011 [ 31 ] hospital/Australia Observation of analgesia use among patients with hip fracture requiring surgery in correlation to hip fracture subtype, cognitive status and type of surgery in the post-acute period. PwD utilised markedly less analgesia at all time periods measured.…”

“…It is to be taken into account that in the study by Jensen-Dahm et al [ 22 ], which met six quality criteria, five of the items were “not applicable” in terms of the critical appraisal. Three of the four cross-sectional studies met 11 quality criteria [ 28 , 31 , 32 ], while the study by Holdgate et al [ 27 ] met 10 of the 17 quality criteria of the NICE checklist. The case study by Ardery et al [ 21 ] met seven out of the ten quality criteria of the Joanna Briggs Institute’s checklist.…”

“…A number of different tools were applied to assess the patients’ mental status. The Mini Mental State Examination (MMSE), which was performed most frequently, was used in six studies [ 10 , 26 , 29 , 31 , 33 , 35 ]. Morrison and Siu [ 12 ] combined the MMSE with the Confusion Assessment Method (CAM) and the Reisberg Global Deterioration Scale to screen their patients not only for dementia but also for delirium, while Adunsky et al [ 10 ] only combined the MMSE and the CAM.…”

Complications after hip fracture surgery: are they preventable?

“…The A3 type intertrochanteric fracture is classified as unstable and more difficult to treat than other trochanteric fractures. Patients seem to need more analgesics [ 23 ], which might lead to more complications. Type of anesthesia is a modifiable risk factor.…”