Acute nursing care of the older adult with fragilityhip fracture: An international perspective (Part 1)

RN

Director) b,1, Karen Hertz RN, BSc(Hons), MSc (Advanced Nursec,2

NICHE Program, Akron General Medical Center, Akron, OH, USAc University Hospital of North Staffordshire, UK

Nursing experts and guided by a range of information from research and clinical practice,

1878-1241/$ - see front matter c 2012 Elsevier Ltd All rights reserved.http://dx.doi.org/10.1016/j.ijotn.2012.09.001

3 Swedish Orthopaedic Nurses Association.4 Canadian Orthopaedic Nurses Association.5 Irish Orthopaedic Nurses Section.6 Danish Orthopaedic Nurses Association.7 Australian and New Zealand Orthopaedic Nurses Association.

International Journal of Orthopaedic and Trauma Nursing (2012) 16, 177194

www.elsevier.com/locate/ijotn* Corresponding author. Address: 35 Pavilion Avenue, Long Branch, NJ 07740, USA. Tel.: +1 732 571 1218.E-mail address: annmaher@verizon.net (A.B. Maher).

1 International Collaboration of Orthopaedic Nurses.2 Royal College of Nursing Society of Orthopaedic and Trauma Nursing.d Dept. of Orthopaedics, Skane University Hospital, Lund/Dept. of Health Sciences Lund University,Swedene Fraser Health Authority, BC, Canadaf Cork University Hospital, Wilton, Cork, Irelandg Dept. of Orthopaedics, Vejle Hospital, Vejle, Denmarkh Royal Adelaide Hospital, Adelaide, SA, Australia

KeywordsHip fracture;Clinical review;

Summary This paper provides those who care for orthopaedic patients with evi-dence-supported international perspectives about acute nursing care of the olderadult with fragility hip fracture. Developed by an international group of nursePractitioner T&O) , Ami Hommel RN, CNS, PhD (AssociateProfessor) d,3, Valerie MacDonald RN, BSN, MSN, ONC (Clinical NurseSpecialist) e,4, Mary P OSullivan RGN, RM, BNS/RNT, MSc Nursing (ClinicalDevelopment Co-ordinator) f,5, Kirsten Specht RN, MPH (PhD Student/Research Nurse) g,6, Anita Taylor RN, OrthoNCert, GradDipOrtho, MNSc(Orthopaedic Nurse Practitioner) h,7

a Long Branch, NJ, USAbAnn Butler MaherAnita J Meehan RN-BC, MS, FNP-BC, ONC (Family Nurse Practitioner) a,*,1,, MSN, ONC (Clinical Nurse Specialist, Gerontology/

sitive quality indicators during the acute hospitalisation forptimal care for the patient who has experienced such a frac-Thi

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Introduction

Hip fracture is a devastating inand family often resulting inincreased reliance on others,and sometimes death. Approxhip fractures occur worldwideyear 2050 the worldwide incidincrease by 310% for men andwith estimated totals reachin6.3 million hip fractures per yof older hip fracture patientsof fracture and, of those thamated that between 24% andto their pre-fracture level of inational Osteoporosis Foundaglobal incidence of hip fracturhealth care systems around thmeet the demands for serviincreasing economic constraint

Purpose/scope

Editors commentsWe are proud to announce the publication of this important international document that provides a clinicalreview for the care of the older person with a fracture of the hip. This important and ground-breakingclinical review document is published online at: http://dx.doi.org/10.1016/j.ijotn.2012.09.001 and intwo parts in print format the first part here and the second part in a subsequent edition of the Interna-tional Journal of Orthopaedic and Trauma Nursing.In many countries hip fracture is the most important issue facing trauma services in the 21st century andthis document will help to provide those caring for this vulnerable group of older people with sound, evi-dence-based advice on the best ways to ensure that care is as sensitive and effective as possible. It is ourfervent hope that the clinical review will be used around the globe to ensure care is sensitive to the com-plex needs of this group of patients. JS-T.

178 A.B. Maher et al.e world struggle toce in the face ofs.

Constipation/Catheter Associated Urinary TractInfection.75% will not returnndependence (Inter-tion, 2012). As thees continues to rise,

PainDeliriumPressure UlcersFluid Balance/Nutritionjury for both patientimpaired mobility,diminished health

imately 1.6 millioneach year. By the

ence is projected toby 240% for womeng between 4.5 andear. As many as 28%die within one yeart survive, it is esti-

This paper provides nurses who care for orthopae-dic patients with evidence-supported internationalperspectives about acute nursing care of the olderadult with fragility hip fracture. Guided by a rangeof information from research and clinical practice,as well as reviews from international nursingexperts in each content area, we focus on nursesensitive quality indicators during the acutehospitalisation for fragility hip fracture. Theseinclude:it focuses on nurse senfragility hip fracture. Oture is the focus here.

PainDelirium

and in the second

Pressure UlcersFluid Balance/NutConstipation/Cath

Vigilant nursing asment of the complicon, they may resolv

This tool kit hCollaboration of Ortof orthopaedic nursic 2012 Elsevier Ltd Alls includes in this part:

bsequent, part

onr Associated Urinary Tract Infection

sment and prompt intervention may prevent the develop-ons we discuss. If they do occur and are identified earlyith appropriate and timely nursing management.been developed under the auspices of the Internationalaedic Nursing (ICON) a coalition of national associations(www.orthopaedicnursing.org).hts reserved.

identified early on, they may resolve with appropri-

the effects of any particular mobilisation strategy

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 179ate and timely nursing management.This tool kit has been developed under the

auspices of the International Collaboration ofOrthopaedic Nursing (ICON) a coalition of nationalassociations of orthopaedic nursing (www.ortho-paedicnursing.org). The project grew out of ongo-ing discussions among ICON leaders about thegrowing number of older adults with fragility hipfracture being treated in each of their respectivecountries. The work group that developed this pa-per includes orthopaedic and gerontological nursesrepresenting nine countries: Australia/New Zea-land, Canada, Denmark, Great Britain, Hong Kong,Ireland, Malta, Sweden, and the USA. The Hip Frac-ture Group that wrote this paper first met in Dub-lin, Ireland in June 2010 and worked via SKYPEand email with one more face to face meeting inBristol, England in September 2011.

Mobility considerations

The primary goal of nursing care for the older adultwith fragility hip fracture remains to maximisemobility and to preserve optimal function. Towardthat end, mobilisation is a major component ofpostoperative care and rehabilitation. The individ-ual patient goal will partly be determined by pre-admission mobility and functional status. If thepatient was bed or chair bound prior to surgery,pain and symptom management as well as preser-vation of that baseline may be the primary goalof postoperative care. For the individual who wasmobile pre-fracture, postoperative mobility is crit-ical to recovery.

There is currently insufficient evidence fromrandomised controlled trials (RCTs) to determineThe group acknowledges that the optimal ap-proach to addressing the increasing number of fra-gility hip fractures is to focus attention onprevention. Bone density and quality are reducedwith ageing and complicated by a range of risk fac-tors leading to osteoporosis in both women andmen over 50 years old. A substantial number ofthese individuals will sustain a fragility fracturelinked directly to osteoporotic bone with the high-est risk related to falling (Jarvinen et al., 2008).However, a complete discussion of fracture pre-vention and reduction of fracture risk due to oste-oporosis is beyond the scope of this paper. Rather,providing optimal care for the patient who hasexperienced such a fracture is the focus here.

