ORIGINAL ARTICLE
Analgesics in postoperative care in hip fracture patients with dementia – reported by nurses Maija Rantala, Sirpa Hartikainen, Tarja Kvist and P€ aivi Kankkunen
Aims and objectives. To describe the analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by nurses. Background. Nurses play a pivotal role in treating postoperative pain in patients with dementia and monitoring the effects of administered analgesics. Design. Cross-sectional descriptive questionnaire study in seven university hospitals and 10 central hospitals in Finland. Methods. The study was conducted from March until May in 2011 in Finland. For this analysis, the focus was on the sample of nurses (n = 269) who were working in orthopaedic units. Analgesics were classified according to the Anatomical Therapeutic Chemical Classification System. Nonparametric tests were applied to find out the significant differences between analgesic use and different hospitals. Results. Paracetamol and strong opioids administered orally or parenterally seemed to be the most typical of postoperatively used types of analgesics in patients with dementia. Nonsteroidal anti-inflammatory analgesics and weak opioids were also commonly reported to be in use. There were no statistically significant differences between hospitals in typical daily doses. The majority of the nurses reported that the primary aim of postoperative pain management in hip fracture patients with dementia was ‘slight pain, which does not prevent normal functioning’ (72%). Conclusion. The pharmacological postoperative pain treatment in acute care was commonly based on the use of strong opioids and paracetamol in hip fracture patients with dementia. The reported use of transdermal opioids and codeine combination warrants further examination. Further studies are also needed to find out whether the pain is appropriately and adequately treated. Relevance to clinical practice. Transdermal opioids and codeine combination may not be relevant analgesics for acute pain management in older adults. It is important to create a balance between sufficient pain relief and adverse effects of analgesics to allow early mobilisation and functional recovery. Authors: Maija Rantala, MNSc, PhD Student, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio; Sirpa Hartikainen, MD, Professor of Geriatric Pharmacotherapy, Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio; Tarja Kvist, PhD, University Researcher, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio; P€aivi Kankkunen, PhD, Docent, University Lecturer, Department of Nursing Sciences,
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106, doi: 10.1111/jocn.12548
What does this paper contribute to the wider global clinical community?
• There is need for consistent pro-
•
•
tocols for analgesics administration in hip fracture patients with dementia in postoperative setting. Flexibility in dose titration should be the priority when choosing analgesics in acute care setting. Problems with swallowing in patients with dementia should be taken into account when administering analgesics.
Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Correspondence: Maija Rantala, PhD Student, Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, Kuopio 70211, Finland. Telephone: +358 40 8401515. E-mail: [email protected] I state on behalf of all authors that the work has not been published and is not being considered for publication elsewhere.
3095
M Rantala et al.
Key words: acute care, dementia, hip fracture, medication, nurse, pain relief, postoperative pain Accepted for publication: 5 December 2013
Introduction Surgery is the best analgesic for hip fractures (Griffiths et al. 2012), and the majority of postsurgical pain can be well managed with the appropriate use of analgesics (Wells et al. 2008). More than 98% of fractures are repaired surgically for the purposes of pain relief, early rehabilitation and good mobility (Griffiths et al. 2012). Approximately 21–25% of patients with a hip fracture have at least moderate cognitive impairment (Zakriya et al. 2002, Griffiths et al. 2012), which poses extra complexity for achieving optimal postoperative pain control (Scherder et al. 2009). Despite a high risk of adverse events of analgesics in older adults (AGS 2009), these risks need to be carefully assessed in relation to potential benefits (Burris 2004, Barber & Gibson 2009). The risks may not become as considerable when appropriate monitoring takes place (Macintyre et al. 2010) and when there is short-term administration of high-dose opioids (Barber & Gibson 2009). The perspective of nurses is important because nurses have an ethical obligation to appropriately treat older patients’ pain, especially those who are vulnerable (Denny & Guido 2012). They play a pivotal role in monitoring pain and choosing the administrated analgesics (McCaffery & Ferrell 1997, Prowse 2006, Rantala et al. 2012), especially when these are provided ‘as needed’.
