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