Hip fracture is a commonly occurring event for elderly individuals that produces pain and is associated with significant disability and loss of independence. Several factors have been identified as contributors to postoperative functional outcomes for hip fracture patients (e.g., age^ gender, pre-fracture functioning, mental status, depression, poorer self-rated health, operative risk rating or number of comorbidities, fracture type, hospital type) (Fox, Hawkes, Magaziner, Zimmerman, & Hebel, 1996; Rovai, Skovron, Aharonoff, Meadows, & Zuckerman, 1995; Myers, Palmer, Engel, Warrenfeltz, fie Parker, 1996; Young, Brant, German, Renzora, Magaziner, 1997).
In most functional outcome studies, pain repon or treatment has not been considered as a factor influencing functional outcomes. However, some research indicates that undertreated pain is a problem for hospitalized older adults with hip fractures (Bell, 1997; Feldt & Oh, in press; Feldt, Ryden, & Miles, 1998; Morrison & Siu, 1998). Patients who are cognitively impaired and have hip fracture have been identified as having poorer functional outcomes, a higher likelihood of being institutionalized following hip fracture, and higher mortality rates (Egol, Rovai, OC Zuckerman, 1997; Goldstein, Strasser, Woodard, Oc Roberts, 1997; Young et al., 1997).
Recent evidence suggests that almost two thirds of older adults hospitalized for hip fractures are discharged from the hospital to a longterm care or rehabilitation facility following hip fracture (Krämer et al., 1997). Few studies examine the report or treatment of pain for older adults with hip fracture after discharge from the hospital. Three studies have noted that hospitalized cognitively impaired older adults receive significantly less analgesia postoperatively when compared with patients who are cognitively intact (Bell, 1997; Feldt, Ryden, & Miles, 1998; Morrison & Siu, 1998).
Differences in pain assessment and treatment have been documented for long-term care residents with cognitive impairment as well. Two studies identified that cognitively impaired residents were prescribed and administered significantly less analgesia when compared with intact residents with similar painful conditions (Horgas Oc Tsai, 1998; Raasalainen et al., 1998). Wagner et al., (1997) reported inadequate pain treatment for one fourth of the longterm care residents studied. Others have noted more than half of longterm care residents do not use the p.r.n. medications prescribed for them, although it is not clear whether residents do not need or request these medications, or do not know they are available (Brown & DeSimone, 1980; Raasalainen et al., 1998). Given the important role long-term care facilities have in the rehabilitation of elderly individuals, it is important to understand how pain is treated in these settings to determine how quality of care and potentially functional outcomes might be improved.
The purpose of this study was to compare the experience of pain and treatment of pain for cognitively impaired versus cognitively intact older adults residing in a long-term care or rehabilitation setting during the 3 weeks following surgical repair of a hip fracture.
A prospective comparative survey design was used. Patients who had undergone surgical repair of a hip fracture were interviewed in the hospital and again at approximately postoperative Day 20. Data from the hospital interview have been reported elsewhere (Feldt, Ryden, fie Miles, 1998). This report focuses on data from the nursing home interview and medical record review (approximately Day 20 postoperatively).
Setting and Participants
The study was approved by human subjects committees at each of three Midwestern urban hospitals. Approval for the follow-up interview at Day 20 postoperatively was obtained from each of the administrators of the rehabilitation or long-term care settings to which the participants had been discharged. Participants met the following inclusion criteria:
* Age 65 or older.
* Hospitalized on an orthopedic unit for surgical repair of a hip fracture.
* English speaking.
* Plan for discharge to rehabilitation center or nursing home.
Because of possible complications from multiple sources of new acute pain, participants were excluded if hip fracture was sustained related to a motor vehicle accident in which other trauma was sustained, or if they underwent multiple surgeries during hospitalization.
Between February and October 1995, a convenience sample of 88 participants (53 cognitively impaired and 35 intact) were enrolled in the study and interviewed in the hospital. Of these 88, five were discharged directly to home from the hospital and are not included in the data for the second interview. Eighty-three of the participants were discharged to rehabilitation centers or nursing homes throughout the metropolitan area.