Background Problems related to dementia in pain treatment include difficulties to recognise pain due to deterioration of cognitive and verbal capacities (AGS 2009, Macintyre et al. 2010), and therefore, insufficient care of acute pain is more likely to occur in cognitively impaired patients (Forster et al. 2000, Ardery et al. 2003, Hwang et al. 2006). There is evidence that patients with dementia recovering from hip fracture surgery receive only one-third of the amount of opioids that cognitively intact subjects receive (Morrison & Siu 2000). A recent study suggests that the mean single opioid dose was approximately half of the dose of cognitively intact patients in hip fracture patients with dementia and a lower number of them receive any opioids in postoperative setting (Sieber et al. 2011). Additionally, delirium is common (34–61%) following hip fracture (Holmes & House
3096
2000, Bj€ orkelund et al. 2010), especially in cognitively impaired patients (Sieber et al. 2011), and severe pain is one of its risk factors (Fong et al. 2006, Siddiqi et al. 2007, Bj€ orkelund et al. 2010). However, in severe pain, an overtly low dose of opioids is also a risk factor for delirium in cognitively intact (Morrison et al. 2003) and cognitively impaired patients (Sieber et al. 2011). A combination of two or more analgesics with different mechanisms is considered to be the best practice for offering greater relief with lower toxicity (Myles & Power 2007, AGS 2009). For example, paracetamol combined with opioids provides an opioid-sparing effect (Myles & Power 2007, Gaskell et al. 2009). Paracetamol can routinely be used on a regular basis for relieving postoperative pain (Cuvillon et al. 2007, Myles & Power 2007, Bj€ orkelund et al. 2010, Griffiths et al. 2012, Jahr et al. 2012). According to the study of Titler et al. (2003), it is the primary nonopioid for managing postoperative pain in hip fracture patients. Previous studies have mainly focused on pain assessment in long-term settings (Prowse 2006), but there are some studies on pharmacological pain treatment in acute care settings (e.g. Morrison & Siu 2000, Eid & Bucknall 2008, Herr & Titler 2009, McLiesh et al. 2009, Sieber et al. 2011). An examination of medical records concerning analgesic use in hip fracture patients reveals that paracetamol (61%), oxycodone (8%), morphine (8%), tramadol (8%) and codeine combination (14%) were the most frequently administered medications in hip fracture patients (Eid & Bucknall 2008). Codeine is considered a weak opioid and is thus not appropriate for treating postoperative pain. It is also suggested that codeine should not be administered, as it is constipating, emetic and associated with perioperative cognitive dysfunction (Griffiths et al. 2012). According to the study of McLiesh et al. (2009), only 62% of a total number of eighteen cognitively impaired older patients with acute pain received any analgesia before mobilisation or having their dressing completed. Herr and Titler (2009) abstracted medical records (n = 285) of older adult patients treated for hip fractures in twelve acute care hospitals. According to the findings, only 60% (n = 172) of patients were prescribed any analgesics, and more than half of this group (59%) had been put on an opioid. Only one patient received paracetamol (Herr & Titler 2009), © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106
Original article
even though the combination of oxycodone and paracetamol enhances postoperative pain relief more than oxycodone alone when managing moderate to severe pain (Gaskell et al. 2009).
Aims and Objectives The aim of the present study was to describe analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by nurses in orthopaedic units. All the questions concerned analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by the nurses. The specific research questions were: 1 What kind of analgesics, routes of administration and typical daily doses are administered? 2 What are the typical combinations, routes of administration and daily doses of analgesics? 3 What are the other used pharmacological pain relieving methods (e.g. epidural or spinal anaesthesia) used? 4 What kind of problems did nurses identify in postoperative pharmacological pain treatment of hip fracture patients with dementia?
Methods Ethical considerations This study was approved by the Hospital District of Northern Savo’s committee on research ethics (permission number 83/2010), and permission to conduct the study was obtained separately from each hospital. Participation in the study was voluntary, and the nurses responded to the questionnaire anonymously. No one could be identified based on the results.
