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Table 1 Overview of the included studies (for methods and data analysis see Table 3)

From: Drug-based pain management for people with dementia after hip or pelvic fractures: a systematic review

Author, year Setting/country Objectives Findings
COHORT STUDIES
Adunsky et al. 2002 [10] hospital/Israel Are PwD treated differently to those without cognitive impairment, and what factors might affect this? PwD received only 53% of the amount of opioid that was administered to cognitively intact patients. Significant association between cognitive status and amount of opioid analgesia.
Feldt et al. 1998 [33] hospital/USA Experience and treatment of pain in PwD vs. those without cognitive impairment? Prescription of pain medication did not differ significantly, but cognitively impaired subjects received fewer opioid analgesics. Both groups received less than 25% of the mean prescribed amount of opioid analgesics.
Feldt et al. 2000 [35] hospital/USA Is post-operative pain a predictor of functional outcomes for elderly hip fracture patients who were previously independent ambulators? Undertreated post-operative pain contributes to poor functional outcomes. No differences between PwD and those without cognitive impairment in the amounts of opioid analgesics or acetaminophen prescribed or administered in the first or second 48 h post-op.
Feldt & Gunderson 2002 [29] across settings/USA Observing the treatment of pain following hip fracture across settings. Subjects received significantly less medication during the first 24 h in the nursing home (NH) as compared with the last 24 h in the hospital. Over one-thrid of the subjects received no opioid analgesics and 18.3% received no analgesic of any kind during the first 24 h of NH stay. 91.5% of the opioid analgesics were prescribed PRN. Subjects in the hospital setting received more analgesia regardless of MMSE score. Setting is the only relevant factor.
Grall 2010 [34] hospital/USA Are there differences in pain expression, assessment and management in hospitalised elderly persons? Pain in PwD is under-recognised and undertreated in the acute care setting, and current clinical practice guidelines with regards to pain assessment are not being followed. People without dementia received almost 50% more pain medication compared with their counterparts with dementia following acute hip fracture.
Jensen-Dahm et al. 2016 [22] hospital/Denmark Do hip fracture patients with dementia receive less post-operative pain treatment than those without cognitive impairment? PwD received lower doses of oral morphine equivalents during the first and second post-operative day, lower doses of acetaminophen during the first 3 days post-op, and were more likely to receive opioids PRN.
McDermott et al. 2014 [26] ED/UK To identify inconsistencies in pain management within the acute setting. PwD received a weaker level of analgesia both in the ambulance and in the accident and emergency setting.
Morrison & Siu 2000 [12] hospital/USA Observation of the treatment of pain following hip fracture. Advanced dementia patients received one-third of the amount of morphine sulphate equivalents received by the cognitively intact patients. 76% of the PwD and 83% of the cognitively intact patients did not have a standing order for their analgesic agent during their entire hospitalisation.
CROSS-SECTIONAL STUDIES
Holdgate et al. 2010 [27] ED/Australia To identify patterns of analgesia administered and real or potential barriers to providing analgesia after hip fracture. Cognitive impairment and language difficulties as most reported barriers.
Hwang et al. 2006 [28] ED/USA What is the effect of emergency-department crowding on assessment and treatment of pain in older adults? Dementia as a risk factor for undertreatment of pain, considerable delays in analgesic administration, and treatment with inappropriate analgesics.
Mak et al. 2011 [31] hospital/Australia Observation of analgesia use among patients with hip fracture requiring surgery in correlation to hip fracture subtype, cognitive status and type of surgery in the post-acute period. PwD utilised markedly less analgesia at all time periods measured.
Titler et al. 2003 [32] hospital/USA Observation of acute pain management practices for patients hospitalised for hip fracture. Only 27% received patient-controlled analgesia and only 22.3% received around-the-clock administration during the first 24 h after admission of analgesics that had been ordered PRN. PwD received significantly less mean parental morphine equivalents of opioids than those without dementia.
CASE SERIES
Ardery et al. 2003 [21] hospital/USA Why did eight patients recruited from a previous study (Titler et al. 2003 [32]) receive no opioid during the first 72 h after admission? Mental status cannot by itself account for patterns of analgesic administration.
HEALTHCARE PROFESSIONALS’ SURVEYS
Rantala & Kankkunen et al. 2012 [14] hospital/Finland Common aim of both studies: to identify current post-operative pain management practices for PwD and hip fracture; barriers to post-operative pain management in hip fracture PwD; nurses’ expectations and facilitators offered by employers to overcome barriers in pain management. The major barrier to effective pain management was stated to be difficulties in assessing pain because of a decline in cognition.
Rantala & Kankkunen et al. 2014 [23]
Rantala & Hartikainen et al. 2014 [25] hospital/Finland Common aim of both studies: to identify the analgesic use in hip fracture PwD during the first two post-operative days as reported by nurses, and nurses’ knowledge regarding relevant adverse effects of different types of analgesics when treating post-operative pain in PwD. Nurses older than 50 and with over 15 years of work experience in healthcare had complete pain relief as the main goal of pain management significantly more often than younger nurses with less work experience in healthcare.
Rantala & Hartikainen et al. 2015 [24]