A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture

Advanced dementia patients may be at substantial risk for undetected or und ertreated pain. To examine the treatment of pain following hip fracture, a prospective cohort study was conducted in an academic teaching hospital. Fi fty-nine cognitively intact elderly patients with hip fracture and 38 patie nts with hip fracture and advanced dementia were assessed daily. The cognit ively intact patients rated their pain on a numeric scale ranging from 0 (n one) to 4 (very severe). Analgesics prescribed and administered were record ed and compared to hip fracture patients with advanced dementia. The advanc ed dementia patients received one-third the amount of morphine sulfate equi valents as the cognitively intact patients. Forty-four percent of cognitive ly intact individuals reported severe to very severe pain preoperatively an d 42% reported similar pain postoperatively. Half the cognitively intact pa tients who experienced moderate to very severe pain were prescribed inadequ ate analgesia for their level of pain. Eighty-three percent of cognitively intact patients and 76% of dementia patients did not receive a standing ord er for an analgesic agent. These data reveal that a majority of elderly hip fracture patients experienced undertreated pain. The fact that advanced de mentia patients received one-third the amount of opioid analgesia as compar ed to cognitively intact subjects-40% of whom reported severe pain postoper atively-suggests that the majority of dementia patients were in severe pain postoperatively. This study and others suggest that directed interventions to improve pain detection and alter physician prescribing practices in the cognitively impaired are needed. J Pain Symptom Manage 2000;19:240-248. (C ) U.S. Cancer Pain Relief Committee, 2000.