Study design and participants This article presents a questionnaire study with structured and open-ended questions describing analgesic use (analgesics, routes of administration and typical daily doses) in patients with dementia during the first two postoperative days as reported by nurses. In addition, the questionnaire inquired about typical combinations of analgesics and other pharmacological pain treatment (e.g. epidural/spinal analgesia). Nurses were asked to recall typical analgesic practice for the first postoperative 48 hours in hip fracture patients who had been diagnosed with dementia. The study was conducted from March until May in 2011 in Finland. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106
Analgesics in hip fracture patients with dementia
Sample There are five university hospital districts in Finland. Of the five districts, four include one hospital, and the Helsinki University central Hospital (HUCH) includes three hospitals in total. The participants worked in orthopaedic units of seven university hospitals and 10 central hospitals in Finland. The mean number of patients’ first hip fractures in each hospital included in this study was 315 in university hospitals and 196 in central hospitals accordingly by year 2009 [National Institute for Health and Welfare (NIHW) 2012]. All university hospitals and 10 central hospitals of fifteen were included in the study. We excluded four central hospitals that had approximately less than 100 hip fractures per year in 2009 and one central hospital that refused to participate. Finally, the 17 hospitals included in this study treated approximately 70% of all of the patients admitted to hospital for hip fractures in Finland (NIHW 2012). A total of 269 (n = 494) registered nurses responded to the questionnaire, giving the response rate of 54%. Altogether, 127 registered nurses worked at university hospitals, and 142 worked at central hospitals. No significant differences were found between these two groups regarding the characteristics of nurses, apart from the fact that there were fewer (80% vs. 88%) three-shift workers (p = 0017). The mean age was 408 108 (401 107 vs. 415 109) years. Mean work experience in the current unit was 97 82 (97 78 vs. 97 86) years and in health care 153 98 (149 90 vs. 157 105) years. Most of the participants (88%) (90% vs. 86%) were full-time workers and had a permanent contract (82%) (82% vs. 83%) (Table 1).
Classification of analgesic drugs The analgesics in the questionnaire were classified, and their daily doses were defined (DDD) by the Anatomical Therapeutic Chemical Classification (ATC) recommended by the World Health Organization (WHO 2012). Accordingly, analgesics drugs were defined as: (1) paracetamol, (ATC-code N02BE); (2) nonsteroidal anti-inflammatory analgesics (NSAID) (M01A) included 2a) coxibs (M01AH) included celecoxib, parecoxib, etoricoxib and 2b) other NSAIDs, diclofenac, etodolac, ketorolac (M01AB), meloxicam (M01AC), ibuprofen, naproxen, ketoprofen, dexketoprofen (M01AE), mefenamic acid, tolfenamic acid (M01AG); (3) weak opioids included buprenorphine (N02AE01), codeine combination (N02AA59), tramadol (N02AX02); and (4) strong opioids included morphine
3097
M Rantala et al. Table 1 Characteristics of the nurses (n, %)
Variable
All (n = 269) n (%)
Seven university hospitals (n = 127) n (%)
Age 005). In both types of hospitals, the most typical daily dose of paracetamol was 1 DDD = 3 g administered by oral and parenteral route. The typical mean dose of oral oxycodone was 018–034 DDDs, which is 14–26 mg
Table 2 Nurses’ reports of the types of most commonly post-operatively administered analgesics for hip fracture patients with dementia in university hospitals and central hospitals (n, %, p-value) Nurses in seven university hospitals (n = 127)
Nurses in 10 central hospitals (n = 142)
Analgesic
n (%)
Hospitals (n)
n (%)
Hospitals (n)
p-Value
Paracetamol (n = 269) Infusion Orally Suppository Nonsteroidal anti-inflammatory analgesics (NSAIDs) (n = 213) NSAIDs traditional Injection/Infusion Orally Suppository NSAIDs coxsibs Injection Orally Weak opioids (n = 175) Buprenorphine Injection Plaster Orally Tramadol Injection Orally Codeine/Paracetamol Orally Strong opioids (n = 268) Oxycodone Injection/Infusion Orally Oxycodone/Naloxone Morphine Injection Orally Fentanyl Plaster
127 (100) 93 (73) 116 (91) 1 (1) 79 (70)
7 7 7 1 7
142 95 122 2 124
(100) (67) (86) (1) (87)
10 10 10 1 10
1000 0259 0164 n.a. 0001
(70) (24) (63) (2)
7 7 7 2
121 46 120 1
(85) (32) (85) (1)
10 10 10 1
0003 0148
Analgesics in postoperative care in hip fracture patients with dementia – reported by nurses Maija Rantala, Sirpa Hartikainen, Tarja Kvist and P€ aivi Kankkunen
