OTA 2013 Posters
Scientific Poster #27 Geriatric OTA 2013
Preoperative Cognitive Impairment, Pain, and Psychological Stress in Hospitalized Elderly Hip Fracture Patients
Alan H. Daniels, MD; Lori A Daiello, PharmD, ScM; Craig R Lareau, MD;
Daniel L Aaron, MD; Kathryn A. Robidoux, BA; Wylie Luo, BA; Roman A. Hayda, MD;
Christopher T. Born, MD
Warren Alpert Medical School of Brown University and Rhode Island Hospital,
Providence, Rhode Island, USA
Purpose: The purpose of this study was to evaluate the prevalence of cognitive impairment (CI) in hospitalized elderly patients awaiting surgery for hip fracture. The secondary objectives were to compare preoperative ratings of pain and psychological distress among those with and without cognitive impairment, in addition to hospital length of stay (LOS). We hypothesized that diagnoses of dementia or CI would be documented infrequently in the medical record, and that compared to cognitively intact patients, patients with CI would have greater pain and psychological stress preceding operative intervention, as well as increased LOS following hip fracture.
Methods: This prospective cohort study included English-speaking individuals 65 years of age or older who were admitted to a single institution following acute hip fracture. Exclusion criteria included pathologic hip fractures, alcohol dependence, CI secondary to cerebral vascular accident, unstable psychiatric disorders, and delirium. The preoperative assessment included the Confusion Assessment Method (CAM), Montreal Cognitive Assessment (MoCA), Visual Analogue Scales (VAS) for Anxiety and Fear, Wong-Baker FACES Pain Scale, and the Everyday Cognitive Screen (EDC). Patients with and without CI were compared based on their scores on each assessment test.
Results: Of the 122 eligible hip fracture patients, 53% (N = 65) were enrolled, including 46 females (71%) and 19 males (29%). The mean age was 82.5 (standard deviation [SD] 7.4) years (range, 66-97). Of the 65 hip fracture patients enrolled in the study, 62 had evaluable baseline cognitive data. Of these, 37.1% (23) had normal cognition (MoCATotal Score ≥23), while 62.9% (39) were identified as cognitively impaired (MoCATotal Score <23). Only 7.7% of patients (5 of 65) had a documented diagnosis of CI or dementia at the time of hospitalization. Preoperatively, the mean pain score for patients with CI was 5.3 (SD 2.8) compared to 2.8 (SD 1.5) in patients without CI (P = 0.0002). Prior to assessment, 30.4% of patients without CI and 17.9% of patients with CI had received analgesic medication (P = 0.28). The mean VAS anxiety (56.2 [SD 35.5]) and VAS fear scores (42.0 [SD 37.7]) for patients with CI were not statistically significantly different from those without CI (mean VAS anxiety, 50.0 [SD 38.3]; mean VAS fear, 40.0 [SD 31.7]; P = 0.524)). The mean hospital LOS was 1.1 days longer in patients with CI compared to cognitively intact patients (5.6 vs 6.7 days; P = 0.390).
Conclusion: This prospective study revealed that 62.9% of elderly hip fracture patients had CI prior to surgery, although dementia/CI was underreported in the medical record and only documented in 7.7% of patients. Patients with CI expressed statistically significantly greater degrees of preoperative pain, and a trend towards higher anxiety and fear ratings compared to those without CI. In this small cohort, higher pain levels in cognitively impaired patients may have been due to undermedication. High levels of pain, fear, and anxiety can influence long-term outcome following hip fracture, thus appropriate identification of preoperative CI and appropriate pain control is critical in order to optimize patient outcomes. Larger prospectively controlled trials are needed to determine optimal methods for identifying and caring for cognitively impaired hip fracture patients.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.