Vigilant nursing assessment and prompt inter-vention may prevent the development of the com-plications we discuss. If they do occur and areor programme. However, demonstrational studiesand non-randomised trials generally indicate thatit is possible to enhance mobility (Handoll et al.,2011) and improve functional status (Healeeet al., 2011) post hip fracture. Stenvall et al.(2007) found that a multidisciplinary postoperativeintervention programme enhances activities of dai-ly living performance and mobility after hip frac-ture, from both a short term and long termperspective. More recently, Stenvall et al. (2012)demonstrated that patients with dementia whosuffer a hip fracture can benefit from multidisci-plinary geriatric assessment and rehabilitationand should not be excluded from rehabilitationprogrammes.

Some recommendations from the Canadian Na-tional Hip Fracture Tool Kit (Waddell, 2011) tomaximise mobility include:

Patients should be mobilised as soon as medi-cally stable (i.e. within 1224 h of surgery).

Mobility can start with sitting/dangling legs overthe side of the bed in very frail patients, butshould progress to standing within 24 h ofsurgery.

Weight-bearing status should be as tolerated;if not, discuss with surgeon regarding ambula-tion prognosis.

Patients who were mobile pre-surgery should bemobilised at least twice daily, regardless of cog-nitive status.

The focus is on gait quality, walking endurance,transfers, activities of daily living and safety.

Treatment goals to progress the patients ambu-lation, transfer and ADL status should be setdaily based on their pre-fracture capacity.

Patients should be up in a chair for meals when-ever possible and should spend as much of theday as tolerated out of bed to encourage cogni-tive alertness and promote activity and indepen-dent self-care.

Independence in self-care and hygiene should beencouraged to the degree possible with assis-tance provided as necessary.

All care staff should be involved in encouragingmobility/independence in toileting and trans-fers, not just nursing staff.

A high protein diet and adequate hydrationshould be encouraged so that patients can toler-ate mobilisation and activity.

Mobilisation and pain management should becoordinated to maximise the patients abilityto participate in rehabilitation.

There should be daily assessments of patientsprogress to determine needs for post-acute

rehabilitation and prevent delays in transfers to iof.org), National Osteoporosis Foundation

result in impeded mobility, functional impairmentand prolonged hospital stay resulting in increased

180 A.B. Maher et al.rehabilitation/home or other careenvironments.

Bachmann et al. (2010) also found that multidis-ciplinary inpatient rehabilitation provided to bothgeneral geriatric and orthopaedic geriatric patientsimproves physical function and reduces risk ofnursing home placement. A systematic review bythe Joanna Briggs Institute (Garcia, 2012) foundthat multidisciplinary interventions, includingexercise, reduced length of stay and increased pa-tient return to home rather than to institutionalsettings. Such evidence underscores the impor-tance of nursing care that encourages patients toperform those activities that they can in the inter-est of promoting return to optimal function. Whenthe patient is discharged from acute care, sharethose strategies that have been successfully em-ployed during the acute hospitalisation with appro-priate staff in rehabilitation and other transitionalcare settings.

As the patient transitions to a structured settingor to home for rehabilitation, prevention of futurefracture is an important component of the plan. Ahip fracture, typically due to osteoporosis, placesthe patient at the highest risk of recurrent frac-tures. One in three hip fracture patients sustainanother fracture within the first year of whichmany involve the contralateral hip; and over onein two patients will suffer another fracture withinfive years (Waddell, 2011). Minimising the hipfracture patients risk for falling as they return tomaximum mobility postoperatively is essential.Specific information on falls and fall preventioncan be found at (http://www.stopfalls.org/inter-national/index.shtml); and (http://americangeri-atrics.org/health_care_professionals/clinical_practive/clinical_guidelines_recommendations/2010).

Assessment for osteoporosis in the patient whohas sustained a fragility fracture is an equally impor-tant part of the postoperative treatment plan. Oste-oporosis is amenable to a number of effectivetreatments (Sanders and Geraci, 2011). The pa-tients and caregivers understanding of this dis-ease, its risk factors and the importance of theirparticipation in the treatment plan is essential tosecondary fracture prevention. Ascertaining the pa-tients/caregivers understanding of the relation-ship between osteoporosis and the fractureunderlies successful patient participation (Gian-gregorio et al., 2008; Meadows et al. 2007). Informa-tion about osteoporosis for both professionals andpatients can be found at many websites includingthe International Osteoporosis Foundation (www.healthcare costs (Morrison et al., 2003; Bjorkelundet al., 2009; American Geriatrics Society, 2009).Pain may also contribute to the development ofdelirium, depression and sleep and appetite distur-bances (American Geriatrics Society, 2009; Vaurioet al., 2006).

Pain-related conditions and injuries increasewith age so patients may have a combination ofacute pain related to the fracture and subsequentsurgical repair as well as chronic pain related to apre-existing condition. Among institutionalisedpeople over age 65, up to 80 percent suffer signif-icant persistent pain and, in the community, up to50 percent report persistent pain (Ramage-Morin,2008). Osteoarthritis, osteoporotic fractures,degenerative spine disease, cancer and diabeticor vascular neuralgias are some of the painful con-ditions prevalent in the older adult hip fracturepopulation (American Geriatrics Society, 2009).

Pain is often under reported by older patientsand health professionals frequently underestimate(www.nof.org/professionals/clinical-guidelines),National Institutes of Health in the US (www.niams.-nih.gov) and The National Institute for Health andClinical Excellence in the UK (www.nice.org.uk).

In partnership with the patient and family,orthopaedic nurses can be advocates for treatmentprotocols and post discharge programs that supportpatients wishes and focus on realistic goals to re-turn to optimal function. This partnership beginson admission and extends through transition tothe post discharge phase. Recent research by Boltzet al. (2012) suggests that nursing interventionsthat support functional independence and physicalactivity may mitigate risk for hospital-acquiredfunctional decline. Patients and their familiescan be part of this initiative. Nurses Improving Carefor Healthsystems Elders (NICHE) (2010) has pub-lished a helpful brochure focused on preventingfunctional decline (http://nicheprogram.org/need_to_know); click on Need to Know: FunctionalDecline.

Pain

Significance prevalence

Pain following a fall, hip fracture and surgical re-pair is distressing for the older patient with the po-tential for serious adverse consequences. Olderpatients with hip fractures are at high risk of un-der-managed acute pain after surgery which can

and under treat their pain. Older patients tend to Duration

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 181under report pain for a variety of reasons includingthat they:

Prefer a passive role in pain management, pre-ferring to be asked about pain rather than initi-ating a pain complaint.

Fear being a burden to their families or bother-some to staff.

Assume the nurse knows that they are in painand is doing all that can be done.

Believe that pain is inevitable with ageing and beresigned to suffering.

Fear that admitting pain could result in lostindependence.

Have previously experienced analgesic sideeffects such as constipation and sedation andwant to avoid these medications.

Fear becoming addicted to opioid painmedications.

Be unable to communicate clearly due to adementia, delirium or language barrier.

Have an illness such as Parkinsons or dementiathat masks typical facial or verbal expressionsassociated with pain.

Healthcare providers may hold common miscon-ceptions or lack knowledge that hampers paindetection and treatment such as:

Pain is normal, harmless and an inevitable partof ageing.

Visual signs either physiological (elevated vitalsigns) or behavioural (grimacing, moaning etc.)must accompany pain.

A cognitively impaired person is incapable ofreliably reporting pain.

Cognitively impaired patients do not experienceas much pain as those that are cognitivelyintact.

Older adults experience lower pain intensity Patients will become addicted to opioid painmedications.

Identifying, discussing and dispelling misconcep-tions held by patients and health professionals areessential for improving pain management (Paseroand McCaffery, 2011).

