Hip Fractures: Pain Meds And Pain Intensity Scores
Overview
Following proximal femoral fractures (PFF), pain is a prevalent symptom, yet there is limited information regarding effective treatment options, including the types of medications used and their administration methods (scheduled versus as needed). This study aimed to analyze pain medication regimens based on pain severity following PFF and to assess the implementation of medication plans.
The research was part of the “ProFem” study, which examines healthcare access, functional ability, and quality of life post-PFF, using data from Germany’s statutory health insurance alongside linked survey data collected at various intervals, focusing on medication use. This particular analysis utilized baseline interviews conducted approximately three months post-fracture, from 2018 to 2019, in participants’ homes.
The study included 444 participants with an average age of 81.2 years, of whom 71.0% were female. Half of the participants reported experiencing high-intensity pain, with a mean score of 50.8 on the EuroQol visual analogue scale. The most frequently prescribed analgesics were metamizole and tilidine/naloxone. Among those experiencing severe pain, 21.9% received only as-needed (PRN) pain medication, while 17.2% reported receiving no pain relief whatsoever. Notably, 61.5% of participants had access to any form of printed medication plan, yet only 25.2% adhered to a standardized federal medication plan.
In conclusion, a significant portion of patients continue to report severe pain three months after sustaining a PFF, and the high incidence of individuals receiving no medication or only PRN treatment raises concerns about the adequacy of pain management strategies. Additionally, the low engagement with standardized medication plans suggests there is considerable room for improvement in managing pain following PFF.
Introduction
Proximal femoral fractures (PFF) are a common type of fracture in older adults and are associated with significant risks, including increased mortality, permanent disabilities, care dependency, and potential institutionalization. Research indicates that many patients regain walking abilities and independence in daily activities within six months post-discharge. A recent Norwegian study highlighted that the most substantial improvements in health-related quality of life (HRQoL) and function occur within the first three months after a hip fracture, underscoring the importance of this initial recovery period.
Pain is a prevalent symptom following PFF, which can hinder recovery, mobility, functioning, and overall quality of life. Effective pain management is essential for enhancing mobility and maintaining independence; however, treating pain in frail older adults presents challenges due to physiological changes, multiple comorbidities, and polypharmacy. Some studies suggest that individuals with cognitive impairments may experience undertreatment following fractures.
Pain management must be tailored to each patient, considering the specific indications, effectiveness, and tolerability of treatments. The analgesic options include various drug classes categorized by the World Health Organization’s pain ladder. Treatment regimens can involve scheduled medication, administered regularly regardless of pain levels, or pro re nata (PRN) medication, which patients can take as needed, or a combination of both. Despite the complexity of pain medication schedules in PFF cases, little research has been conducted on this aspect. Previous studies have either covered broad timeframes or concentrated exclusively on opioid usage.
Given the variability of pain conditions and their potential fluctuations, clear guidance for patients is crucial to ensure effective and safe pain management. Information regarding dosages and schedules can be provided on medication packages or through patient-owned medication lists. In Germany, the federal standardized medication plan (Bundeseinheitlicher Medikationsplan, BMP) was established in 2016, entitling individuals with statutory health insurance who use multiple systemic drugs to have an up-to-date medication plan. Early studies indicate that there is room for improvement in the BMP’s availability and accuracy. However, the application of the BMP in managing specific pain conditions, such as post-fracture pain, has not yet been explored.
This study aims to assess pain medication regimens concerning scheduling and the types of agents used based on pain intensity approximately three months after a PFF. Additionally, it seeks to investigate whether the BMP or other medication plans are utilized in this patient population.
Method
The “ProFem” study is a population-based prospective cohort investigation that focuses on healthcare provision, functional ability, and quality of life following proximal femoral fractures (PFF). Conducted in North Rhine-Westphalia, Germany, between January 2018 and September 2019, the study targeted individuals aged 60 and above who had been continuously insured for at least one year with AOK Rheinland/Hamburg and had experienced a PFF. The inclusion criteria were defined using specific ICD-10 codes for various types of femoral fractures, supplemented by surgical and procedural classifications.
Out of 2,866 invited individuals with PFF, 2,819 were eligible for the survey, with the primary reasons for exclusion being incomplete insurance data and absence of a PFF during the relevant period. Ultimately, 515 participants agreed to participate in baseline interviews, with 444 providing additional medication information.
The data collection involved three main phases post-hospital discharge: at 3 months (baseline), 6 months, and 12 months. For participants unable to be interviewed at the baseline, substitute visits were arranged. The structured questionnaire included 85 items, covering patient demographics, medication usage, and health status. For those unable to participate due to health conditions, proxy interviews were conducted, although pain assessments were not included when proxies provided information.
