title: A case-control study examining inconsistencies in pain management following fractured neck of femur: an inferior analgesia for the cognitively impaired.
abstract: Previous research suggests individuals who suffer from cognitive impairment are less able to vocalise pain than the rest of the cognitively-intact population. This feature of cognitive impairment may be leading to a chronic underdetection of pain as current assessment tools strongly rely on the participation of the patient. To explore inconsistencies in pain management within the acute setting, we conducted a retrospective assessment of 224 patients presenting with fractured neck of femur at a large teaching hospital's accident and emergency (A&E) department between 2 June 2011 and 2 June 2012. These patients were split into either a cognitively-impaired or cognitively-intact cohort based on their Abbreviated Mental Test Scores. Patients with cognitive impairment, on average, received a weaker level of analgesia than individuals without impairment both in the ambulance and in A&E. In the ambulance, 45% of cognitively-impaired patients were prescribed no pain relief compared with just 8% of those individuals who remain cognitively intact. After arrival at A&E, these inconsistencies continued with 69% of the cognitively-intact cohort receiving the strongest opioid analgesia compared with just 37% of the cognitively-impaired cohort. The cognitively-impaired cohort would also wait on average an hour longer before receiving this initial pain relief. We believe that these differences stem from cognitively-impaired patients being unable to vocalise their pain through traditional assessment methods. This work discusses the potential development or adoption of a tool which can be applied in the acute setting and relies less on vocalisation but more on the objective features of pain, so making it applicable to cognitively-impaired individuals.
authors.affiliation: Department of Orthopaedic Surgery, Wythenshawe Hospital, Manchester, UK.
authors.forename: J H
authors.initials: JH
authors.lastname: McDermott
authors.affiliation: Department of Orthopaedic Surgery, Wythenshawe Hospital, Manchester, UK.
authors.forename: D R
authors.initials: DR
authors.lastname: Nichols
authors.affiliation: Department of Orthopaedic Surgery, Wythenshawe Hospital, Manchester, UK.
authors.forename: M E
authors.initials: ME
authors.lastname: Lovell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D016022:Case-Control Studies; D003072:Cognition Disorders / Q000150:complications* / Q000523:psychology; D015331:Cohort Studies; D004363:Drug Utilization; D004632:Emergency Medical Services; D005260:Female; D005265:Femoral Neck Fractures / Q000150:complications* / Q000523:psychology / Q000628:therapy; D006801:Humans; D008297:Male; D020380:Needs Assessment; D010146:Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D059408:Pain Management; D010147:Pain Measurement; D061665:Time-to-Treatment; D006113:United Kingdom; D014705:Verbal Behavior
chemical_list: D000701:Analgesics, Opioid