Pain classifications

Understanding pain classification is essential as tar-geted interventions are more effective in managingspecific pain types. Pain is classified based on dura-tion and physiology, as delineated below.Acute short term pain, related to an illness orinjury with a predictable course of healing. Forexample, surgical pain that subsides in theweeks following surgery is acute pain.Persistent/chronic pain lasting at least twoweeks or often much longer. Degenerative jointand spine diseases are examples of painful con-ditions that tend to persist long term.PhysiologyNociceptive pain, which has two subtypes: 1)somatic, involving skin and musculoskeletalstructures. Somatic pain tends to be well local-ised and is typically characterised as aching,sharp or throbbing pain that is intensified bymovement. Osteoarthritis and fractures arecommon forms of somatic pain. 2) visceralinvolving injury or inflammation of organs andthe GI tract. It is often characterized by a deep,dull, ache or cramping. Visceral pain tends to bepoorly localised and frequently radiates to sur-rounding structures. Constipation is an exampleof a common visceral pain in the older adult(Pasero and McCaffery, 2011; Registered NursesAssociation of Ontario, 2007).Neuropathic pain is associated with injury ordisease of the peripheral or central nervous sys-tem (Macintyre and Schug, 2007). It can becaused by degeneration, pressure, inflamma-tion, trauma, metabolic disorders, tumours, pri-mary neurological disease or infection. Theintensity of nerve pain varies from mild tosevere and is described as any one or a combina-tion of the following: 1) dysesthetic, pins andneedles, burning or freezing, 2) lancinating,sharp, shooting, shock like or 3) allodynia,pain in response to non-painful stimuli. Exam-ples of neuropathic pain include spine compres-sion fractures and diabetic neuralgia (RegisteredNurses Association of Ontario, 2007; Macintyreand Schug, 2007; Dworkin et al., 2003).

The patient with a hip fracture may have severaloverlapping pain types. For examples, they willhave pain at the injury/surgical site but may alsohave chronic constipation and an osteoporoticspine fracture with nerve compression. Identifyingall presenting pain types is necessary as effectivemanagement strategies vary depending on the paintype.

Assessment/detection

Pain is a multidimensional experience influencedby physical, emotional, psychological and social

factors. The most accurate and reliable method of

breakthrough pain. Rule out pain as the cause of

182 A.B. Maher et al.determining the presence and severity of pain inthe cognitively intact patient is self- report (Paseroand McCaffery, 2011; American Geriatrics Society,2002).

Frequent evidence-based pain assessment is thefoundation for effective pain management in hipfracture patients. Standards for pain assessmentinclude using an evidence-based tool to conductan admission interview, a screen of health recordsto detect pre-existing painful conditions. Severalvalidated assessment tools are available on the fol-lowing website http://ltctoolkit.rnao.ca/re-sources/pain#Assessment-.

An initial assessment usually includes:

location of pain(s), pain descriptors/character-istics of both new acute and existing persistentpain

pain intensity rating at rest and during activity pain management history current and pastboth pharmacological and non-pharmacologicalstrategies, their relative effectiveness and anyadverse effects experienced by the patient

Pain intensity rating scales identify the intensityof the pain and serve as a measure for the effec-tiveness of the pain intervention in relation tothe individuals pain goal. In studies of long termcare residents, individual preference and abilityto respond varied by scale. The most commonlypreferred tools include the: numerical rating scale(010), faces pain scale, verbal descriptor scaleand IOWA Pain Thermometer (Pasero and McCaff-ery, 2011; Herr et al., 2007; Hadjistavropouloset al., 2007). Identification and consistent use ofthe patients preferred pain rating tool is recom-mended when a range of acceptable options isavailable.

For ongoing pain assessment the following mne-monic is easy to remember and may be useful:

O onset and duration of painP provoking what make it worse or palliat-ing what makes it betterQ quality what does the pain feel like e.g. dis-comfort, aching, burning etc.R radiation and regionS severity or pain intensity measured on a val-idated scaleT timingU understanding: Patient or family beliefs orconcerns about the painV values: What is the patients goal for painrelief? (American Geriatrics Society, 2002; Reg-istered Nurses Association of Ontario, 2002).unsettled behaviours prior to administering psycho-tropic medications.

If the patient has a pre-existing condition suchas spinal osteoporosis that increases the risk forneuropathic pain or when pain is not respondingto usual analgesics, assessment using a validatedneuropathic pain scale is recommended. ValidatedNot all older adults will use or respond to theterm pain when assessed. The use of otherdescriptors such as discomfort, aching or hurtingmay assist in revealing the presence of pain (Amer-ican Geriatrics Society, 2009; Pasero and McCaff-ery, 2011; Herr et al., 2011; Hadjistavropouloset al., 2007).

Special considerations

Older adults frequently have vision and hearingdeficits and may be slow to comprehend informa-tion. Addressing any sensory impairment (hearingaids and glasses in place, enlarged pain ratingtools, adequate lighting) and providing sufficienttime for older adults to process and respond toquestions is vital (Pasero and McCaffery, 2011).

Even in the presence of mild to moderatedementia or delirium, patients can reliably reportpain through simple questions and valid assessmenttools developed specifically for this population(Herr et al. 2011).

Patients with advanced cognitive impairmentwill require systematic assessment using a vali-dated behavioural scale. Zwakhalen et als (2006)systematic review of behavioural pain assessmenttools can be accessed through the following link:http://www.biomedcentral.com/1471-2318/6/3.

Validated behavioural pain scales typically in-volve observing the patient at rest and movementto note changes in behaviours that may indicatepain (see Table 1).

Evaluation of changes in usual behaviours suchas increased agitation, aggression, guarding orwithdrawal includes pain as a potential cause.When signs of distress are evident, sources otherthan pain are also assessed and addressed. Thesemay include positioning, hunger, thirst, heat, cold,over or under stimulation, toileting needs etc.Family/care providers are an important resourceto provide insights into patient behaviours or re-sponses indicative of pain or discomfort (AmericanGeriatrics Society, 2002; Herr and Garand, 2001).

Patients who manifest pain with agitation orcombativeness may be at risk for inappropriatetreatment with psychotropics for behaviour man-agement rather than adequate analgesia for the

Table 1 Common pain behaviours in cognitively impaired older persons.

Pain behaviour Description

The

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 183neuropathic pain assessment tools can be found athttp://consultgerirn.org/uploads/File/trythis/try_this_sp1.pdf.

As depression frequently co-exists with persis-tent pain (American Geriatrics Society, 2002) usinga validated screening tool may assist in its diagnosis

Facial expressions

Verbalisations and vocalisations

Body movements

Changes in interpersonal interactions

Mental status changes

American Geriatrics Society Clinical Practice Guideline (2002):with permission from the American Geriatrics Society.and management where concern exists. Identifyingand managing untreated depression is important aspain contributes to depression and depressionmakes pain more difficult to bear. A depressionscreening tool can be found at http://www.fpnote-book.com/psych/exam/DprsnScrngTls. Refer alsoto the section on Delirium in this paper for someadditional information on depression.

Management strategies

Effective pain management is dependent uponaccurate assessment of pain and the developmentof a holistic approach to pain that includes non-pharmacological and pharmacological methods fortreatment (Registered Nurses Association of On-tario, 2007). Partnering with the patient and familyis vital to managing the patients pain. Understand-ing and addressing the patients preferences,goals, fears and biases is essential in crafting a careplan with which the patient can successfully partic-ipate (Gordon et al., 2005). The patient may havefirmly held beliefs based on personal or familyexperience. For example, a patient may fear andrefuse analgesics because of severe side effectsexperienced previously.