Medication reconciliation was performed in three stages: photographing medication plans or current medications, electronically recording this data, and validating it through a secondary review of a random sample. Pain management was categorized according to WHO guidelines, utilizing specific ATC codes for analysis. Pain intensity was measured using the von Korff grading system, providing a numerical scale from 1 (no pain) to 5 (worst pain imaginable).
Additional variables assessed included self-rated health status through the EQ-5D visual analogue scale, activities of daily living via the Oxford Hip Score, and subjective social status on a 10-point scale. Participant characteristics were also recorded, including age, sex, duration of hospital stay, and care dependency status.
Statistical Analysis
Descriptive statistics were applied to summarize demographics and patient-reported outcomes, stratified by data source (proxy or participant) and pain intensity levels. The analysis included a review of overall medication use, types of pain medication, and the eligibility for medication management plans. The study adhered to ethical standards and received approval from the appropriate ethics committee, with all participants providing written informed consent. Statistical analyses were conducted using SAS software, Version 9.4.
Result
The study involved 444 participants with a mean age of 81.2 years, predominantly female (71.0%). A significant portion (41.2%) of the participants had no care grade, while 51.9% were classified as normal weight (BMI: 18.5–<25 kg/m²). More than half (54.5%) identified as having a medium social status, with mean self-assessment on a social ladder scoring 5.0. The average hospital stay following a proximal femoral fracture (PFF) was 22 days, with an average of 102.1 days since discharge; 84.9% of interviews occurred more than three months post-discharge. For 92.4% of patients, this incident was their first hip fracture. The mean scores on the EQ VAS and OHS were 50.8 and 20.2, respectively.
Data from 140 participants were collected primarily through proxies, who were generally older (mean age: 85.7 vs. 79.2 years) and had higher care grades (63.6% vs. 19.1%) compared to those responding directly. Participants surveyed through proxies reported lower scores on the EQ VAS and OHS (mean values: 40.4 vs. 55.5 and 15.0 vs. 22.6, respectively).
Among the 304 self-respondents, 50.3% reported no or minor pain, while 49.7% experienced high pain intensity. Those with high pain levels were more frequently female (72.9% vs. 67.3%), had higher care grades (22.6% vs. 15.7%), and a BMI of 25 or above (44.9% vs. 40.5%). Additionally, participants reporting high pain intensity often identified with low social status (30.7% vs. 16.8%) and had a higher likelihood of previous fracture incidents (8.8% vs. 4.7%). Pain severity was associated with significantly lower EQ VAS (48.2 vs. 62.8) and OHS scores (17.4 vs. 27.7).
Regarding medication, 73.6% of participants reported having a medication plan, with the primary reason for lacking one being minimal medication usage. Among those surveyed, 61.5% presented any medication plan, while 25.2% provided a basic medication plan (BMP). On average, participants were prescribed eight medications, with 86.0% taking at least three scheduled medications. Analgesics constituted five of the ten most frequently used PRN medications, alongside macrogol and salbutamol. Pantoprazole was the leading scheduled medication, with six of the top ten medications relating to cardiovascular conditions.
Three months post-PFF, 75.9% of participants reported using pain medication. Among those with specified usage, 43.5% utilized at least one PRN analgesic, while 49.2% used at least one scheduled pain medication. The majority of participants (41.2%) were treated with only non-opioid analgesics, 7.7% with opioids, and 27.0% with both types. Metamizole was the most prevalent analgesic, used by 54.1% of patients, followed by tilidine/naloxone (18.2%) and ibuprofen (14.6%). Notably, metamizole was more commonly utilized as a scheduled medication compared to other non-opioids. Most opioids were prescribed as scheduled medications, with nearly all being extended-release formulations.
Participants using scheduled pain medication were more likely to have a medication plan compared to those using only PRN medication or no pain medication. Those on scheduled pain medication had a higher median number of different drugs (nine) than individuals using only PRN pain medication (five). Among those without pain medication, 31.7% reported high pain intensity, with proportions rising among PRN (39.8%) and scheduled medication users (66.1%). Ultimately, 17.2% of high pain intensity patients received no pain management, while 22.1% were managed solely with PRN medication.
Conclusion
In this study, we discovered that around three months after a proximal femur fracture (PFF), 50% of participants reported significant pain intensity, which correlated with a diminished self-rated health status. Notably, nearly 40% of those experiencing high pain levels received either only “as-needed” (PRN) medication or no pain relief at all. Despite 85% of participants qualifying for a federal standardized medication plan (BMP), the actual implementation of such plans was significantly lower.
