A case-control study examining inconsistencies in pain management following fractured neck of femur: an inferior analgesia for the cognitively impaired.

Previous research suggests individuals who suffer from cognitive impairment are less able to vocalise pain than the rest of the cognitively-intact population. This feature of cognitive impairment may be leading to a chronic underdetection of pain as current assessment tools strongly rely on the participation of the patient. To explore inconsistencies in pain management within the acute setting, we conducted a retrospective assessment of 224 patients presenting with fractured neck of femur at a large teaching hospital's accident and emergency (A&E) department between 2 June 2011 and 2 June 2012. These patients were split into either a cognitively-impaired or cognitively-intact cohort based on their Abbreviated Mental Test Scores. Patients with cognitive impairment, on average, received a weaker level of analgesia than individuals without impairment both in the ambulance and in A&E. In the ambulance, 45% of cognitively-impaired patients were prescribed no pain relief compared with just 8% of those individuals who remain cognitively intact. After arrival at A&E, these inconsistencies continued with 69% of the cognitively-intact cohort receiving the strongest opioid analgesia compared with just 37% of the cognitively-impaired cohort. The cognitively-impaired cohort would also wait on average an hour longer before receiving this initial pain relief. We believe that these differences stem from cognitively-impaired patients being unable to vocalise their pain through traditional assessment methods. This work discusses the potential development or adoption of a tool which can be applied in the acute setting and relies less on vocalisation but more on the objective features of pain, so making it applicable to cognitively-impaired individuals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.