A pain management plan is based on achieving agoal mutually established by the patient and

Slight frown; sad frightened faceGrimacing, wrinkled forehead, closed or tightened eyesAny distorted expressionRapid blinkingSighing, moaning, groaningGrunting, chanting calling outNoisy breathingAsking for helpVerbally abusiveRigid, tense body postureGuarding, fidgetingIncreased pacing, rockingRestricted movementGait or mobility changesRefusing food, appetite changesIncrease in rest periods or changes in sleep patternsSudden cessation of common routinesIncreased wanderingCrying or tearsIncreased confusionIrritability or distress

Management of Persistent Pain in Older Persons. Reproducedhealthcare provider. This goal enables the personto mobilise, improve function and achieve anacceptable quality of life (American GeriatricsSociety, 2009). Pain management following hipfracture may employ a combination of non-phar-macological and pharmacological interventions.

Non-pharmacological interventions

Non-pharmacological therapies are an integral partof the treatment plan. A variety of non-pharmaco-logical interventions for pain have been effectiveas stand alone treatments or in combination withappropriate medications. Selecting strategies thepatient believes in will enhance the effectivenessof pain management. Recommended therapies in-clude, but are not limited to:

Applying ice packs to the hip for fifteen minutesat a time.

Warm blankets and gentle massage provide asense of caring and security.

Table 2 Pharmacological changes with ageing.*Pharmacology concern *Change with normal ageing Clinical implication

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184 A.B. Maher et al.Gastrointestinal absorptionor function

Slowing of GI transit timeffects of continuous redrugs.Opioid-related bowel dybe enhanced in older pa

Distribution Increased fat to lean bomay increase volume offor fat soluble drugs.

Liver metabolism Oxidation is variable anresulting in prolonged dConjugation usually preFirst-pass effect usuallyGenetic enzyme polymoaffect some cytochrome

Renal excretion Glomerular filtration raadvancing age in manyresults in decreased exc

Active metabolite Reduced renal clearanceffects of metabolites.

Anticholinergic side effects Increased confusion, coincontinence, movemen

* Adapted with permission from the American Geriatrics SocietyOlder Persons (2009). Cognitive-behavioural strategies: breathingexercises, relaxation therapy, humour, musictherapy and socialisation/distraction.

Reposition regularly with supportive pillows. Use an interdisciplinary approach. Occupationaltherapists may provide custom seating, splintsor adaptive devices. Physiotherapists will assistin individual mobility, exercise and strengthen-ing programs.

Physical activity to improve range of motion,mobility and strength. (American GeriatricsSociety, 2009).

Pharmacological strategies

The pharmacological approach includes the use ofmultimodal analgesia to maximise the positive ef-fect of the selected medications while at thesame time limiting the associated adverse effects(Kehlet and Dahl, 2003). Older adults are gener-ally more susceptible to adverse medication reac-tions. However, analgesics can be used safely andeffectively in the older adult population whenconsiderations of age related differences inay prolongse enteral

tility mayts.

Monitor for effectiveness.Prolong the interval between doses asanalgesic effects may last longer.Use constipation prevention strategies.

weight ratiotribution

Start with a lower analgesic dose.Prolong the interval between dosesDo not use the intramuscular route.

ay decreasehalf-life.ed.hanged.isms mayzymes.

Start with a lower analgesic dose.Prolong the interval between dosesUse a lower dose of acetaminophen.

ecrease withents whichion.

Avoid NSAIDS and meperidine.Start with a lower analgesic dose.Prolong the interval between doses

ill prolong Avoid meperidine.Select opioids with minimal metabolites:e.g. hydromorphone, and oxycodone.Morphine is not a first line opioid choicedue to metabolite.

pation,sorders.

Avoid anticholinergic drugs.

ideline: The Pharmacological Management of Persistent Pain inabsorption and distributions of these medications,as well as individual risk factors, are considered(American Geriatrics Society, 2002, 2009). See Ta-ble 2 for specific changes with ageing that affectthe individuals response to drugs and related clin-ical implications.

Opioid analgesia is a key component in managinghip fracture pain, but there remains wide variabil-ity in individual patient need. Opioid requirementsdecrease with ageing and side effects can impedemobility, impair cognition and interfere withrecovery. Opioid requirements decrease with age-ing, there remains but wide variability in individualpatient needs. Analgesic names and their availabil-ity vary by country so there will be differencesamong countries regarding specific analgesics used.Pure opioid agonists with short half-lives such ashydromorphone and oxycodone are the usualchoice for the older adult (Pasero and McCaffery,2011; Macintyre and Schug, 2007). Morphine has apotent active metabolite and therefore is not thefirst choice for older patients with decreased renalfunction (Pasero and McCaffery, 2011; Jovey,2008). Meperidine is contraindicated due to active,toxic metabolites (Pasero and McCaffery, 2011).

Other medications such as sedatives, antiemet-ics and neuroleptics to manage agitation maypotentiate opioid sedation and the added potential

mended with selection and titration based on thepain condition, severity and response to treatment.

The American Geriatric Society Panel Pharmaco-

what medication to take, when and how to take

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 185for adverse effects needs to be considered whendosing and titrating opioids (Jarzyna et al., 2011).

Multimodal analgesia

A major principle in multimodal analgesia (the useof more than one drug classification) is to reducedose requirements of each individual drug and thusminimise side effects. The use of peripheral or re-gional anaesthetic techniques and a combination ofopioid and non-opioid analgesic agents for break-through pain result in superior pain control andattenuation of the stress response, besidesdecreasing the need for opioids (Kehlet and Dahl,2003).

Specific multimodal analgesic recommendationsfor older adults in the immediate postoperativeperiod include:

1. Regular administration of low dose opioidstitrated to effect, using the least invasivemethod for administration, for the first 4872 h post operatively, then as needed (Regis-tered Nurses Association of Ontario, 2002).

2. Regular administration of acetaminophen, for4872 h postoperatively then as needed. Themaximum 24 h dose for a healthy adult is4 Gms. For those with diminished renal or hepa-tic function, the suggested decrease in acetami-nophen dosage is 5075% of the adult dose(American Geriatrics Society, 2009).

While COX-2-selective and traditional non-ste-roidal anti-inflammatory drugs (NSAIDS) are effec-tive agents in postoperative musculoskeletal painmanagement, older adults are at high risk for asso-ciated cardiovascular and gastrointestinal adverseevents. People with diminished renal function,dehydration, congestive heart failure and/or a his-tory of peptic ulcers or gastrointestinal bleedsshould not take these medications. TraditionalNSAIDS can enhance the anticoagulant action andincrease the risk of bleeding due to their effectson platelet function. Therefore, NSAIDs are usedwith extreme caution and only if benefits outweighrisks and generally are not recommended for theolder adult (American Geriatrics Society, 2009.

For neuropathic pain, adjuvant medicationsincluding antidepressants, anticonvulsants andother pain modulating medications are recom-them and any activity precautions. Prevention strategies to mitigate analgesic sideeffects: e.g. constipation, delirium. (Paseroand McCaffery, 2011)Engaging patients and families in developing thecapacity to manage their pain is vital for effectivepain treatment and an improved quality of life.Consider education and coaching to develop self-care knowledge and skills in the following areas:

Importance of pain management for rest, activ-ity and healing.

Early warning signs of pain signifying complica-tions: e.g. infection, venous thrombo embolism,hip dislocation etc.

How to use non medication strategies: e.g. coldpacks, positioning, breathing exercises, distrac-tion etc.

