A randomised control trial: Improving analgesic administration time for the cognitively impaired older persons

Prof. Margaret Fry1,2, Professor Lynn Chenoweth3, Professor Glenn Arendts4

1University Of Technology Sydney, Broadway, Australia; 2Northern Sydney Local Health District, St Leonards, Australia; 3University of New South Wales, Randwick, Australia; 4University of Western Australia, Perth, Australia

Introduction: Unless pain is recognised and attended to early in the patient’s journey, inadequate and inappropriate pain relief for people with cognitive impairment may result in adverse events, hospital readmissions, increased functional decline, cognitive decline, behavioural changes and co-morbid mental illness.  The aim of the study was to measure the impact of an observational pain assessment tool on analgesic administration time for cognitively impaired patients in the Emergency Department (ED).

Methods: An 18-month multi-site cluster controlled randomised trial was conducted in eight Sydney EDs. Sites (n=4) were randomised to receive the intervention. The intervention tested was the Pain Assessment in Advanced Dementia (PAINAD) tool. For the intervention sites patients, aged 65 years or older, suspected of a long bone fracture and with a confirmed cognitive impairment were screened for pain using the PAINAD. The primary outcome was time to first dose of analgesia.

Results: We enrolled 602 patients with 323 (54%) recruited from intervention and 279 (46%) non-intervention sites respectively. The medium time to analgesia was 82 minutes (IQR 45-151 minutes); intervention sites 83 (IQR 48-158 minutes) and non-intervention 82 minutes (IQR 41-147 minutes) respectively (p=.414). ED analgesia was provided to 180 (30%) patients within 60 minutes of being triaged. After adjusting for age, fracture type, arrival mode and triage category in a Cox regression model, there was no significant difference in time to analgesia between the two groups (HR 0.97, 95% CI 0.80-1.17, p 0.74).

Conclusion: While there was a small clinical trend that suggests PAINAD may improve analgesic administration time, improving practice is more complicated than the introduction of a tool. While PAINAD is a reliable and valid tool, socio-cultural, organisational and role factors may have a greater impact on ED pain management practice.


Professor Fry is Director of Research and Practice Development for Northern Sydney Local Health District and holds a Professorial Chair position with the University of Technology Sydney. Professor Fry has a strong emergency care background, has held CNC positions and is an authorised Nurse Practitioner (NSW). Professor Fry has extensive senior nursing experience and a proven research track with 118 peer reviewed publications and over $2.2million in grant, research tenders and or scholarship funding. Her program of research has led to significant state and national practice change. She was awarded Australasian emergency nurse of the year in 2005 and St George Hospital nurse of the year in 2001 and was a finalist in 2014 Nursing Excellence Awards for ‘Innovation in Research”. Professor Fry has also been awarded NSW Heath Care awards for innovative research making a difference for practice.