Of these 83 participants, 3 died prior to the second interview and 1 3 were discharged to home from the nursing home before the interview. Eight participants were not interviewed because of re-hospitalization, request by family, or scheduling difficulties. The final sample of 59 patients interviewed at the rehabilitation or long-term care settings consisted of 32 individuals who were cognitively impaired and 27 who were cognitively intact. Characteristics of the 59 participants who completed the interview at Day 20 postoperatively are listed in Table 1 . Measures
CHARACTERISTICS OF SUBJECTS
Mental status was assessed using the Folstein Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975). Mental status was assessed at the time of the interview in the hospital and again at the time of the interview in the nursing home at Day 21 postoperatively. Only MMSE scores from the nursing home interview are reported in this article. Participants whose MMSE scores were 23 or lower were categorized as cognitively impaired. Mean MMSE for each of the groups is reported in Table 1. No educational level adjustments to MMSE were made because of limited and conflicting information about the educational level of these participants.
To adjust for the concern that multiple chronic conditions could impact the prescription and use of medications in this population, an illness severity score was calculated for each participant. Illness severity scores were the sum of the number of comorbid medical diagnoses (from a list of 13 possible common diagnoses in older adults) on admission plus the number of in-hospital complications (a list of 16 hospital complications) (Parmelee et al., 1996). Because renal functions also impact amount and type of medication used, creatinine clearance was estimated using a formula by Cockroft and Gault (1976).
Verbally responsive participants' pain were assessed using an adaptation of Ferrell's Pain Experience Interview (FPEI) (Ferrell, Ferrell, & Osterweil, 1990) and the Verbal Descriptor Scale (VDS) (Herr & Mobily, 1993), a pain intensity rating scale. Questions from the FPEI have been written for "yes" and "no" responses, simplifying answers for patients with some cognitive impairment. The VDS is a ranked pain intensity rating (typed in large bold print), which allowed participants to rate pain as "no pain," "slight pain," "mild pain," "moderate pain," "severe pain," "extreme pain," or "pain as bad as it could be." All pain measures were tested for reliability. Test-retest reliability of pain reports have been reported elsewhere (Feldt, Ryden, & Miles, 1998).
All participants were observed for pain indicators during a simple movement (a routine transfer by nursing staff) using a Checklist of Nonverbal Pain Indicators (CNPI) (Feldt, 2000). This simple dichotomous measure of six observed pain behaviors was based on the University of Alabama Pain Behavior Scale (Richards, Nepomuceno, Riles, & Suer, 1982). The CNPI has good face validity based on literature related to pain behaviors in patients with chronic pain and older adults who are cognitively impaired (Baker, Bowring, Brignell & Kafford, 1996; Kaasalainen et al., 1998; Parke, 1992; Parmelee, 1996). Behaviors most frequently cited by other researchers are included in the CNPI: verbal and nonverbal vocalizations, grimacing, bracing, rubbing, and restlessness (Marzinski, 1 99 1 ; Parke, 1992; Parmelee, 1996; Richards, Nepomuceno, Riles, & Suer, 1982). Scoring of the tool is a simple frequency of the number of pain behaviors observed (range O to 6). Two master's prepared gerontological nurse practitioners simultaneously observed a subset (13) of the participants to obtain interrater reliability. There was a 93% agreement on the behaviors observed on the CNPI (K = 0.625 to 0.819, ? = .019 to .0057) (Feldt, 2000).
PAIN REPORT OF SUBJECTS
All opioid analgesics were converted to morphine equivalencies (Acute Pain Management Guideline Panel, 1992). The mean daily prescribed amounts of opioid and nonopioid analgesics were calculated using a formula devised by Faherty & Grier, (1984). If more than one analgesic was prescribed, the minimum and maximum doses of all analgesics were summed and the mean was calculated. Because many of the participants were given acetaminophen, either with opioid analgesics or as a separate analgesic, the mean daily prescribed dose of acetaminophen and total administered daily amount of acetaminophen was calculated.
PAIN BELIEFS OF SUBJECTS
Chi-square analysis was performed for comparison of the two groups on the variables of gender, marital status, surgery type, dichotomous pain report variables, and documentation of pain. The Mann-Whitney test was used for comparison of the two groups on the nonverbal signs of pain during movement score (CNPI-m). Differences between the groups on MMSE, VDS, weight, illness severity, and mean daily prescribed and administered doses of opioid and nonopioid analgesics were determined using the Student t test.