Preventing pain with appropriate selection, doseand timing of pain management strategies e.g.analgesics and or cold packs before exercise.

Safe and appropriate use of analgesics: e.g.logical Management of Persistent Pain in Older Per-son 2009 (American Geriatrics Society, 2009) canbe found at: http://www.americangeriatrics.org/files/documents/2009_Guideline.pdf.

Prevention and management of side effects

Anticipate and monitor for common side effectssuch as sedation, constipation, nausea and vomit-ing and institute preventive treatment as appropri-ate (Registered Nurses Association of Ontario,2002). The older adult has an increased risk ofrespiratory depression with opioids due to age re-lated changes and coexisting diseases. Regularlymonitoring sedation levels is recommended assedation generally precedes respiratory depression(Jarzyna et al., 2011; Pasero and McCaffery, 2011).The ASPMN Nursing Guidelines on Monitoring forOpioid Induced Sedation and Respiratory Depres-sion (Jarzyna et al., 2011) can be found at:http://www.aspmn.org/Organization/documents/GuidelinesonMonitoringforOpioid-InducedSedationandRespiratoryDepression.pdf.

Self-management strategies

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low ds ne

186 A.B. Maher et al.ASSESSMENT/DETECTION

Pain is often under reported by patients and undetected by staff. Frequent appropriate pain assessment is essential. Assessment of pain is multi-dimensional including:

Onset and duration of pain Pain locations Predisposing factors Pain type or quality Beliefs about treatments and effectiveness Co-existing painful conditions Prior to admission treatment type, dose &

effect Pain intensity using a valid scale preferred

by the patient. e.g. IOWA Pain thermometer, verbal descriptor scale

Severely impaired patients can respond to verbal assessments simply stated and focused on the present. For those unable to respond verbally, use a valid behavioural scale e.g.. Pain AD. A change in baseline such as agitation, aggression or withdrawal is indicative of pain. Family/care providers are an important resource.

TYPES OF PAIN

Older people may have both nociceptive and neuropathic pain types. Effective treatment is

Neuropathic Nervespecialized approach

Dysesthetic, pins freezing

Lancinating, shar Allodynia - pain in

stimuli.

NONPHARMACOLOG

Reposition regular Warm blankets &

sense of caring an Apply cold packs t

minutes at a time. Breathing exercise

distraction. Identify & use wha

be effective. Consult OT/PT for

PHARMACOLOGICAL

Use a multimodal apprnonpharmacological, o

Immediate postoperati

1) Regular dosing ofhrs post op, then aDelirium

Delirium is one of the most prevalent cognitive dis-turbances in older adults with rates ranging be-tween 16% and 62% after hip fracture (Bitschet al. 2004; White et al., 2011). Delirium is definedas a sudden alteration in baseline mental functioncharacterised by rapid development of fluctuatingdisturbances of consciousness, attention and per-ception (American Psychiatric Association, 2000).Delirium is independently associated with a varietyof adverse outcomes including pressure ulcers,functional decline, institutionalisation, and death(McAvay et al., 2006; Andrew et al., 2005). Krogs-eth and colleagues (2011) conducted a prospective6-month follow-up study of 106 elderly hip fracturepatients, free from dementia prior to fracture, andfound the development of delirium in the acutephase to be a strong predictor of dementia6 months later. Patients with persistent delirium

predicated on targeting the specific pain type.

Nociceptive

Visceral organ

Deep dull ache Radiates to surrounding areas

Somatic musculoskeletal

Well localized Aching or sharp Intensified by movement.

opioids include: hydrom& morphine (less prefemetabolites.

2) Regular dosing of acetaGrams for 48-72 hourspatients with decreasedfunction.

NSAIDS and COXIBS are odue to susceptibility to adve

Principles of Analgesic Atify MD: Requires a

eedles, burning or

ooting, shock like onse to non-painful

MEASURES

th supportive pillows. e massage for a curity. site for fifteen

cialization /

person believes will

ing/mobility/exercise.

ATEGIES

: s, acetaminophen .

commendations:

ose opioids for 48-72 eded. Appropriate

Begin with a low dose. Titrate slowly to effect.

Assess sedation scale before & after dosing. Reduce/ withhold dose if sedation occurs.

Select appropriate medication with lowest potential for toxicity or adverse effects.

Individualize dosing. Ensure baseline opioid dosing is factored into treatment plans, when opioids have been regularly used prior to admit.

Use a step wise approach (WHO) - Step 1: Mild pain: acetaminophen/ comfort measures. - Step 2 Moderate pain: Step 1 plus low dose Opioid - Step 3: Step 1 plus Opioid titrated to effect.

Prevent constipation: bowel protocol with laxatives if opioids used.

If delirium, assess for underlying cause. If analgesic related, reduce dose or use alternate medication.

Use low dose anti-emetics only if significant nausea or vomiting. Investigate /address underlying cause of N/V e.g. obstruction.

Self Care: Patient Education & Coaching

Importance of pain management for rest, activity and healing are 2.9 times more likely to die within one yearthan those whose delirium resolves (Kiely et al.,2009). In addition to increased morbidity and mor-tality, there is significant added monetary cost percase to treat and care for patients with deliriumcompared to those without. This is in part due tolonger hospital stays and the need for increasedpost discharge services (Leslie et al., 2008).

Despite its prevalence, significant cost and neg-ative outcomes, delirium is often overlooked ormisdiagnosed by both physicians and nurses (Lem-iengre et al., 2006; Inouye et al., 2001). Nurses of-ten miss delirium, especially when dementia or thehypoactive form of delirium is present (Fick et al.,2007; Steis and Fick, 2008). The ability to differen-tiate between dementia and delirium is importantbecause unlike dementia, the cognitive changesin delirium are potentially preventable, are likelyreversible and may be the only presenting symptomof an acute health crisis.

orphone, oxycodone, rred due to active

minophen up to 4 . Use lower doses for renal or hepatic

ften contraindicated rse effects.

dministration

Early warning signs of pain signifying complications: e.g. infection, venous thrombo embolism, hip dislocation etc.

Comfort measures: e.g. cold packs, positioning, breathing exercises, distraction etc.

Preventing pain with appropriate selection, dose and timing of pain management strategies e.g. analgesics and or cold packs before exercise.

Safe and appropriate use of analgesics: e.g. what medication to take, when.

How to safely manage activities. Prevention of side effects: e.g. constipation,

delirium, sedation.

Orthopaedic nurses play a pivotal role in ensur-ing optimal outcomes for patients at risk for orsuffering from delirium. Prevention requires clini-cians that are knowledgeable of delirium risk fac-tors, are vigilant in screening and documentingtheir findings and implement evidence-based pro-tocols to reduce the incidence of delirium. Inthe older adult, delirium is considered a medicalemergency requiring prompt attention, ongoingassessment and targeted medical and nursinginterventions aimed at addressing the underlyingacute medical problem. Targeting identified riskfactors has proven to be effective in reducingthe incidence, duration and severity of delirium.(Holroyd-Leduc et al., 2010; Mak et al., 2010;Bjorkelund et al., 2010).

When Delirium is suspected, a comprehensiveassessment to uncover the root causes should beperformed. The acronym PRISM-E was developedby the Vancouver Island Health Authority Hospitalto help focus nursing assessment on common riskfactors that may be contributing to the delirium.

