A more nuanced approach to pain management may be warranted in older patients who are hospitalized for rib fractures, according to the results of a study published in JAMA Surgery.

Compared with younger patients with rib fractures, geriatric patients (≥65 years of age) were almost 4 times more likely to report no pain, and when they did report pain, their pain scores were much lower than their younger counterparts. This finding supports the theory that geriatric patients may underreport pain and may require a lower threshold to escalate analgesic care, reported the authors.

The research team evaluated adult patients admitted for ≥4 days with isolated chest wall injuries at a level I trauma center; patients were divided into geriatric (≥65 years) and nongeriatric (18-64 years) age groups. The primary outcome was comparison of numerical rating scale pain scores during hospitalization, taken in 12-hour increments. Data analysis was conducted from June to December 2019.

A total of 385 patients were included in the study; 166 of whom were ≥65 years of age. The geriatric group had more women compared with the nongeriatric group (53% vs 18%). Older patients suffered more falls and less motorcycle or bicycle injuries than younger patients (falls: 60.2% vs 20%; motorcycle crash: 2.4% vs 21%; and bicycle crashes: 7.8% vs 20.5%, respectively), and had lower injury severity scores (10.4 vs 14, respectively).  The geriatric group received fewer opioids per day (oral morphine equivalents: 75.5 mg vs 177.1 mg for nongeriatric patients) but had similar rates of epidural nerve block use as the nongeriatric group.


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The adjusted odds ratio for reporting no pain was 3.85 times higher (95% CI, 3.11-4.77) in the geriatric group compared with the nongeriatric group. Among patients with a pain score ≥1, scores were 15% lower in the geriatric group compared with the nongeriatric group. Patients with isolated rib fractures showed similar results of pain severity.

“Whether lower reported pain scores among geriatric patients reflect underreported pain or truly less pain remains unclear,” stated the authors. “In light of prior knowledge that geriatric patients under report pain and patient-reported pain scores often dictate rib fracture analgesic management, it may be prudent to consider a lower pain score threshold for geriatric patients with rib fractures or place heavier weight on functional measures, such as incentive spirometry volumes, to escalate analgesic care.”

Reference

Choi J, Khan S, Zamary K, et al. Pain scores in geriatric vs nongeriatric patients with rib fractures [published online July 1, 2020]. JAMA Surg. doi:10.1001/jamasurg.2020.1933.

This article originally appeared on Clinical Advisor