Background & Aims
Every year, 1.7 million individuals sustain a hip fracture [1]. Although surgery is the gold standard treatment for hip fracture repair, it is not recommended for all patients [2-4]. Given the high mortality rate in frail patients with neurocognitive disorders (NCDs), as well as their low level of recovery following hip fracture, non-surgical treatment and management by a palliative care team may be warranted in this population [2,4,5]. However, non-operated patients were reported to have more pain than operated patients for up to several months after fracture [6]. Pain assessment can be complex in patients with NCD and may affect the appropriateness of pain treatments [7-9]. Thus, the aims of this study were to: 1) describe pain following hip fracture in non-operated palliative care patients in whom a validated tool for assessing pain in the context of NCD was used, and 2) examine pain management strategies used with these patients.
Methods
A retrospective descriptive study was conducted among non-operated patients with hip fracture and NCD receiving palliative care. The study took place in a Level I trauma center in Canada. Inclusion criteria were to have been managed by a palliative care team following a traumatic femoral neck or inter-trochanteric fracture, and to have been diagnosed with NCD. Data collection was based on a medical record review of patients admitted to palliative over a one-year period in 2022-2023. Pain at rest and on mobilization was assessed four times a day during the first five days of hospitalization following admission to palliative care. The ALGOPLUS behavioral tool [10] was completed using nursing and medical documentation forms. Descriptive statistics were calculated based on the presence or absence of pain (score on the ALGOPLUS higher or equal to 2) [10], and the total amount of analgesics and non-pharmacological strategies used daily and over the five days of observation.
Results
We reviewed the medical records of 49 patients. The mean age of patients was 87 years (±7.1), and the majority were women (73%). All patients (100%) had sustained a hip fracture secondary to a fall. The mean MOCA score was 17.9, reflecting moderate cognitive impairment [11]. All patients (100%) were frail, and the mean Rockwood Score was 7.2, indicating severe frailty [12]. One in five patients died within five days of observation. Nearly three-quarters of patients experienced pain on mobilization (71%) and over a third at rest (36%) on average over the five days of observation, with a decrease in prevalence from day one to day five (82% to 61% on mobilization and 55% to 38% at rest). A mean of 17.7 mg/day of oral morphine equivalence was administered over the five days of observation (from 12.1 to 23.5 mg/day), and 43% of patients received coanalgesia, mainly acetaminophen (67%). Non-pharmacological strategies, mostly positioning in bed, were used in 49% of patients.
Conclusions
Pain is a major issue in hip fracture patients with NCD, despite the availability of palliative care. The results of this study suggest several potential solutions for optimizing pain relief in this population in order to offer them a comfortable end of life. Training healthcare providers in the use of validated tools to assess pain based on behavioral observation, optimization of analgesia, more systematic use of non-pharmacological strategies and mobilization protocols should be considered to improve pain management in non-operated hip fracture patients with NCD. Specialized units enabling healthcare providers to acquire the expertise needed to provide palliative care to this complex and vulnerable population also seems to be an avenue worth considering.
References
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Presenting Author
Alexandra Tremblay
Poster Authors
Alexandra Tremblay
BSc
Université Laval
Lead Author
Stéphane Pelet
MD
CHU de Québec-Université Laval
Lead Author
Étienne Belzile
MD
CHU de Québec-Université Laval
Lead Author
Diane Tapp
PhD
Faculté des sciences infirmières, Université Laval, Québec, QC, Canada
Lead Author
Chantal Morency
MD
CHU de Québec-Université Laval
Lead Author
Norbert Dion
MD
CHU de Québec-Université Laval
Lead Author
Justine Boulet
MD
CHU de Québec-Université Laval
Lead Author
Marcel Émond
M.Sc. CCMF(MU)
CHU de Québec-Université Laval
Lead Author
Mélanie Bérubé
NP
Université Laval
Lead Author
Topics
- Pain in Special Populations: Elderly