P Pain, poor nutritionR Retention (urine or stool), restraintsI Infection (urinary, pulmonary, wound),immobilityS Sleep disturbances, sensory deficits (hear-ing, vision)M Metabolic imbalance, mental status,medicationsE Environmental changes

tin

dicnsnerty//erloa

tur/imathion

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 187Risk factors

There is no single cause of delirium. Multiple fac-tors including dementia, advanced age, sensorydeficits, chronic medical conditions, medicationsand orthopaedic surgery increase the risk of devel-oping delirium in the older patient with hip frac-ture. Unfortunately, there is no single laboratorytest for delirium. Detection depends on knowl-edgeable care providers who identify the risk fac-tors and maintain a high level of suspicion whensudden behavioural changes occur, including in-creased somnolence and lethargy. Causative riskfactors fall into two categories; predisposing fac-tors those issues that increase a persons vulner-ability to developing delirium and precipitatingrisk factors those issues that occur as a resultof hospitalisation that lower the threshold to trig-ger delirium (Inouye and Charpentier, 1996). SeeTable 3 for examples of predisposing and precipi-tating factors. The more vulnerable the patient,the fewer precipitating factors required to createa delirious state.

Table 3 Risk factors.

Predisposing factors Precipita

History of, delirium, dementia or depression OrthopaeAdvanced age > than 75 years Medicatio

anticholiSensory deficits; Hearing/visual ImmobiliMetabolic/electrolyte disturbances:diabetes, hypothyroid; dehydration

Metabolicfluid ove

Infection/severity of illness Pain.Alcohol/substance abuse Sleep disDependency on others for ADL Tethering

urinary cIncontinence Constipathoc/psychosocial/SPMSQ.pdf are examples of validand reliable tools that can be used to identify cog-nitive deficits (Schofield et al., 2010).

g factors

surgery prolonged time to surgery.: either addition &/or withdrawal especiallygics, benzodiazepines and opioid naivety or sensitivity.restraint use.ndocrine/electrolyte disturbances, hypoxia;d, dehydration.

bances; noisy environment, overstimulation.mobilising medical devices e.g. IVs, indwelling

eters..http://geropsychiatriceducation.vch.ca/docs/edudownloads/delirium/delirium_screening_PRISME.pdf

Assessment/detection

Determining baseline mental status is a critical andoften challenging first step in obtaining an accurateassessment of cognition. The best resource todetermine mental status changes, especially forthose with dementia, is often the family or in-homecare provider. In addition to information from fam-ily, ongoing cognitive assessment and documenta-tion of findings is important. Incorporating acognitive assessment screen into routine nursingdocumentation may help to ensure ongoing evalua-tion across shifts, enhancing the opportunity to de-tect subtle changes. The Abbreviated Mental Test 4(AMT4) http://www.ncbi.nim.nih.gov/pubmed/9360037 and the Short Portable Mental StatusQuestionnaire http://www.npcrc.org/usr_doc/ad-

Screening tools for delirium Differentiating delirium from dementia and

188 A.B. Maher et al.There are several delirium assessment and ratingscales to assist clinicians to identify delirium.Examples of some commonly used instrumentsinclude:

The Confusion Assessment Method (CAM) http://www.consultgerirn.org/uploads/File/trythis/try_this_13.pdf.

The Delirium Observation Screen (DOS) and theNEECHAM confusion assessment scale http://www.biomedcentral.com/1472-6955/6/3 and theNurses Delirium Screen (NuDESC) http://www.caresearch.com.au/Caresearch/LinkClick.aspx?fileticket=jub2P5CbteE%3D&tabid=1179.

When selecting an assessment instrument it isimportant to choose one with established validityand reliability and one that was designed for useby nurses at the bedside. Consideration should alsobe given to the practice setting and patient popula-tion for which it will be used, the time required foradministration and/or training of staff to use aswell as the culture of the organisation.

Identifying cardinal features of delirium

Regardless of the tool chosen, it is important thatclinicians are able to identify the cardinal featuresof delirium. The hallmark features of delirium aresudden onset, developing within hours or days, afluctuating nature of symptoms and inattention.Fluctuation of symptoms is commonly noted bythe family and best captured by consistency ofscreening and documentation of findings. Inatten-tion can be gauged quickly by simply asking the pa-tient to say the days of the week backward or spelltheir last name backward. Disorganised thinking which may or may not be present can be gaugedby asking the patient What would you do if yourhouse were on fire? or Which is heavier: a feath-er or a rock?

Another challenge is that delirium presents inseveral forms or subtypes. The hyperactive formis characterised by high levels of anxiety, distract-ibility, restlessness and wandering. Patients suffer-ing from this form of delirium are easy to identifybecause they demand our attention. The hypoac-tive subtype characterised by lethargy/sleepi-ness in a previously engaged person is the morecommon form of delirium in older adults and sev-eral studies associate hypoactive delirium withpoorer outcomes and an overall poorer prognosis(de Rooji et al., 2005). The mixed subtype mani-fests with fluctuating periods of anxiety andlethargy.depression

Delirium is more common in patients with demen-tia and may coexist with disorders such as depres-sion, a common condition in the elderly (Fick andForeman, 2000). Cognitive changes, such as in-creased anxiety, visual hallucinations, delusionsand pulling/picking at devices, are often attributedto the dementia rather than an emerging deliriumsuperimposed on the dementia. Patients experi-encing hypoactive delirium may be misdiagnosedas sedated, tired or suffering from depression. Dif-ferentiating delirium from depression or dementiarequires astute clinical assessment skills and anawareness of the distinguishing clinical featuresof each condition (see Table 4).

Delirium superimposed on Dementia, one ofthe John A. Hartford Foundation Institute for Geri-atric Nursings Try This series, provides valuableinformation to assist in teasing apart delirium fromunderlying dementia (Fick and Mion 2008).www.mmc.org/workfiles/mmc_services/geriatrics/Improving_Detection.How_to_try_this_DSD.Fick.pdf.

The Registered Nurses Association of Ontario(RNAO) best practice guidelines for identifyingdelirium, dementia and depression in the elderlypatient and the Vancouver Island Health Authoritywebsite are two other excellent resources.http://www.rnao.org/bestpractices/PDF/BPG_DDD. pdf. http://www.viha.ca/search.htm?q=delirium&ChannelGuid=%7bAB3EE633-0F65-4C25-8C40-6502866E96DF%7d.

Prevention and management strategies

Studies suggest that it is possible to prevent up to30% of the cases of delirium (Inouye et al 1999;Marcantonio et al., 2001). Early attention (onadmission) to risk factors and implementation oftargeted nursing management strategies may avertthe development of delirium and/or for those whodo develop it these strategies may ameliorate theseverity of their symptoms. Table 5 provides someexamples of targeted intervention strategies. Acomprehensive list of delirium prevention strate-gies published by the National Institute for Healthand Clinical Excellence (NICE, 2010) are availableat the following website: http://www.nice.or-g.uk/nicemedia/live/13060/49909/49909.pdf.

Delirium is a frightening experience for the pa-tient, their family and the staff. A number of cog-nitively intact older adults who experienced adelirium while acutely ill or following surgery

Table 4 Clinical features of depression, dementia and delirium.

D

Dadpdia

Gpd

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 189Depression

Presenting symptoms Depressed mood,negative self-talk,lethargy, appetite andsleep disturbances.

Onset/course Gradual; typically worsein morning. May beconnected to onset ofvividly recall their feelings while delirious and howfrightened they felt. The Vancouver Island HealthAuthority in Canada developed a video depictinga delirious episode from the patients perspective.http://www.youtube.com/watch?v=wcCcS4NiCHU.

Nursing management strategies to reduceseverity of delirium

Once delirium has been identified, the major focusof nursing care should be safety and reduction of

physical illness, loss offamily or friends,changes in financial orliving situation.

tofaft

Cognitive features Loss of cognitivefunctioning is rare, buthas difficultyconcentrating andmaking decisions andmay experience minormemory loss.

