www.postersession.com
Pain in the cognitively impaired older adult can
be difficult to assess and manage well. When we
discovered that post hip fracture pain was
routinely being managed with PCA (Patient
Controlled Analgesia) a review of those patients
was done to determine to determine outcomes
and complications. A large number were frail
older adults; many with cognitive deficits. This
practice many times resulted in less than
adequate pain management, leading to
complications such as delirium and functional
decline.
Interviews with surgeons and RNs revealed that
neither group was confident of an alternative
pain management strategy. A review of older
adults with PCA orders was done. Through this
evaluation we discovered a large percentage of
these patients had no awareness of the PCA or
how it worked; also undermanaged pain and an
inability to participate with physical therapy.
Many required additional medications to manage
the resultant acute confusion.
An interdisciplinary team was formed including
staff RNs, orthopedic surgeons, CNS, pharmacist
and physical therapist. Current practice and
outcomes were examined, the older adult pain
management literature was reviewed and an
alternative order set was developed to be
substituted for the PCA order. The order set
includes a scheduled around the clock analgesic
with as needed medication for breakthrough
pain. The RN has the capability to change from IV
to oral medication when appropriate.
The order set has been trialed specifically on hip
fracture patients over the age of 80 and those
with suspected cognitive deficits. The trial phase
is just ending with improved outcomes for these
patients; decrease incidence of over sedation
and acute confusion and increased ability to
participate with physical therapy on a daily basis.
The plan is to make the order set house wide by
the end of this year.
Observations: Conclusions
PCA Alternative for Older Adults Lisa Baumhover, MS, GCNS-BC / Mary May BSN
Order Set Documentation Bibliography
• 45 patients over 30 day timeframe
• Age range: 65 to 99 years of age
• PCA for pain management: 100%
• Evidence of dementia per history: 22%
• Change in mental status documented
concurrent to PCA use: 33%
• Positive for delirium per Confusion
Assessment Method at time of CNS visit:
27%
Aim Statement: Improve pain management in cognitively
impaired adult patients in the acute care
setting.
Pilot Inclusion Criteria • Admitted to DMOS on 2North @ ILH
• Post fall resulting in fracture
• Positive for dementia or greater than age
80
Older adult patients… • Will likely not request pain medicine
• Will not be able to give you a numerical pain
score
• May not respond to the term PAIN
• Alternate pain descriptors:
• Sore, achy, stiff
• Always assess twice:
• At rest and with movement
Techniques: • Eliminate distractions (TV, radio)
• Maintain eye contact
• Speak clearly and calmly
• Allow sufficient time to answer (wait at least 30
seconds for a response)
• If hearing deficit use assistive hearing device
or hearing aide
The pilot to date has included a total of seven patients:
• Average age: 83 years
• Age range: 73 to 99 years of age
• All patients were female
• Only one patient had documentation of
dementia per history and physical
• None experienced complications due to the
pain management order set 9acute confusion
or respiratory distress
Recommendations:
• Continue current trail of order set.
• When reach ten patients educate staff on all
surgical units and begin use of order set
house wide
Introduction Assessment:
1. Robinson S, Volmer C. Undermedication for pain and precipitation of delirium. MEDSURG Nursing. 2010; 19(2): 79-83.
2. Pioli G, Guisti A, Barone, A. Orthogeriatric care for the elderly with hip fractures: Where are we? Aging Clinical and Experimental Research. 2007; 20(2): 113-122.
3. Gordon DB, Dahl J, Phillips P, et al: The use of “as needed” range orders for opioid analgesics in the management of acute pain: A consensus statement of the american society for pain management nursing and the american pain society. Pain Management Nursing. 5(2); 53-58.
4. Morrison RS, Magaziner J, Gilbert M, et al: Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Journal of Gerontology: Medical Sciences. 2003; 58A: 76-81.
5. Herr K, Bjoro K, Steffensmeier J, Rakel B. Evidnece-based practice guideline: Acute pain management in older adults. In: Titler M, ed. The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core. University of Iowa; 2006.
6. D’Arcy Y. How to Manage Pain in the Elderly, Indianapolis, IN: Sigma Theta Tau International; 2010.
7. Horgas AL, Saunjoo SL. Pain management. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence–Based Geriatric Nursing Protocols for Best Practice. New York, NY: Springer Publishing Company; 2008: 223.
8. Zwicker D, Fulmer T. Reducing adverse drug reactions. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence–Based Geriatric Nursing Protocols for Best Practice. New York, NY: Springer Publishing Company; 2008: 257.
9. 10. D’Arcy Y. Pain Management: Evidence-Based Tools and Techniques for Nursing Professionals, Marblehead, MA: HCPro, Inc; 2007.
NICHE Annual Conference
New Orleans, LA
March 7-9, 2012