Aims and objectives. To describe the analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by nurses. Background. Nurses play a pivotal role in treating postoperative pain in patients with dementia and monitoring the effects of administered analgesics. Design. Cross-sectional descriptive questionnaire study in seven university hospitals and 10 central hospitals in Finland. Methods. The study was conducted from March until May in 2011 in Finland. For this analysis, the focus was on the sample of nurses (n = 269) who were working in orthopaedic units. Analgesics were classified according to the Anatomical Therapeutic Chemical Classification System. Nonparametric tests were applied to find out the significant differences between analgesic use and different hospitals. Results. Paracetamol and strong opioids administered orally or parenterally seemed to be the most typical of postoperatively used types of analgesics in patients with dementia. Nonsteroidal anti-inflammatory analgesics and weak opioids were also commonly reported to be in use. There were no statistically significant differences between hospitals in typical daily doses. The majority of the nurses reported that the primary aim of postoperative pain management in hip fracture patients with dementia was ‘slight pain, which does not prevent normal functioning’ (72%). Conclusion. The pharmacological postoperative pain treatment in acute care was commonly based on the use of strong opioids and paracetamol in hip fracture patients with dementia. The reported use of transdermal opioids and codeine combination warrants further examination. Further studies are also needed to find out whether the pain is appropriately and adequately treated. Relevance to clinical practice. Transdermal opioids and codeine combination may not be relevant analgesics for acute pain management in older adults. It is important to create a balance between sufficient pain relief and adverse effects of analgesics to allow early mobilisation and functional recovery. Authors: Maija Rantala, MNSc, PhD Student, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio; Sirpa Hartikainen, MD, Professor of Geriatric Pharmacotherapy, Clinical Pharmacology and Geriatric Pharmacotherapy Unit, School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, Kuopio; Tarja Kvist, PhD, University Researcher, Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio; P€aivi Kankkunen, PhD, Docent, University Lecturer, Department of Nursing Sciences,
© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106, doi: 10.1111/jocn.12548
What does this paper contribute to the wider global clinical community?
• There is need for consistent pro-
•
•
tocols for analgesics administration in hip fracture patients with dementia in postoperative setting. Flexibility in dose titration should be the priority when choosing analgesics in acute care setting. Problems with swallowing in patients with dementia should be taken into account when administering analgesics.
Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland Correspondence: Maija Rantala, PhD Student, Department of Nursing Science, University of Eastern Finland, P.O. Box 1627, Kuopio 70211, Finland. Telephone: +358 40 8401515. E-mail: [email protected] I state on behalf of all authors that the work has not been published and is not being considered for publication elsewhere.
3095
M Rantala et al.
Key words: acute care, dementia, hip fracture, medication, nurse, pain relief, postoperative pain Accepted for publication: 5 December 2013
Introduction Surgery is the best analgesic for hip fractures (Griffiths et al. 2012), and the majority of postsurgical pain can be well managed with the appropriate use of analgesics (Wells et al. 2008). More than 98% of fractures are repaired surgically for the purposes of pain relief, early rehabilitation and good mobility (Griffiths et al. 2012). Approximately 21–25% of patients with a hip fracture have at least moderate cognitive impairment (Zakriya et al. 2002, Griffiths et al. 2012), which poses extra complexity for achieving optimal postoperative pain control (Scherder et al. 2009). Despite a high risk of adverse events of analgesics in older adults (AGS 2009), these risks need to be carefully assessed in relation to potential benefits (Burris 2004, Barber & Gibson 2009). The risks may not become as considerable when appropriate monitoring takes place (Macintyre et al. 2010) and when there is short-term administration of high-dose opioids (Barber & Gibson 2009). The perspective of nurses is important because nurses have an ethical obligation to appropriately treat older patients’ pain, especially those who are vulnerable (Denny & Guido 2012). They play a pivotal role in monitoring pain and choosing the administrated analgesics (McCaffery & Ferrell 1997, Prowse 2006, Rantala et al. 2012), especially when these are provided ‘as needed’.