Drdmwfijsc

Emotional features Loss of interest orpleasure in favouriteactivities; persistentsadness, irritability, &hopelessness. Seemslethargic and apatheticor intensely worried.

PMwctp

Physical features Vague somaticcomplaints.

Fc

Looks sad Lcisementia Delirium

ifficulty with recentnd remote memory,isorientation to time,lace and person;isturbances inntellectual reasoningnd thinking.

Fluctuatingdisorientation, mentalconfusion, emotionallability, manic-likebehaviour, visualhallucinations. May belethargic, sleepy/difficult to awaken.May be delusional

radual onset;rogression of courseepends on cause;

Sudden; may occurduring acute illness orsurgery; often at twilightstress. The initial management strategy is to iden-tify and manage any possible underlying cause orcombination of causes (British Geriatric Society,2006; Robinson et al., 2008). The PRISM-E guide de-scribed above is also a useful tool in managingdelirium. Monitor for the use of potentially inap-propriate drugs and consider withdrawing themwhenever possible. Critically evaluate the use ofbenzodiazepines and medications with anticholin-ergic properties for necessity and dose, especiallyin the elderly. If the suspected cause of deliriumis opiates, it may be possible to reduce the doseor change to an alternative analgesic. However, it

ypically slow with lossf intellectualunctioning; loss ofbility to performamiliar tasks; inabilityo problem solve.

or in darkness; functiondeteriorates quickly.

ifficulty rememberingecent events, (in severeementia, remoteemory impaired asell), words difficult tond. Impairedudgment. In earlytages attempts toonceal deficits.

Cognitive changes thatoccur rapidly.Inattention, Fluctuatinglevels of awareness;Disorganised thinkingmay experiencehallucinations/illusions/delusion.

assive and withdrawn.ay become agitatedhen confronted aboutognitive losses or feelshreatened by neweople or environment.

Hyper-agitated, erraticmood swings, anxious,uncooperative.aggressive.Hypo-lethargic, difficultto awaken.

ragmented sleep wakeycle.

Sleep cycle may bereversed. May have wild-eyed look (anxious); maybe disinhibited ordisinterested in selfcare.

ooks lost andonfused. May dressnappropriately or lackelf care.

Table 5 Delirium prevention strategies.

y/sicks,n a

s wand

emlose

ncoionassi

190 A.B. Maher et al.Clinical factor Prevention strategy

Dementia/cognitiveimpairment/disorientation

Routine screeningEncourage visits from familEnvironmental cues i.e. cloReorient/remind of situatioProvide reassurance

Dehydration/constipation Encourage fluids; offer fluidEnsure fluids are accessibleEncourage mobilityLaxatives, Suppositories, En

Hypoxia Monitor oxygen saturation cestablished protocols

Limited mobility Avoid prolonged bed rest/eEncourage active participatEnsure access to necessaryAvoid restraintsis important to note that hip fractures are painfuland unrelieved pain is a leading contributor tothe development of delirium (Schreier, 2010). A re-view of medications by a clinical pharmacist is of-ten helpful in identifying medication contributors.

Infection is known to cause delirium. Universalprecautions must be strictly adhered to preventinfections. Devices that increase risk of infectionsuch as indwelling urinary catheters should be dis-couraged and if necessary, removed as soon as clin-ically possible. If urinary retention presents as apost-operative symptom; rather than reinsertingan indwelling catheter, direct nursing efforts to-ward mobilising the patient and consider the use

Initiate fall precautions

Infection Monitor for signs and symptomAvoid devices that increase riskAdhere to universal precaution

Medications Careful medication reviewCritically evaluate use of benzoAlert to potential withdrawal fe.g. benzodiazepinesAvoid medications that have CN

Pain Assess for pain; monitor for sighttp://consultgerirn.org/uploaInitiate and monitor effectivenScheduled, non-opioid analgesipatients. (Refer to Pain section

Poor nutrition Conduct nutrition screen for alProvide nutritional support forEnsure dentures fit wellAssist as needed to ensure oralBe alert to swallowing difficult

Sensory impairment Assess and resolve any reversibEnsure availability of glasses anDisplay large print accurate sigAvoid glareEnsure environment is appropri

Sleep disturbances Limit environmental noiseBundle nursing services to avoiTime medications to optimizeAvoid pharmacological interven

Source: National Institute for Health and Clinical Excellence. Julygnificant otherssigns, day calendar

s long as not anxiety producing

ith each patient visit unless restrictedin container easy to manipulate

as based on protocol or provider ordersly, apply oxygen when indicated according to

urage mobilityin ADLsstive devicesof bladder scan and intermittent straight catheteri-sation until normal voiding returns (Palese et al.,2010). Assess for the possibility that an anti-cholin-ergic drug may be the cause of the retention. Inmen determine whether an enlarged prostate isthe cause and refer for appropriate urologicalconsult.

Alcohol abuse increases the risk of developingdelirium and its occurrence in the elderly popula-tion and may be overlooked. Incorporation of aprotocol to manage chemical dependency with-drawal, such as the Clinical Institute WithdrawalAssessment (CIWA) http://www.reseaufranco.com/en/assessment_and_treatment_information/

s of infection; i.e. urinary catheterss/infection control practices

diazepines and anticholinergic medicationsrom routine medications not reordered on admission,

S side effectsns in non verbal patients (PAINAD assessment)ds/File/trythis/try_this_d2.pdf.ess of pain managementcs are effective treatment for arthritic pain in elderly)l patientsall patients with special attention to malnourished older adults.

hygiene is maintainediesle causes; e.g. wax impactiond hearing aidsnage

ately lit for time of day

d multiple disruptionstherapeutic effects and maximize sleeptions unless routine

2010. Delirium Clinical Guideline (103).

assessment_tools/clinical%20institute%20with- wakefulness is recommended. Systematic reviewof the literature finds that the use of low dose typ-

main at the bedside as long as their presence iscalming to the patient. It is important to provide

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 191drawal%20assessment%20for%20alcohol%20(ciwa).pdf may help ensure symptoms of withdrawal areidentified and addressed early. Drug misuse suchas benzodiazepines for sleep or anxiety may alsobe a contributing factor. Failure to renew thesemedications while hospitalised may lead to with-drawal. Withdrawal is very difficult and assessmentby a physician or advanced practice nurse to deter-mine continuance of the drugs while in the hospitalmay be necessary. Withdrawal from benzodiaza-pines can take many months and sometimes years.

Effective communication is important. To theextent that it does not enhance agitation, it isimportant to provide reorientation. For example,explain where the person is and your role. Use ofa white board to post date, room number and thenames of persons providing care are importantreorientation strategies. Invite and encourage par-ticipation of family, friends and in-home carers asthey bring the element of familiarity. Provide atherapeutic care environment by ensuring ade-quate lighting, appropriate noise and temperaturecontrol and remember to provide reassurance toboth the patient and family to allay their fears.

An additional institutional strategy to consider isa program such as the Hospital Elder Life Program(HELP). To learn more see: http://www.hospitalel-derlifeprogram.org/public/public-main.php.

If delirium does not resolve consider:

Re-evaluation of underlying causes Follow up, referral to appropriate geriatricresources to assess for possible dementia

Continual provision of supportive care to patientand family

Short term pharmacological management ifbehaviour interferes with treatment.

