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Pain, Opioids, and Confusion After Arthroplasty in Older Adults

DeCrane, Susan K.; Stark, Lori D.; Johnston, Beth; Lim, Eunjung; Hicks, Mary K.; Ding, Qinglan

doi: 10.1097/NOR.0000000000000066

BACKGROUND: Postoperative confusion is a common complication in older adults, particularly after total joint replacement (arthroplasty). Confusion after surgery can result in slower mobility progression, longer hospital stay, and increased patient distress. Postoperative pain has been shown to be a risk factor related to confusion; however, there is limited evidence regarding pain level, medication use, and confusion development in postoperative arthroplasty patients.

PURPOSE: To evaluate development of postoperative confusion and the current practice of pain management for older adult patients with hip or knee arthroplasty.

METHODS: Two-month retrospective chart review of medical records at a large, Midwestern, private hospital. Pain assessments were performed on a regular basis using self-report 11-point Numeric Rating Scale (0–10). Opioid use was scored using an equianalgesic conversion chart.

RESULTS: Ninety-eight patients met inclusion criteria and 97 received treatment with opioids during the first 48 hours postoperatively. No patients received opioid agents that are contraindicated in older adults. Thirty-three patients had evidence in the medical record of confusion during the first 48 hours postoperatively. Lower equianalgesic dose was significant for increased age and increased confusion on postoperative day 1 (POD 1) and POD 2. Patients with higher equianalgesic scores were less likely to meet benchmark pain scores less than 5 on POD 0, POD 1, and POD 2.

CONCLUSIONS: Patients receiving lower amounts of opioids in the first 48 hours after surgery were more likely to be confused on POD 1(p = .023) and POD 2 (p = .049).

Susan K. DeCrane, PhD, RN, ACNS-BC, Assistant Professor, School of Nursing, Purdue University, West Lafayette, IN.

Lori D. Stark, MSN, RN, ONC, Clinical Nurse Specialist, St. Vincent Orthopedic and Spine Center, Indianapolis, IN.

Beth Johnston, PharmD, BCPS, Surgery Clinical Pharmacist, Department of Surgery and Anesthesia, St. Vincent Hospital, Indianapolis, IN.

Eunjung Lim, PhD, Research Biostatistician, Statistics Department, University of Hawaii, Honolulu, HI.

Mary K. Hicks, BSN, RN, Staff Nurse, Community North Hospital, Indianapolis, IN

Qinglan Ding, MS, BSN, RN, Graduate Student, School of Nursing, Yale University, New Haven, CT.

This project was funded by an unrestricted educational grant from The Regenstrief Center for Healthcare Engineering (RCHE), Purdue University, West Lafayette, Indiana. None of the authors has a conflict of interest. The authors participated in the project as follows: Susan DeCrane, design of project and oversight, data collection and analysis, manuscript preparation; Lori Stark, design of project, data collection, manuscript preparation; Beth Johnston, design of project, manuscript approval; Mary K. Hicks, data collection, data entry, manuscript approval; Eunjung Lim, statistical analyses, manuscript preparation; Qinglan Ding, data analysis, manuscript preparation.

©2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.