Postop Opioids and Cognitive Function After Hip Fracture
Postop Opioids and Cognitive Function After Hip Fracture
Objectives: To determine the relationship between opioid consumption and cognitive impairment after hip fracture repair.
Design: Prospective study of consecutive patients.
Setting: Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Participants: Two hundred thirty-six participants aged 65 and older undergoing hip fracture repair.
Measurements: Older adults without preoperative delirium who underwent hip fracture repair between April 2005 and July 2009 were followed for pain, opioid consumption, and postoperative delirium. Participants were tested for delirium using the Confusion Assessment Method preoperatively and midmorning on Postoperative Day 2. The nursing staff assessed pain on a numeric oral scale (range 0–10). Opioid analgesia was provided in response to pain at rest to achieve scores of 3 or less. Opioid consumption was analyzed with respect to the occurrence of incident postoperative delirium, presence of dementia, and other demographic variables.
Results: Of the 236 participants, 66 (28%) had dementia, and 213 (90%) received opioids postoperatively, including 55 (83%) with dementia and 158 (93%) without. There was no association between the use of any postoperative opioid and incident delirium (P = .61) in participants with (P = .33) and without (P = .40) dementia. Dementia, but not postoperative delirium, was associated with less opioid use (P < .001 for dementia; P = .12 for delirium; P = .04, for their interaction; Wald chi-square = 142.8, df = 7). Opioid dose (P ≥ .59) on Postoperative Days 1 and 2 was not predictive of incident delirium. Dementia (P < .001) and intensive care unit admission (P = .006), not opioid consumption, were the most important predictors of incident postoperative delirium.
Conclusion: Concern for postoperative delirium should not prevent the use of opioid analgesic therapy sufficient to achieve a generally accepted level of comfort in individuals with or without preexisting cognitive impairment.
The relationship between opioid analgesic use and postoperative delirium when managing pain in elderly adults after hip fracture repair is poorly defined. For one, there is controversy as to whether opioid administration may itself be a risk factor for postoperative delirium. Although one study showed opioid administration to have an inverse relationship with postoperative delirium, others have shown the opposite. Alternatively, perioperative pain may be a risk factor for postoperative delirium. In mixed populations of surgical patients, an association has been reported between high levels of pain at rest and the development of postoperative delirium. Similarly, in elderly adults with hip fracture, undertreated pain has been associated with greater incidence of postoperative delirium. Given these data, it is unclear whether opioid administration or pain precipitates delirium.
Cognitive impairment is common in people with hip fracture. Up to 21% of individuals who require hip fracture repair present with dementia. Although the overall prevalence of postoperative delirium in elderly adults after major elective surgery has been estimated to be 10%, for procedures such as hip fracture repair, the rate of incident postoperative delirium has been reported to be as high as 40%. Cognitive impairment may make pain assessment more difficult, and many practitioners express concern regarding evidence that opioid administration may precipitate postoperative delirium.
Because opioid administration and pain have been associated with risk of postoperative delirium and because of the difficulty managing pain in individuals with dementia, it was desired to further define the relationship between opioid consumption and cognitive impairment. Therefore, opioid consumption and pain were measured in participants with and without cognitive impairment on a hip fracture service (HFS), where postoperative pain management is based on an established clinical pathway.
Abstract and Introduction
Abstract
Objectives: To determine the relationship between opioid consumption and cognitive impairment after hip fracture repair.
Design: Prospective study of consecutive patients.
Setting: Johns Hopkins Bayview Medical Center, Baltimore, Maryland.
Participants: Two hundred thirty-six participants aged 65 and older undergoing hip fracture repair.
Measurements: Older adults without preoperative delirium who underwent hip fracture repair between April 2005 and July 2009 were followed for pain, opioid consumption, and postoperative delirium. Participants were tested for delirium using the Confusion Assessment Method preoperatively and midmorning on Postoperative Day 2. The nursing staff assessed pain on a numeric oral scale (range 0–10). Opioid analgesia was provided in response to pain at rest to achieve scores of 3 or less. Opioid consumption was analyzed with respect to the occurrence of incident postoperative delirium, presence of dementia, and other demographic variables.
Results: Of the 236 participants, 66 (28%) had dementia, and 213 (90%) received opioids postoperatively, including 55 (83%) with dementia and 158 (93%) without. There was no association between the use of any postoperative opioid and incident delirium (P = .61) in participants with (P = .33) and without (P = .40) dementia. Dementia, but not postoperative delirium, was associated with less opioid use (P < .001 for dementia; P = .12 for delirium; P = .04, for their interaction; Wald chi-square = 142.8, df = 7). Opioid dose (P ≥ .59) on Postoperative Days 1 and 2 was not predictive of incident delirium. Dementia (P < .001) and intensive care unit admission (P = .006), not opioid consumption, were the most important predictors of incident postoperative delirium.
Conclusion: Concern for postoperative delirium should not prevent the use of opioid analgesic therapy sufficient to achieve a generally accepted level of comfort in individuals with or without preexisting cognitive impairment.
Introduction
The relationship between opioid analgesic use and postoperative delirium when managing pain in elderly adults after hip fracture repair is poorly defined. For one, there is controversy as to whether opioid administration may itself be a risk factor for postoperative delirium. Although one study showed opioid administration to have an inverse relationship with postoperative delirium, others have shown the opposite. Alternatively, perioperative pain may be a risk factor for postoperative delirium. In mixed populations of surgical patients, an association has been reported between high levels of pain at rest and the development of postoperative delirium. Similarly, in elderly adults with hip fracture, undertreated pain has been associated with greater incidence of postoperative delirium. Given these data, it is unclear whether opioid administration or pain precipitates delirium.
Cognitive impairment is common in people with hip fracture. Up to 21% of individuals who require hip fracture repair present with dementia. Although the overall prevalence of postoperative delirium in elderly adults after major elective surgery has been estimated to be 10%, for procedures such as hip fracture repair, the rate of incident postoperative delirium has been reported to be as high as 40%. Cognitive impairment may make pain assessment more difficult, and many practitioners express concern regarding evidence that opioid administration may precipitate postoperative delirium.
Because opioid administration and pain have been associated with risk of postoperative delirium and because of the difficulty managing pain in individuals with dementia, it was desired to further define the relationship between opioid consumption and cognitive impairment. Therefore, opioid consumption and pain were measured in participants with and without cognitive impairment on a hip fracture service (HFS), where postoperative pain management is based on an established clinical pathway.
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