Demographically, our study population mirrored other German studies focused on hip fracture patients. The overall subjective social status was consistent with the oldest age group in the “German Health Update” (GEDA) study. Both Oxford Hip Scores (OHS) and EQ-5D Visual Analog Scale (EQ VAS) scores were relatively low, with OHS at 20.2 and EQ VAS at 50.8. In contrast, a UK cohort of hip fracture patients (mean age 83.6 years, 75% female) reported mean OHS scores of 29.1 (after 4 weeks) and 35.5 (after 4 months), along with EQ VAS values of 62.6 and 65.4 at the same intervals, respectively. A Norwegian study similarly found an EQ VAS of 64.1 three months post-surgery.
Only about 6% of participants reported no pain three months post-PFF, while half reported high pain intensity. Although pain assessment methods varied across studies, our findings suggested a high prevalence of pain. Comparatively, a Dutch study reported that around 20% of frail and 30% of non-frail patients experienced no pain or discomfort three months after hip fractures. Similarly, the Norwegian Hip Fracture Register noted that 25.3% of patients had no pain four months post-fracture, particularly among those aged 80 and older.
Individuals reporting high pain intensity in our study scored lower on OHS and EQ VAS compared to those with minor or no pain, which aligns with expectations since these patient-reported outcomes (PROs) are closely linked to pain. Moreover, the scores for those with minor pain were still lower than the averages reported in other studies, indicating a poorer health status in our cohort three months after PFF.
Among those experiencing high pain, 17.2% received no pain medication, and 22.1% were prescribed only PRN medications. Our assessment, which included over-the-counter medications like paracetamol, indicated a comprehensive overview of analgesic use. This finding aligns with other German studies, where around 18% of patients with rheumatoid arthritis and severe pain reported not receiving analgesics. Notably, 34.7% of our participants were opioid users, which is consistent with findings from similar studies at comparable time points. Most opioid users in our study opted for extended-release formulations, and approximately 81% used them on a scheduled basis, in accordance with the World Health Organization (WHO) pain management guidelines.
The predominant analgesics used were non-opioids, primarily metamizole and a combination of metamizole with tilidine/naloxone, reflecting German guidelines that advocate for the use of several non-opioids for pain management. While metamizole is effective, its association with agranulocytosis has led to restrictions in its use in several countries. Nevertheless, it remains prevalent in German studies focusing on various pain conditions.
Despite three-quarters of patients claiming to possess a medication plan, only about one in four produced a BMP. Given that 85% of participants were on three or more scheduled medications, this low percentage is concerning, especially since all had experienced a significant medical event that likely altered their treatment plans. Previous studies also reported low BMP utilization rates in hospital settings, indicating a potential gap in patient management.
The highest BMP usage was found among those on scheduled analgesic treatments. However, nearly 47% of participants using only PRN medications had neither a BMP nor any written plan. This lack of documented instructions could lead to undertreatment or inappropriate medication use, impeding recovery. Recent reviews highlight that patient involvement and shared decision-making are crucial for effective PRN medication management. Thus, employing tools like pain diaries to document PRN medication use may help clinicians assess and adjust pain management strategies, which is especially vital for improving mobility post-fracture.
The study’s strengths include the thorough drug assessment conducted in participants’ home environments, encompassing both over-the-counter medications and medication schedules. This approach allowed for in-depth analyses of pain medication and intensity. Furthermore, the study’s design enabled the inclusion of vulnerable populations, such as individuals with dementia. However, selection bias may be present, as healthier participants could have been overrepresented.
Pain assessment was general and did not differentiate between PFF-related pain and other chronic conditions, complicating our ability to link analgesic use to specific pain sources. Additionally, only 444 of the 515 participants provided medication information, although the demographic similarities suggest that this limitation does not significantly affect the overall findings.
The study highlights that a significant proportion of patients reported high-intensity pain approximately three months post-PFF, raising concerns about the adequacy of pain management, particularly for those receiving no or only PRN medications. The notably low BMP utilization underscores a need for improvements in medication management strategies for this patient population.
Pain is common after hip fractures, impacting recovery and quality of life. The “ProFem” study evaluated healthcare provision, functional ability, and quality of life following hip fractures, utilizing health insurance data and participant surveys. Data from 444 participants, with an average age of 81.2 years (71% female), revealed that half experienced significant pain, with self-rated health indicating low status. Among those in pain, 21.9% received only PRN medication, and 17.2% received no pain relief. While 61.5% had a medication plan, only 25.2% had a BMP. These findings raise questions about the adequacy of pain treatment, highlighting potential areas for improvement in medication management.