Background Problems related to dementia in pain treatment include difficulties to recognise pain due to deterioration of cognitive and verbal capacities (AGS 2009, Macintyre et al. 2010), and therefore, insufficient care of acute pain is more likely to occur in cognitively impaired patients (Forster et al. 2000, Ardery et al. 2003, Hwang et al. 2006). There is evidence that patients with dementia recovering from hip fracture surgery receive only one-third of the amount of opioids that cognitively intact subjects receive (Morrison & Siu 2000). A recent study suggests that the mean single opioid dose was approximately half of the dose of cognitively intact patients in hip fracture patients with dementia and a lower number of them receive any opioids in postoperative setting (Sieber et al. 2011). Additionally, delirium is common (34–61%) following hip fracture (Holmes & House
3096
2000, Bj€ orkelund et al. 2010), especially in cognitively impaired patients (Sieber et al. 2011), and severe pain is one of its risk factors (Fong et al. 2006, Siddiqi et al. 2007, Bj€ orkelund et al. 2010). However, in severe pain, an overtly low dose of opioids is also a risk factor for delirium in cognitively intact (Morrison et al. 2003) and cognitively impaired patients (Sieber et al. 2011). A combination of two or more analgesics with different mechanisms is considered to be the best practice for offering greater relief with lower toxicity (Myles & Power 2007, AGS 2009). For example, paracetamol combined with opioids provides an opioid-sparing effect (Myles & Power 2007, Gaskell et al. 2009). Paracetamol can routinely be used on a regular basis for relieving postoperative pain (Cuvillon et al. 2007, Myles & Power 2007, Bj€ orkelund et al. 2010, Griffiths et al. 2012, Jahr et al. 2012). According to the study of Titler et al. (2003), it is the primary nonopioid for managing postoperative pain in hip fracture patients. Previous studies have mainly focused on pain assessment in long-term settings (Prowse 2006), but there are some studies on pharmacological pain treatment in acute care settings (e.g. Morrison & Siu 2000, Eid & Bucknall 2008, Herr & Titler 2009, McLiesh et al. 2009, Sieber et al. 2011). An examination of medical records concerning analgesic use in hip fracture patients reveals that paracetamol (61%), oxycodone (8%), morphine (8%), tramadol (8%) and codeine combination (14%) were the most frequently administered medications in hip fracture patients (Eid & Bucknall 2008). Codeine is considered a weak opioid and is thus not appropriate for treating postoperative pain. It is also suggested that codeine should not be administered, as it is constipating, emetic and associated with perioperative cognitive dysfunction (Griffiths et al. 2012). According to the study of McLiesh et al. (2009), only 62% of a total number of eighteen cognitively impaired older patients with acute pain received any analgesia before mobilisation or having their dressing completed. Herr and Titler (2009) abstracted medical records (n = 285) of older adult patients treated for hip fractures in twelve acute care hospitals. According to the findings, only 60% (n = 172) of patients were prescribed any analgesics, and more than half of this group (59%) had been put on an opioid. Only one patient received paracetamol (Herr & Titler 2009), © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106
Original article
even though the combination of oxycodone and paracetamol enhances postoperative pain relief more than oxycodone alone when managing moderate to severe pain (Gaskell et al. 2009).
Aims and Objectives The aim of the present study was to describe analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by nurses in orthopaedic units. All the questions concerned analgesic use in hip fracture patients with dementia during the first two postoperative days as reported by the nurses. The specific research questions were: 1 What kind of analgesics, routes of administration and typical daily doses are administered? 2 What are the typical combinations, routes of administration and daily doses of analgesics? 3 What are the other used pharmacological pain relieving methods (e.g. epidural or spinal anaesthesia) used? 4 What kind of problems did nurses identify in postoperative pharmacological pain treatment of hip fracture patients with dementia?
Methods Ethical considerations This study was approved by the Hospital District of Northern Savo’s committee on research ethics (permission number 83/2010), and permission to conduct the study was obtained separately from each hospital. Participation in the study was voluntary, and the nurses responded to the questionnaire anonymously. No one could be identified based on the results.