NONVERBAL PAIN INDICATORS
The participants were predominantly women, White, non-Hispanic, widowed, with an age range from 65 to 101 years (Table 1). The mean age of the post-discharge sample as a whole was 84.4 years. Although the cognitively impaired group was significantly older than the Cognitively intact group, the groups did not differ significantly with regard to weight, type of hip fracture, or type of surgical hip repair that had been done. The majority of participants had intertrochanteric (37.5%) or transcervical fractures (31.8%), although slightly more than one fourth had their femoral neck fracture unspecified (26%). Nearly two thirds of the participants (63.6%) had open reduction with internal fixation surgeries, and the remainder had Austin Moore or bipolar prosthesis.
Pain report. Sixty-one percent of the participants said "yes" when asked if they had pain (Table 2). Only two of the cognitively impaired participants were unable to respond to the yes-no pain questions. Slightly more of the intact group reported pain than those in the impaired group. This approached, but did not reach, statistical significance (?2 = 3.48, df- l,p = .062). More participants in both of the groups responded "yes" when asked if pain was intermittent than when initially asked if they had pain. One quarter of the participants reported pain as being constant. More participants in both groups answered affirmatively to the word discomfort (73.7%, ? = 42) than the original question "Do you have pain?"
Participants in the intact group said "yes" to more pain synonyms than did the cognitively impaired group, but the difference did not reach significance. The participants who were cognitively intact did not identify more locations of pain than the participants who were impaired. Most (81.3%) of the participants who were cognitively impaired were able to complete the VDS. Ratings of the intensity of pain did not differ between the two groups. The average rating of pain was between mild and moderate at the time of the second interview, with 15.4% (n = 4) of the cognitively impaired group and 18.5% (« = 5) of the cognitively intact group reporting pain as severe or worse.
Pain beliefs. Responses from selected questions of the Ferrell interview addressing pain beliefs are summarized in Table 3. Fifty-three participants were able to respond to the pain belief questions. More cognitively intact participants than cognitively impaired participants (25.9% vs. 7.4%; NS, P = .071) indicated they were afraid to take pain medication. Reasons given included a fear of constipation, addiction, or drowsiness.
More than half the participants in both groups indicated they should "just learn to live with their pain." Significantly more of the participants who were cognitively intact were concerned about becoming a complainer and expressed they were afraid to bother the nurses. Some participants said, "They seem so busy," or fear that complaining may impact future care. One said, "If I complain too much they might not come when I really need them." However, few of the participants in either group believed their pain could not be treated at all, indicating they believed relief was possible.
Observed pain. Observations for nonverbal signs of pain at rest using the CNPI were completed on 58 of the participants (Table 4). One participant in the cognitively intact group was not observed because of an interruption by physical therapy. Ten participants (six impaired and four intact) were not observed for nonverbal signs of pain during movement because they were in a wheelchair or recliner and refused transfer back to the bed.
PRESCRIBED AND ADMINISTERED ANALGESICS 48 HOURS PRIOR TO INTERVIEW
There were no significant differences between the two groups related to the individual pain behaviors observed or the sum of all pain behaviors observed. Few nonverbal signs of pain were observed at rest for participants in either group. The most frequently observed behaviors during movement for all participants were facial grimaces, nonverbal vocalizations, and verbal complaints. Nonverbal indicators of pain were more commonly observed during movement rather than at rest. One of the behaviors, rubbing, was not observed at all, either at rest or with movement. Both groups had a very low frequency of nonverbal indicators at rest and with movement.
Documentation of pain. Nursing care plans at the post-discharge settings included pain or comfort for less than half (41%) of the participants, which did not differ based on cognitive status. The type of documentation about pain by nurses differed significantly between the groups, although the number of pain notations did not differ. Nurses wrote one or more notes about pain medications being administered on 92.6% (n = 25) of the charts for the participants who were Cognitively intact compared to only 65.6% (n = 21) of the charts for the participants who were Cognitively impaired (?2 = 6.2, df = 2, ? = .04). Nurses rarely identified the intensity or severity of pain or used standardized measures for describing pain for either group. A common documentation was "Patient complained of pain, acetaminophen given."
Prescription and administration of pain medications. The narcotic analgesics at the post-discharge settings were prescribed and administered in much lower doses than at the hospital setting (Feldt, Ryden, & Miles, 1998), even though most of the participants were discharged from the hospital on their fourth or fifth postoperative day. Twenty-five percent (n = 8) of the impaired group and 14% (n = 4) of the intact group had no narcotic analgesic prescribed at the post-discharge setting. Two thirds of the participants had one type of narcotic analgesic prescribed. None of the participants in either group had more than two types of narcotic analgesics prescribed. Most (91.5%) of the narcotic analgesics were prescribed p.r.n. Of the five participants who had analgesics prescribed routinely, all were Cognitively impaired.
