Pain and pain management with femoral nerve block following hip fracture : effects and experiences: the perspective of older patients and staff

Abstract: Background: Older people with hip fractures are often frail with several comorbidities and roughly half of them have dementia disorders. Pain is common among patients with hip fracture and pain management in these patients is a challenge. Opioids are known to relieve pain while at rest but are not as effective in movement. One alternative to opioids is a femoral nerve block (FNB). Previous studies have shown that FNBs can decrease pain and the need for opioids, but these studies excluded patients with dementia. Few studies have investigated whether FNBs decrease the incidence of complications in general, and delirium in particular. These studies were also based on different types of nerve blocks and methods. Few studies have described patients’ experiences of pain and pain management, and there are no studies on patients’ experiences of receiving or being treated with FNBs. In addition, there are no studies on staff´s experience of nursing care among patients with hip fractures who received an FNB. Objectives: The overall aim of this thesis is to investigate the effect of a preoperative FNB in patients with hip fracture in terms of pain and complications, and, further, to describe experiences of pain and pain management among patients with hip fracture who received FNBs as well as staff´s experiences of treating them. The first two papers (I and II) investigate the effect of an FNB compared to opioids, with a focus on pain and complications. To gain a deeper understanding, the final two papers (III and IV) describe experiences of pain and pain management in patients with hip fractures who received an FNB, and the staff's experiences of nursing care with patients with hip fractures who received an FNB. Methods: Papers I and II are based on a randomized controlled study which included patients aged 70 years or older with hip fractures, including those with cognitive impairment or dementia. Patients were randomized on arrival at the orthopaedic ward in terms of pain treatment to be administered; the options were FNB (with opioids if needed) or opioids alone. In paper I, 266 patients were included; the mean age was 84 years, 64% were women, and 45% had a dementia diagnosis. Paper II included 236 patients; the mean age was the same, 66% were women, and 46% had a dementia diagnosis. Pain assessment scales (self-rated VAS and VAS by proxy) was used preoperative to assess patients’ pain in rest. Nurses assessed the incidence of delirium using Nu-DESC, both pre- and postoperatively. In addition, a structural interview was performed with validated assessments 3 to 5 days after surgery by the author (AU). The assessments, nursing and medical records were subsequently evaluated by a specialist in geriatric medicine together with a trained research nurse in terms of complications, dementia, depression and delirium. Data collected in papers I and II were analysed using comparative and descriptive statistical analysis. In papers III and IV, semi-structured interviews were performed with patients (paper III) and with staff (nurses and assistant nurses, paper IV) based on interview guides with open-ended questions that offered opportunities for clarification and follow-up questions. In paper III, 23 patients with hip fractures aged 70 years or older who were treated with FNBs were interviewed, and in paper IV, staff working in the orthopaedic ward and emergency department with experience of caring for patients with hip fractures treated with FNBs were interviewed. The interviews were audio-recorded, transcribed and analysed using qualitative content analysis. Results: The results in paper I showed that patients who received an FNB assessed lower pain scores over a period of 12 hours. Patients required smaller amounts of opioids and the number of patients requiring opioids was reduced compared with the group that received opioids alone. Overall, in paper II was it a high incidence of complications, common complications in both groups were pre and postoperative delirium (44% and 73%), nutritional problems (71%), anaemia (66%), constipation (64%) and urinary tract infection (45%), but no statistical difference was found between groups of those complications. The results in paper II showed that 39% of the patients who received an FNB and 49% of those who received opioids developed delirium before surgery, with no statistical difference. In paper III, patients described how the pain before surgery was experienced from no pain, to the worst possible pain and everything in between. They described how they dealt with pain in their own way, but also how they felt dependent on the staff's willingness to relieve the pain. They described that the pain treatment could be lifesaving, but that it could also create the feeling of a near-death experience. Further, some patients experienced memory loss regarding the time before surgery, which made it difficult to remember the pain and pain treatment they received.  Finally, in paper IV, the staff described that the FNB setting the agenda when caring for older patients with hip fracture in the preoperative phase. Nursing care required timing, with a need of staff orienting to time and customizing their communication. The outcome of the FNB affected nursing care, depending on if the FNB was successful or not successful. Further, staff faced ethical challenges regarding doing good and not harm and relieving pain and avoiding side-effects.     Conclusion: This thesis shows that FNB is a feasible preoperative pain management for patients with a hip fracture, even among those with dementia. Evidence-based guidelines are necessary as a basis for assessing pain and providing pain management, but staff should add an individualized pain management approach. Staff should evaluate every patient and see each patient as a unique individual with different experiences of pain and pain management to successfully relieve pain among patients with a hip fracture.