Study design and participants This article presents a questionnaire study with structured and open-ended questions describing analgesic use (analgesics, routes of administration and typical daily doses) in patients with dementia during the first two postoperative days as reported by nurses. In addition, the questionnaire inquired about typical combinations of analgesics and other pharmacological pain treatment (e.g. epidural/spinal analgesia). Nurses were asked to recall typical analgesic practice for the first postoperative 48 hours in hip fracture patients who had been diagnosed with dementia. The study was conducted from March until May in 2011 in Finland. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 3095–3106
Analgesics in hip fracture patients with dementia
Sample There are five university hospital districts in Finland. Of the five districts, four include one hospital, and the Helsinki University central Hospital (HUCH) includes three hospitals in total. The participants worked in orthopaedic units of seven university hospitals and 10 central hospitals in Finland. The mean number of patients’ first hip fractures in each hospital included in this study was 315 in university hospitals and 196 in central hospitals accordingly by year 2009 [National Institute for Health and Welfare (NIHW) 2012]. All university hospitals and 10 central hospitals of fifteen were included in the study. We excluded four central hospitals that had approximately less than 100 hip fractures per year in 2009 and one central hospital that refused to participate. Finally, the 17 hospitals included in this study treated approximately 70% of all of the patients admitted to hospital for hip fractures in Finland (NIHW 2012). A total of 269 (n = 494) registered nurses responded to the questionnaire, giving the response rate of 54%. Altogether, 127 registered nurses worked at university hospitals, and 142 worked at central hospitals. No significant differences were found between these two groups regarding the characteristics of nurses, apart from the fact that there were fewer (80% vs. 88%) three-shift workers (p = 0017). The mean age was 408 108 (401 107 vs. 415 109) years. Mean work experience in the current unit was 97 82 (97 78 vs. 97 86) years and in health care 153 98 (149 90 vs. 157 105) years. Most of the participants (88%) (90% vs. 86%) were full-time workers and had a permanent contract (82%) (82% vs. 83%) (Table 1).
Classification of analgesic drugs The analgesics in the questionnaire were classified, and their daily doses were defined (DDD) by the Anatomical Therapeutic Chemical Classification (ATC) recommended by the World Health Organization (WHO 2012). Accordingly, analgesics drugs were defined as: (1) paracetamol, (ATC-code N02BE); (2) nonsteroidal anti-inflammatory analgesics (NSAID) (M01A) included 2a) coxibs (M01AH) included celecoxib, parecoxib, etoricoxib and 2b) other NSAIDs, diclofenac, etodolac, ketorolac (M01AB), meloxicam (M01AC), ibuprofen, naproxen, ketoprofen, dexketoprofen (M01AE), mefenamic acid, tolfenamic acid (M01AG); (3) weak opioids included buprenorphine (N02AE01), codeine combination (N02AA59), tramadol (N02AX02); and (4) strong opioids included morphine
3097
M Rantala et al. Table 1 Characteristics of the nurses (n, %)
Variable
All (n = 269) n (%)
Seven university hospitals (n = 127) n (%)
Age 005). In both types of hospitals, the most typical daily dose of paracetamol was 1 DDD = 3 g administered by oral and parenteral route. The typical mean dose of oral oxycodone was 018–034 DDDs, which is 14–26 mg
Table 2 Nurses’ reports of the types of most commonly post-operatively administered analgesics for hip fracture patients with dementia in university hospitals and central hospitals (n, %, p-value) Nurses in seven university hospitals (n = 127)
Nurses in 10 central hospitals (n = 142)
Analgesic
n (%)
Hospitals (n)
n (%)
Hospitals (n)
p-Value
Paracetamol (n = 269) Infusion Orally Suppository Nonsteroidal anti-inflammatory analgesics (NSAIDs) (n = 213) NSAIDs traditional Injection/Infusion Orally Suppository NSAIDs coxsibs Injection Orally Weak opioids (n = 175) Buprenorphine Injection Plaster Orally Tramadol Injection Orally Codeine/Paracetamol Orally Strong opioids (n = 268) Oxycodone Injection/Infusion Orally Oxycodone/Naloxone Morphine Injection Orally Fentanyl Plaster
127 (100) 93 (73) 116 (91) 1 (1) 79 (70)
7 7 7 1 7
142 95 122 2 124
(100) (67) (86) (1) (87)
10 10 10 1 10
1000 0259 0164 n.a. 0001
(70) (24) (63) (2)
7 7 7 2
121 46 120 1
(85) (32) (85) (1)
10 10 10 1
0003 0148