The most frequently prescribed medications for the all participants in the post-discharge setting were acetaminophen with codeine (37%, n = 22) and propoxyphene napsylate (34%, n = 20). One participant with cognitive impairment who had received no pain medication for 7 days, received a single dose of 50 milligrams meperidine IM within 48 hours of the followup interview, shortly after the facility had received the letter that the resident was participating in a study on pain.
The group means for daily prescribed dose of narcotic analgesics and acetaminophen are listed in Table 5. The prescribed amounts of medications were significantly lower for the Cognitively impaired group than the group of cognitively intact participants, prior to adjustments for severity of illness or creatinine clearance. However, once controlled for these variables, there was no significant difference in the prescribed amount of opioid analgesics between the two groups.
The difference in the prescribed amount of acetaminophen remained significant even after controlling for illness severity and creatinine clearance. Amounts of medications administered by nurses did not differ significantly between groups with or without adjustments for illness severity and creatinine clearance.
More than half (n = 33, 55.9%) the participants received no opioid analgesic in the 48 hours prior to the interview, and more than a third (n = 24, 40.7%) received no acetaminophen prior to the interview. Of these, 23 participants (38.8%) (13 impaired and IO intact) received neither type of analgesic in the 48 hours prior to the interview. Of the group receiving no analgesics prior to the interview, 17 participants (77.3%; 9 impaired and 8 intact) identified pain as being intermittent and 4 (18%; 3 impaired and 1 intact) identified pain as being constant. Most (78%) of the participants who had not received pain medications rated their pain as slight or mild on the VDS, indicating they may not have required pain medication. There were 5 participants (2 impaired and 3 intact) of those who had received no analgesics who rated their pain as moderate or severe.
Nonpbarmacological pain treatments. Significantly more of the participants in the intact group had documentation of non-pharmacological treatments than did participants in the impaired group (29.6%, n = 8 intact versus 9.4%, n = 3 impaired, ?2 = 3.96, df = 1, ? = 0.046). Physical therapists were more likely than nurses to document use of heating packs or ice packs. Positioning was the most frequently mentioned nonpharmacological treatment, noted for seven participants. Four participants (14.8%) in the intact group and one participant (3.1%) in the impaired group had the use of ice or heat mentioned. One participant who was cognitively impaired had documentation of massage for comfort.
DISCUSSION AND CLINICAL IMPLICATIONS
Pain report was fairly common at the postoperative Day 20, with almost two thirds of the participants reporting pain. Most of these rated pain as slight or mild. Other studies report similar prevalence of pain in nursing home residents, citing rates of 62%, 71%, and 79% for the prevalence of pain in nursing home residents (Ferrell, Ferrell & Osterweil, 1990; Ferrell, Ferrell, & Rivera, 1995; Parmelee, Smith, & Katz, 1993). Ferrell, Ferrell, & Osterweil (1990) reported that 47% of nursing home residents interviewed reported intermittent pain and 24% reported constant pain.
Nurses in long-term care should know that because of the intermittent and fluctuating nature of musculoskeletal pain, cognitively impaired patients may not anticipate when pain will be a problem. These residents may be unlikely to request p.r.n. pain medications before needed for relief. Routinely scheduled medications for residents who are cognitively impaired would help eliminate inconsistent pain relief. Nurses need to anticipate periods of movement and offer pain medications in advance.
Pain intensity ratings in this study did not differ significantly between the participants who were cognitively impaired and cognitively intact, unlike other research on nursing home populations (Parmelee, Smith, & Katz, 1993). Although pain ratings were fairly low for the majority of participants, one of six participants in this study still rated pain as severe or worse at the time of the follow-up interview, indicating under-treatment of pain for some of the participants involved. Undertreated pain has been shown to impact functional outcomes for hip fracture patients 2 months postoperatively (Feldt & Oh, 2000). Nursing home staff could improve pain treatment if standardized assessment tools for pain were available for use.
Although there were no significant differences between the two groups related to the number of pain words used, participants in both groups selected words other than "pain," such as "discomfort," "aching,"* and "soreness." Health care professionals in rehabilitation and long-term care settings should use a variety of synonyms when assessing pain in elderly patients.
