Commentary: ways of talking about experiences of pain among older patients following orthopaedic surgery

Abstract

On reading this paper, four questions occurred to me, some of which might be beyond the intended scope of the paper, but nevertheless would be worth examination: 1. Was any of the pain described due to preexisting chronic painful conditions? 2. Was there a difference between pain expression in those who had elective and those who had emergency surgery? 3. Were there differences in pain expression according to level of cognitive impairment? 4. How could the ideas generated by the authors be developed and/or contribute to a structured approach to pain assessment in day-to-day nursing practice? Each of these is considered below. 1. The UK Office for National Statistics Social Trends Dataset (1996–97) indicated that pain or discomfort was reported by half of over 65-year olds, rising to 56% of women and 65% of men over 75 years of age in the general population. Assuming that this situation is similar in Sweden, pain due to surgery is likely to have been superimposed on chronic pain for a substantial proportion of those undergoing hip surgery. This has important implications for the assessment of pain, as there is a risk of nurses only considering pain due to surgery and omitting to take other types of pain into account. 2. Those who underwent elective surgery were likely to have been suffering moderate to severe chronic pain prior to surgery, while those receiving hip repair following traumatic fracture may or may not have had chronic hip pain. As a result, their respective perceptions of postoperative pain would be likely to differ. While elective hip replacement may be viewed as a pain-relieving intervention (despite experiencing postoperative pain), the pain of hip fracture and repair may simply be experienced as acutely painful. This difference may have influenced how patients experienced and reported their pain and it would be interesting to know whether they expressed clear or subtle differences of any kind. The scores from the Verbal Numerical Rating Scale (VNRS), which are not reported here, might also illuminate this point. 3. As with many other hospital populations, older people with hip fracture have high rates of psychiatric illness. A systematic review has indicated prevalence rates for this group of 9–47% for depression, and 43–61% for delirium and 31–88% for unspecified cognitive impairment including dementia and delirium (Holmes & House 2001). These figures clearly illustrate a major problem for the assessment of pain in hip fracture patients. Depression is thought to interact with pain, and cognitive impairments influence how pain may be communicated. The authors used the Mini-Mental State Examination (MMSE) to assess cognitive status, but no mention is made of their findings. This instrument can be used to divide participants into four groups: those with no cognitive impairment, and those with mild, moderate or severe impairment. Several studies have shown that even those with moderate impairment are able to use simple pain scales and express pain verbally (e.g. Chibnall & Tait 2001). However, I am not aware of any work which has examined specific characteristics or nuances of verbal expression which might be uncovered at each level. It would be fascinating to undertake some additional analysis of the data from this study (assuming that the authors have not already done so) with this question in mind. It might be possible to identify some commonly occurring patterns which could be developed for diagnostic use. 4. At least 12 observational instruments have been developed which aim to assess pain in older people with cognitive impairments. The contents vary, but these instruments tend to take note not only of verbal communication, but also paralinguistic language, facial actions, movement/body position, mood and temper, activities of daily life and physiological responses, in various combinations. They have highly varied psychometric properties, and it is not yet clear which aspects of the variables they assess are of greatest clinical utility.