Expert opinion on the management of pain in hospitalised older patients with cognitive impairment: a mixed methods analysis of a national survey.
BACKGROUND
Hospitalised older patients are complex. Comorbidity and polypharmacy complicate frailty. Significant numbers have dementia and/or cognitive impairment. Pain is highly prevalent. The evidence base for pain management in cognitively impaired individuals is sparse due to methodological issues. A wealth of expert opinion is recognised potentially providing a useful evidence base for guiding clinical practice. The study aimed to gather expert opinion on pain management in cognitively impaired hospitalised older people.


METHODS
Consultant Geriatricians listed as dementia leads in the National Dementia Audit were contacted electronically and invited to respond. The questionnaire sought information on their role, confidence and approach to pain management in cognitively impaired hospitalised patients. Responses were analysed using a mixed methods approach.


RESULTS
Respondents considered themselves very confident in the clinical field. Awareness of potential to do harm was highly evident. Unequivocally responses suggested paracetamol is safe and should be first choice analgesic, newer opiates should be used preferentially in renal impairment and nefopam is unsafe. A grading of the safety profile of specific medications became apparent, prompting requirement for further evaluation and holistic assessment.


CONCLUSIONS
The lack of consensus reached highlights the complexity of this clinical field. The use of paracetamol first line, newer opiates in renal impairment and avoidance of nefopam are immediately transferrable to clinical practice. Further review, evaluation and comparison of the risks associated with other specific analgesics are necessary before a comprehensive clinical guideline can be produced.
Department of Geriatric Medicine, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK. kirstyrodger@nhs.net.
Kirsty T M
KT
Rodger
School of Applied Social Science, University of Stirling, Colin Bell Building, Stirling, FK9 4LA, UK. corinne.greasley-adams@stir.ac.uk.
Corinne
C
Greasley-Adams
Acute Pain Service, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK. zoe.hodge@nhs.net.
Zoe
Z
Hodge
Department of Geriatric Medicine, NHS Fife, Victoria Hospital, Hayfield Road, Kirkcaldy, KY2 5AH, UK. emma.reynish@stir.ac.uk.|School of Applied Social Science, University of Stirling, Colin Bell Building, Stirling, FK9 4LA, UK. emma.reynish@stir.ac.uk.
Emma
E
Reynish
D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000627:therapeutic use*; D003072:Cognition Disorders / Q000150:complications* / Q000523:psychology; D005260:Female; D006801:Humans; D008297:Male; D010146:Pain / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy*; D059408:Pain Management / Q000379:methods*; D011795:Surveys and Questionnaires
D000700:Analgesics