The very low frequency of pain behaviors observed in the post-discharge settings and the lack of differences between the two groups may partially be caused by adaptation to pain over time. As patients adapt to chronic pain, they are less likely to appear in pain. Staff who expect residents to "look like" they are in pain, may not see evidence of these behaviors unless they observe residents during movement. Unfortunately, physical care and movement of residents is more often conducted by nursing assistants than professional staff, limiting assessment time (Middleton, Knezacek, Robinson, Hartley, & Kaasalainen, 1997). Residents who are cognitively impaired may become aggressive during movement and nursing assistant staff may attribute this behavior to dementia rather than pain (Feldt, Warne, Ryden, 1998; Middleton, Richardson, & Berman, 1997).
Less than half of the nursing care plans in these nursing home and rehabilitation settings listed pain or comfort as an issue. This is similar to findings reported by Carr (1997) who identified 44% of care plans on a rehabilitation unit for older adults neglected to address pain or its management. As one of the quality indicators used to evaluate resident care outcomes under the revised long-term care survey process, pain must be addressed in nursing care plans and clearly documented for individuals newly admitted to the nursing home following surgery. Nursing notes should reflect an objective assessment of the resident's pain and response to pain medications.
Prescribed amounts of opioid analgesics for participants who were cognitively impaired were approximately half the amount prescribed to participants who were intact, reflecting the concern primary physicians have for increased confusion and other side effects in this older, more frail group of patients (Ferrell, 1995). However, there were no significant differences in the amount of analgesic administered to residents who were cognitively impaired compared with those who were cognitively intact. This differs from findings reported by Horgas and Tsai (1998). That study analyzed amounts of analgesia administered in a 1-week timeframe, whereas this study examined only the 48 hours prior to the interview. Given the very small amounts of analgesia administered m the current study, the use of an entire week of data may have been more useful in detecting differences for the two groups.
For a majority of the participants in this study, pain was fairly well controlled. However, five of the participants (two impaired and three intact) who had received no analgesics rated their pain as moderate or severe. Nurses in long-term care should be sensitive to residents who are reluctant to complain of pain. Nurses need to educate patients about the harmful effects of untreated pain and encourage treatment of pain.
Although few of the participants in the post-discharge sample had any documentation of non-pharmacological treatments, significantly more of those receiving these treatments were cognitively intact. Patients who were cognitively intact may be better able to express requests for treaanents of heating pads, ice packs, or repositioning. Some of the chart reviews indicated that physical therapists applied heat packs or ice packs as part of therapy. Ferrell, Ferrell, and Rivera (1995) reported only 4% (n = 5) of nursing home residents had documentation of using a heating pad for pain. Nursing staff in long-term care facilities may actually use more of these non-pharmacological strategies without documenting their actions. Participants cited specific cases of nursing actions during the interview (e.g., special positioning with pillows, back rubs) that were not noted in the medical record.
Study bias may have occurred for some participants who received pain medication by simply participating in this study. A letter to gain administrative consent was sent to each nursing home identifying that the participant was in a study examining the experience and treatment of pain post hip fracture. These letters arrived within 5 to 7 days after admission to the nursing home or rehabilitation center facility, approximately I1A weeks before the Day 20 interview. There were four participants who had received no pain medication in their first 3 to 5 days after admission to the facility but began receiving medications more routinely coinciding with the rime of arrival of the letter for administrative permission.
A larger sample size would have been useful in detecting any differences in pain treatment with such small amounts of administered medication. Nurse variables, such as acquaintance with the resident for longer periods of time, personal experience with pain, beliefs about pain, and knowledge of pain medications would be helpful in further development of the understanding of pain treatment in these settings. It is not clear how resident variables influence the treatment of pain in post-discharge settings (e.g., knowing how many refusals of pain medication offered were made and how these relate to pain beliefs of residents).
Nurses in long-term care and rehabilitation facilities play an important role in returning older adults to their highest functional level following hip fracture. Residents should be reassured that staff want to provide the best pain treatment to help them achieve rehabilitation goals. Nursing staff need to assess pain using standardized pain tools that are simple for residents to understand. Documentation of pain in the nursing notes and care plans should reflect levels of pain, efficacy of nonpharmacological and pharmacological treatments, and recommendations to improve or maintain treatment to achieve functional goals.
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CHARACTERISTICS OF SUBJECTS
PAIN REPORT OF SUBJECTS
PAIN BELIEFS OF SUBJECTS
NONVERBAL PAIN INDICATORS
PRESCRIBED AND ADMINISTERED ANALGESICS 48 HOURS PRIOR TO INTERVIEW