Preventing Delirium by Managing Pain

My mother, Alma, was a remarkable woman who had 16 children and was not a complainer. At 94 years old, she was still living independently and driving her prized Volvo around the quiet suburb she called home. But when she broke her hip, those first hours in the emergency room were pure torture.

In my more than 20 years in nursing, I have seen two age groups consistently under-medicated for pain—the very young and the very old. Both groups have physiological characteristics that can make opioid dosing a challenge, and both groups are vulnerable to the side effects of even moderate doses. But babies and those of very advanced age also experience negative sequelae from unrelieved pain. These complications can include anxiety, increased sensitization to pain and reduced efficacy of analgesics in the future. And for those of advanced age, delirium may be the most consequential result of poor pain control. Yet even with research demonstrating the importance of adequate pain management, older people continue to suffer.

In the emergency room that day, my mother was in excruciating pain and the doctor on duty refused to adequately treat it. He was concerned that she would be at risk of depressed respiration and losing consciousness. As a nurse anesthetist, I treat patients’ pain every day, so his rationale was hard for me to accept. It was infuriating to be powerless while my mother writhed in pain. I was relieved when the nurse came into the room with a syringe because I assumed that she had finally gotten orders for more pain medication. Instead, she told me it was the sedative lorazepam. She said the doctor thought my mother was anxious. I refused the sedative on behalf of my mother; she was anxious because she was in terrible pain. Sedation is not an appropriate way to address pain in a patient of any age. The unnecessary sedation would have put her at risk for delirium while not giving her any benefit of pain relief.

Some clinicians still believe that as people age, they develop a tolerance to pain. The mistaken belief that the health care practitioner’s assessment of a patient’s pain is more reliable than the patient’s reported pain level can prevent appropriate management of pain in the elderly. However, in my experience, the primary reason that pain is undertreated in older patients is because of fear. Practitioners are afraid that frail, older people will “fall off the cliff” when pain is well managed, meaning that with the effects of opioids and without the stimulus of pain, the patient will become apneic—that is, they’ll temporarily stop breathing. The need to avoid respiratory depression is the most common excuse that I hear to justify inadequate pain management in the perioperative setting. Clearly, more provider education is needed in these situations in order to ensure quality patient care.

While all patients deserve the best pain management, older patients may be at particular risk when left with undertreated pain. There is a significant increase in the occurrence of delirium for patients whose pain is not adequately managed, according to a 2003 study published in the Journals of Gerontology. Delirium is a serious alteration in mental abilities that often has a sudden onset and results in confused thinking and reduced environmental awareness. In older perioperative patients, delirium is frequently overlooked even though it can have devastating consequences; it can increase length of stay in the hospital and can raise the risk of death after a hip fracture. Many people who experience delirium in the hospital do not return to their baseline cognition after discharge.

Older patients who are cognitively intact are nine times more likely to experience delirium if their pain is not managed well. This was the case with my mother. She experienced delirium within hours of being admitted to the hospital—after enduring hours of pain. People with delirium in the hospital are more likely to be discharged to a skilled nursing facility rather than to their homes. Clearly, ineffectual pain management for these patients can have long-term effects that extend beyond the perioperative period.

Advocating for Pain Management

Advocating for appropriate pain management for older patients is imperative. It is not solely a matter of humanely achieving comfort for patients; it may also be life-saving. Recommendations from the American Academy of Orthopedic Surgeons are aimed at reducing pain and therefore decreasing the incidence of delirium for patients with hip fractures and other injuries. Published in 2014, these are still not universally practiced, so patients and caregivers should push to ensure that best practices are followed. These recommendations include:

• Preoperative regional analgesia should be used to reduce pain in patients with hip fracture. Request that a nerve block be administered before surgery if surgery is going to be delayed. Getting local anesthetic medication infiltrated to the nerves surrounding the fracture will greatly reduce pain and also reduce the need for opioid medications. If necessary, request that an anesthesiologist or a nurse anesthetist evaluate the patient for this type of nerve block.
• Hip fracture surgery should be performed within 48 hours of hospital admission. Having surgery as soon as is practical will decrease the amount of pain medication required and will also help to reduce the length of stay in the hospital. Simply being in the hospital is a risk factor for people over the age of 70 to develop delirium.
• Intensive physical therapy should be conducted post-discharge to improve outcomes. Physical therapy increases the likelihood that patients will return to their preoperative functional status.

Additional tips to prevent delirium in hospitalized older patients include:

• Avoid benzodiazepine sedatives, as well as antihistamines (such as Benadryl), which are sometimes used to promote sleep.
• Have a familiar person at the bedside as much as possible while in the foreign environment.

Thankfully, my mother substantially recovered from the delirium she suffered in the hospital. It required interventions on the part of family caregivers to help her to regain her mental and physical capacities, but she was unable to return to living on her own, and we will never know if the pain she suffered in the emergency room that day contributed to her losing her independence.