A Broken Hip and Uncontrolled Pain, a Recipe for Disaster

More than 800 people every day in the US suffer a broken hip. Hip fractures are one of the most common reasons that people over the age of 65 become patients in the hospital. Without expert care and effective pain control, many of these patients will suffer serious complications

In my over twenty 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 dosing of opioids such as morphine, fentanyl and dilaudid 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 consequences from unrelieved pain. These complications can include anxiety, increased sensitization to pain, and reduced efficacy of pain medication in the future. And, for those of advanced age, delirium may be the most consequential result of poor pain control.

The following is an excerpt from Getting the Best Care. Rescue Your Loved One from the Healthcare Conveyor Belt

When my mother, Alma was a robust ninety-four-year-old, she fell and broke her hip. She had been on her weekly mission of mercy, driving her very frail friend to church and out to lunch afterward. This is a scenario that so many people fear: an aging loved one who had been independent becomes disabled after breaking a hip and dying shortly after. Thankfully, that did not happen to Alma. But, it did take some vigilance on the part of my siblings and me to avoid some of the common difficulties.

In the emergency room that day, Alma was in excruciating pain, but the doctor on duty refused to treat her pain adequately. He was concerned that, at her advanced age, she would be at risk of depressed breathing or losing consciousness. It was infuriating for me to have to sit with Mother while she writhed in pain. I spoke with the nurse and the doctor, trying to convince them by telling them that I would stay with her and monitor her breathing. Still, the doctor would not relent. It was as if we were in a battle of wills, and rather than appropriately caring for his patient, he was determined to defeat me.

I was relieved when the nurse came in with a syringe because I assumed that she had finally gotten orders for more pain medication. But, instead, she told me it was lorazepam (ativan), which is a sedative. She said the doctor felt that my Mother was anxious. I refused the sedative on behalf of my mother and said that she was anxious because she was in terrible pain. Sedation is not an appropriate way to address pain in a patient of any age. And, the unnecessary sedation would have put her at risk for delirium while providing no pain relief, which is what she really needed.

After several hours, Mother was transferred to her hospital room. She had an experienced nurse who understood my request that Mother not be given a urinary catheter. Catheters often cause devastating urinary tract infections, which can lead to many complications in an older person. I requested that she be provided with and use a bedpan when needed. A bedpan is inconvenient and may even be painful with a broken hip, but the risks that a urinary catheter carry are worse than the problems of using a bedpan.

I am fortunate to have many siblings who were able to share the bedside vigil duties to ensure Mother would not be alone. Everyone in the family knew to ask about medication and to refuse any sedation. We were determined to do our best to prevent any delirium from setting in. Still, even with all of our efforts, Alma did experience some episodes of confusion.

Her periods of confusion made us more determined to get her home as quickly as possible after surgery. We arranged for her to have rehabilitation at home, and one of us stayed with her until we could arrange for in-home care. Even with all of our precautions to avoid delirium, Mother did have several weeks of personality changes after her hip surgery. (End of Excerpt)

The confusion and personality changes that my mother experienced was delirium. Delirium is a sudden state of confusion or change in mental state. In general, it is a temporary condition, but it can result in long-term problems for a patient. Restlessness, disorientation, and even hallucinations can be a part of delirium or, most commonly, the person may seem lethargic and slow to respond to questions. Some patients may have a mixed form of the condition that displays a combination of these symptoms at different times. Delirium is not just a concern for patients who are having surgery. Older patients, especially those with any level of dementia or with multiple medical problems, are at risk for developing delirium while in the hospital. It is common for delirium to be misdiagnosed; the most common type is Quiet Delirium without the agitation and hyperactivity symptoms. Up to 87% of patients over the age of sixty-five will have episodes while in the ICU. Plus, fifty percent of patients having hip or heart surgery experience delirium.

Since it can lead to severe complications and be a predictor of who dies in the hospital, any new episode of delirium while hospitalized should be treated as a serious event. But unfortunately, often it goes unrecognized or is called “sun-downing” and not treated as the serious health threat that it has shown to be.
Tips to Avoid Delirium:

  • Satisfactory pain control is absolutely imperative to avoid delirium. All too often doctors and nurses deprive older patients of pain medications because of the fear that the patient will become confused. This is ignoring the research that has shown that unrelieved pain is a risk factor for delirium.

  • Avoid any sedation if at all possible. The class of medications called benzodiazepines are generally not recommended for frail patients and for people over the age of 70. Valium is one such medication. So if you are caring for a loved one and a doctor or nurse is offering medication to “calm” the patient, be sure to ask if it is a Valium-like medication. Also, medications to help sleep such as benedryl (diphenhydramine) are not recommended for these patients because of the risk of delirium.

  • Avoid urinary catheters. Catheters that are a tube going into the bladder to drain urine are a risk for infection. A urinary tract infection can cause delirium.

  • Have a familiar face at the bedside for anyone who is frail, and for anyone over the age of 70. Even people who usually have no difficulties making decisions and handling their own affairs are at risk for delirium when hospitalized. Having a familiar person present will help keep them oriented, as well as help in advocating for pain control.

  • If there is a hip fracture, have surgery within 48 hours of entering the hospital. This will help to shorten the length of stay in the hospital which will help you to avoid infection and delirium.

  • Get back to familiar surroundings as soon as possible and have regular physical therapy. Returning to a normal routine and activity will help to prevent delirium.

A many as 20% of hip fracture patients die within a year of the fracture. And while that is due to many different factors, delirium is one of the common elements among a large number of those who do not survive.

One additional caution I would like to give you is regarding your choice of surgeon. Orthopedic surgeons are skilled and trained in all types of surgery involving bone. But it is important to know that some are specially trained and experienced doing certain kids of surgery. Ask if the surgeon has a specialty within orthopedics. Some specialize in back and spine surgery, some do mostly shoulder and upper extremity surgery and some primarily operate on knees and hips or other procedures of the lower extremities.

Of course people will say that all orthopedic surgeons are trained in most aspects of bone surgery, and that hip surgery is one of the most common. But, in my experience, if your surgeon primarily does operations on the arm and shoulder, you may be better off to request a surgeon whose main focus is the lower extremity. As with most things in healthcare, fewer complications may come from being in a facility and with a surgeon for whom your surgery is commonplace. You do not have to accept the surgeon who is assigned to you in the emergency department.

One question to ask: how many of these specific cases do you  do every month? Or what percent of your surgeries are hip surgeries? If it is less than 30%, I would ask for a different surgeon. But you have to make that decision for yourself. Just be sure that you are not intimidated or afraid of offending the surgeon. Remember you will be the person dealing with the results of your decision.