Elsevier

Archives of Gerontology and Geriatrics

Volume 35, Issue 3, November–December 2002, Pages 245-251
Archives of Gerontology and Geriatrics

Exposure to opioid analgesia in cognitively impaired and delirious elderly hip fracture patients

https://doi.org/10.1016/S0167-4943(02)00044-4Get rights and content

Abstract

The objectives of this study were to characterize patterns of opioid analgesia in elderly hip fracture patients, to investigate the possible differences in the treatment of cognitively impaired, delirious, or cognitively intact patients, and to study the factors that may affect the doses received by such patients. This retrospective study comprised 184 elderly patients with hip fractures undergoing surgical fixation. Data collection included age, sex, length of stay, type of fracture, cognitive status by mini-mental state examination, assessment of possible delirium by the confusion assessment method, type and doses of opioid received by these patients. We found that the amount of morphine equianalgesic dose differed significantly between demented and non-demented patients (7.5±1.8 vs. 14.1±4.9, P<0.001). Patients with cognitive decline or with delirium received only 53 and 34%, respectively, of the amount of opioid that was administered to cognitively intact patients. A significant association was observed between cognitive status, or delirium, and amount of opioid analgesia (P<0.001 and P=0.003, respectively). Other parameters such as age, length of stay and type of fracture, had no effect on the use of opioid analgesia. It is concluded that the management of pain in older persons with hip fracture surgery is suboptimal with regards to insufficient administration of opioid analgesia in demented and delirious patients. The adoption of a standardized protocol for pain control may help in reducing the extent of this problem.

Introduction

Pain control is one of the most important aspects in the treatment of hip fractures. Many of the patients suffering such fractures are elderly with some degree of cognitive decline (Luxenberg and Feigenbaum, 1986, Heruti et al., 1998). The perception of pain and pain intensity, in those cognitively intact or cognitively impaired, has been claimed to be of no difference (Feldt et al., 1998), and it has been concluded that both cognitive status and age strongly influenced the amount of analgesia. Two recent studies (Forester et al., 2000, Morrison and Siu, 2000) have found that demented patients receive about 52% of the non-morphine opioids and 64% of the morphine compared with cognitively intact patients, and have recommended that physicians’ prescribing practices in this population should be altered. However, these studies included relatively small number of cases and an uncommon and questionable cognitive assessment (Forester et al., 2000). No distinction was made between patients with respect to fracture type, and dementia or delirium had not been distinguished. Moreover, these studies considered only the immediate peri-operative period, while pain related to hip fracture may well extend beyond this period.

The purposes of this study were 1. To determine the amount of opioid analgesia used in elderly hip fractured patients, 2. To study the possible differences in the use of such medications in cognitively impaired or delirious patients, compared with intact patients, and 3. To investigate to what extent does cognition affect the amount of opioid analgesia this population.

Section snippets

Patients and methods

This is a retrospective comparative survey study designed to evaluate the use of opioid analgesia in elderly hip fractured patients with and without cognitive decline. The study took place in the orthogeriatric ward of a large tertiary general medical center, which is a level trauma center. The nature and organization of this ward has been previously described (Adunsky et al., 2002).

The analyses included the first 302 consecutive hip fracture patients, aged 60 years or older, who had been

Results

During a 2-year period, a total number of 302 patients were admitted for the purpose of hip fracture surgery. Admission MMSE scores, as well as data regarding the presence or absence of delirium, and data regarding the precise dosage of opioid medications that were consumed during hospital stay, were available for 184 patients (61%). The general characteristics of these patients and data regarding type of fractures are shown in Table 1.

Mean MMSE score was 22.7±5.8. Since cognitive impairment is

Discussion

The present study specifically examines the important issue of opioid analgesia in elderly hip fractured patients, in a relatively large sample of patients, using strict criteria for assessing cognition, delirium and MED. The results are important with regards to practical management, showing that about half of this population, which has a significant cognitive decline, is deprived of sufficient opioid analgesia. Moreover, use of opiates in delirious patients was even more restrained. This is

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