Pain treatment: A risk factor for delirium in older adults with hip fracture.

摘要

Delirium and pain are common following hip fracture. Undertreatment of pain has been shown to increase the risk of delirium in older adults experiencing hip fracture in only a very few earlier studies. This study was conducted to describe the clinical trajectory of delirium following hip fracture, and examine relationships between pain, pain treatment and delirium in older adults with hip fracture.;The consecutive sample included 204 patients ≥65 years of age with no delirium at baseline at two hospitals in Oslo, Norway. The Confusion Assessment Method was used to identify delirium through patient and nurse interview and patient record review. Multiple logistic regression was used to identify risk factors.;Cognitively intact patients reported highest pain intensity at rest and with movement before surgery with gradual decrease over the trajectory. Cognitively impaired patients showed a similar pain pattern based on observed pain behaviors. Despite high pain levels, patients received low doses of opioids and acetaminophen, especially those with cognitive impairment.;Of 204 patients, 70 (34.3%) developed postoperative delirium. Patients who received inadequate multimodal pain treatment (<9.9 mg opioids and ≤3500 mg acetaminophen) had a significantly increased risk of delirium compared to patients who received more analgesics (RR 1.7; 95% CI 1.1--2.3). Additional significant, independent risk factors for delirium were cognitive impairment (RR 2.5; 95% CI 1.7--3.1), low body mass index (RR 1.8; 95% CI 1.2--2.4), complete or hemiarthroplasty performed (RR 1.7; 95% CI 1.1--2.3), prolonged preoperative fasting (RR 1.7; 95% CI 1.1--2.3), and postoperative anemia (RR 1.6; 95% CI 1.0--2.2).;Of 135 cognitively intact patients, 31 (23%) developed delirium. Severity of illness was the only risk factor significant in multivariate analysis in this subgroup. Of 69 cognitively impaired patients, 39 (56.5%) developed delirium. Risk factors were low body mass index, normal white blood cell count, perioperative benzodiazepines, and acetaminophen. However, there was interaction between benzodiazepines and acetaminophen.;Older adults with hip fracture received inadequate pain treatment for their level of pain. Avoiding both opioids and acetaminophen increased the risk of delirium. Undertreated pain appears to be a risk factor for delirium in both cognitively intact and impaired patients.