Pharmacological management

It is recommended that the use of medications tomanage the hyperactive symptoms of delirium bereserved for those occasions where more conserva-tive measures have failed (Campbell et al., 2009).Persons who may benefit from short term medica-tion use tend to be those who are distressed, ac-tively experiencing hallucinations or delusions orconsidered a risk to themselves or others and forwhom verbal and non-verbal de-escalation tech-niques are ineffective or inappropriate. When med-ications are warranted, administration of thelowest clinically appropriate dose with cautioustitration to manage symptoms while maintainingfamilies with information about the nature ofdelirium and the important role family membersplay in providing a sense of security and comfortfor the patient. Patients who have previouslydeveloped delirium are at increased risk for reoc-currence. It is important to advise families andpatients of the value of reporting prior episodesof delirium and strategies that helped to resolveit. Teaching them how to detect and report theearly warning signs of delirium is also important.Nurses Improving Care of the Health System Elders(NICHE) has developed information for patientsand families related to delirium as part of theirNeed to Know Series. This information can beaccessed at http://nicheprogram.org/need_to_-know. Patients with hip fracture may be trans-ferred to a rehabilitation facility and it isimportant to include information regarding delir-ium assessment and effective management strate-gies in the handoff plan of care.ical (first generation) antipsychotics such as halo-peridol (

DELIRIUM - QUICK REFERENCE

changes as well as a change in level of consciousness.

ated/argy;)natinates

SIGNS AND SYMPTOMS

may

ulne hall

time ake c

gy

symative

URE

irium

dden

Assistive devices available

192 A.B. Maher et al.PREVALENCE

Delirium is a common complication of hip fracture occurring in as many as 61% of older patients resulting in increased morbidity and mortality.

RISK FACTORS

Older AgeDementiaSensory impairmentDepressionMetabolic disordersCardiopulmonary disordersPoor functional statusETOH misuseUse of indwelling catheters

Persons with delirium

InattentionConfusion/forgetfVisual or auditoryDisorientation to Disturbed sleep wAgitationSleepliness/lethar

Establishing signs andfrom baseline is imper

COMPARATIVE FEATDEMENTIA

Feature Del

Onset SuDEFINITION

Delirium is a reversible change in cognition, occurring over hours or days. Characterized by impaired cognition, a reduced ability to sustain or shift attention and may include perceptual

Hyperactive: AgitHypoactive: Leth(often overlookedMixed Type: alterand hypoactive stDisclaimer

This article was developed using a range of litera-ture which included evidence-based research,consensus documents, guideline statements, sys-tematic reviews and peer reviewed publicationsand also was informed by best practice and contentexpert commentary. The information presented inthis article is to educate and inform the readerabout common complications of fragility hip frac-ture in older adults. The decision to use specificassessment methods and interventions must bemade by the individual practitioner/health careorganisation relative to the individual patient,available resources and other relevant factors.

Conflict of interest statement

There are no conflicts of interest for the authors ofthis manuscript.

Addition of 3 or more medicationsOrthopaedic Surgery Discontinuation of medicationsUse of physical restraints

ASSESSMENT/DETECTION

Spectrum of Delirium ranges from:

Duration Hours/daweeks

Attention Impaire

Speech Incoherenonsensic

Awareness Reduce Dementia

Slow

Consistency of care providershallucinating excessive sleepiness

g between both hyper

display

ssucinations/illusionsand placeycle

ptoms as a change .

S OF DELIRIUM &

DIAGNOSTICSCREENING TOOLS

Evidence based screening tools such as AMT-4, Mini-Cog assess for cognitive changes which need to be compared to baseline function. If a change is identified, further evaluation with an evidence based tool is warranted.

Examples include:

Confusion Assessment Method (CAM) Nurses Delirium Screen (NUDESC)Delirium Observation Screen (DOS) NEECHAM Delirium Screen

PREVENTION & MANAGEMENT STRATEGIES

Identify risk factors and addressEncourage/invite family participationQuiet therapeutic environmentOrientation clues clock, calendarGlasses/working hearing aidsRole of funding source

No funding was obtained for this study.

Acknowledgements

We would like to acknowledge the support ofICON constituents during the development of thispaper particularly Joyce Lai of AADO, Hong Kong,and Reggie Aquilina of AMON, Malta.

We are grateful to the nurse experts whose inputguided and strengthened the paper. Those who re-viewed the entire document were Marie Boltz, PhD,RN, GNP-BC (USA), Peter Davis MBE (UK), Sue BairdHolmes, MS RN (USA).

Pain section reviewers were: Donna Sipos Cox,MSN, RN, ONC, CCRC (USA) Keela Herr, PhD, RN,AGSF, FAAN (USA), Alan Pearson AM (Australia),Brenda Poulton, RN, MN, NP (Canada).

Delirium section reviewers were Marcia Carr,RN, BN, MS, GNC(C) (Canada), Donna Fick, PhD,

ys/

Months/ Years

d Normal

nt, al

Ordered, anomic, aphasic

d Clear

RN, FGSA, FAAN (USA), Lorraine Mion, PhD, RN,FAAN (USA), Manuela Pretto, MNS, RN

75, 378389.Bjorkelund, K.B., Hommel, A., Thorngren, K.G., Lundberg, D.,

adults a systematic evidence review. Journal of GeneralInternal Medicine 24 (7), 848853.

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1) 193Larsson, S., 2009. Factors at admission associated with4 months outcome in elderly patients with hip fracture. AANAJournal 77, 4958.

Bjorkelund, K.B., Hommel, A., Thorngren, K.-G., Larsson, S.,Lundberg, D., 2010. Reducing delirium in the elderly patientswith hip fracture: a multi-factorial intervention study. ActaAnesthesiologica Scandanavica 54, 678688.

Boltz, M., Resnick, B., Capezuti, E., Shuluk, J., Secic, M., 2012.Functional decline in hospitalized older adults: can nursingmake a difference? Geriatric Nursing 33 (2), 137139.

British Geriatric Society. 2006. Guidelines for the prevention,diagnosis and management of delirium in older people inhospital. .

Campbell, N., Boustani, M., Aybu, A., Fox, G., Munger, S., Ott,C., Guzman, O., Farber, M., Ademuyiwa, A., Singh, R., 2009.Pharmacological management of delirium in hospitalized(Switzerland).Pressure Ulcer section reviewers were Joyce M.

Black, PhD, RN, CSPN, CWCN, FAAN (USA), Chris-tina Lindholm, PhD, RN (Sweden), Zena Moore,PhD, MSc, PG Dip, FFNMRCSI (Ireland).

Fluid Balance/Nutrition/Elimination reviewerswere Joanne Alderman, APRN-CNS, RN-BC, FNGNA(USA), Merete Gregersen, MHSc (Denmark), NickyHayes, RGN, BA(Hons), MSc, PGCert (HE) (UK), AlanPearson AM (Australia).

We thank Jennifer Gibson for her editorialexpertise and meticulous attention to detail andJudy Knight MLS, AHIP, coordinator, library ser-vices for her valuable assistance.

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Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 1)IntroductionPurpose/scopeMobility considerations

PainSignificance prevalencePain classificationsAssessment/detectionSpecial considerationsManagement strategiesNon-pharmacological interventionsPharmacological strategiesMultimodal analgesiaPrevention and management of side effectsSelf-management strategies

DeliriumRisk factorsAssessment/detectionScreening tools for deliriumIdentifying cardinal features of deliriumDifferentiating delirium from dementia and depressionPrevention and management strategiesNursing management strategies to reduce severity of deliriumPharmacological managementSelf-management/transitional care needs

DisclaimerConflict of interest statementRole of funding sourceAcknowledgementsReferences