Disparities in pain management between cognitively intact and cognitively impaired nursing home residents

Pain treatment in elderly persons with and without dementia: a population-based study of institutionalized and home-dwelling elderly

BACKGROUND

Several previous studies have reported an undertreatment of pain in elderly persons with dementia. It has also been suggested that persons with dementia may be at risk for inappropriate treatment of pain with psychotropics.

OBJECTIVES

The objective of this study was to investigate if persons with dementia are as likely as persons without dementia to receive pharmacological pain treatment, after taking into account residential setting and pain-related disorders. We also aimed to investigate whether use of psychotropics is related to pain in persons with and without dementia.

METHODS

We used baseline data from the SNAC-K (Swedish National Study of Aging and Care - Kungsholmen). We analysed use of analgesics and psychotropics, prevalence of pain-related diagnoses, self-reported pain, dementia status and residential setting in 2610 participants aged > 65 years.

RESULTS

Of the persons with dementia, 46% used at least one analgesic drug compared with 25% of those without dementia. Although persons with dementia reported pain less frequently than persons without dementia, the prevalence of pain-related diagnoses was similar. After adjustment for individual factors and residential setting (own home/institution), persons with dementia had a higher probability of use of paracetamol (acetaminophen) and psychotropics, whereas there were no significant differences in use of any analgesic, opioids and NSAIDs. Furthermore, having a pain-related diagnosis was associated with use of psychotropics in persons with dementia.

CONCLUSIONS

Persons with dementia had a higher probability of use of paracetamol and were about as likely as persons without dementia to use any analgesic, opioids and NSAIDs, after adjustment for confounders. This may reflect a recent increased awareness of pain and pain management in persons with dementia, compared with previous studies that have reported an underuse of analgesics in persons with dementia. However, further research is needed to analyse if persons with dementia are appropriately treated for pain with regard to type of analgesic drug, pain intensity, indication, dosage and regimen.

Non-verbal cues to osteoarthritic knee and/or hip pain in elders

Behavioral cues are believed to be useful to identify pain among elders who may be experiencing pain but unable to express it. To examine this assumption, we recruited 192 elders who could verbally express pain to determine whether regression models combining behavioral cues (motor and gait patterns) predicted verbal pain reports. In the best model, age (p < .01) and subscales that measured guarding (p < .001) and joint flexion (p < .01) motor patterns were significant predictors of verbal pain reports. The receiver operating characteristic curve indicated that the best cutoff for predictive probability was 40-44%, with a fair to good C statistic of .78 (SD = .04). With a 40% cutoff, sensitivity and specificity were 71.6% and 71.0%, respectively. The investigators concluded that the final model could serve as a building block for the development of a tool using behavioral cues to identify elders' pain.

Drug utilization in Belgian nursing homes: impact of residents' and institutional characteristics

PURPOSE

This study aims to investigate drug utilization in Belgian nursing homes in relation to the characteristics of residents and the institution.

METHODS

A cross-sectional study design was used. A total of 2510 residents were randomly selected from a stratified random sample of 76 Belgian nursing homes with at least 30 beds, including high-intensity care beds. Data collection was based on medical chart review supplemented with clinical information from general practitioners (GPs)

RESULTS

The residents included had a mean age of 85 and 77% were female. They presented a median of 2 clinical problems (range 0-10), three care problems (range 0-10) and 48% had dementia. Their medical consumption amounted to a mean of 8.4 prescriptions including 7.1 for chronic treatment. Mean expenditure per month for chronic medication was 140 EUR (SD 125), including 53 EUR out-of-pocket payment.This study confirmed that multiple comorbidity was associated with polypharmacy. After peaking in the seventh decade, medical consumption decreased in older age groups. In palliative care, the number of prescriptions decreased while expenditure increased. A marked decrease in prescriptions, particularly of pain-relieving medication, was observed with increasing dementia. Larger public institutions, with an active coordinating physician and served by hospital pharmacists, had lower consumption and expenditure.

CONCLUSION

A high level of drug utilization, influenced by the characteristics of residents and the institution, was observed in Belgian nursing homes. There is a need to develop a comprehensive monitoring system of prescribing quality for nursing home residents.

Nausea and other nonpain symptoms in long-term care

There is a need to improve the quality of end-of-life care in nursing homes by improving the timely assessment and management of various sources of suffering. Much of the research/discussion in this area has focused on the assessment and treatment of pain. This article reviews the frequency and management of nonpain symptoms in the long-term care setting, particularly focusing on patients at the end of life. Although the long-term care setting presents challenges to effective management, an approach for addressing these challenges is discussed and applied to 3 commonly encountered nonpain symptoms.

Challenges in pain assessment in cognitively intact and cognitively impaired older adults with cancer

PURPOSE/OBJECTIVES

To describe approaches to pain assessment in cognitively intact and cognitively impaired older adults with cancer.

DATA SOURCES

MEDLINE literature search, personal reference collection, and clinical experience.

DATA SYNTHESIS

A systematic and comprehensive pain assessment is the cornerstone of effective treatment strategies. Determining the effect of pain on older adults' ability to function is as important as rating pain intensity. Evidence-based recommendations exist to guide practice.

CONCLUSIONS

The undertreatment of pain in older adults persists despite a plethora of published guidelines addressing pain assessment and management. Unrelieved pain affects recovery from illness and all aspects of life. Systematic and ongoing assessment is elementary to effective pain management, yet assessments frequently are neither completed nor documented. Because pain is subjective and individual responses to pain interventions vary widely and are unpredictable, assessment is vital to comprehensive pain care in all clinical settings. Reliable and validated pain assessment tools for cognitively intact and cognitively impaired older adults are available to guide practice.

IMPLICATIONS FOR NURSING

Pain assessment is a core competency for nurses in all clinical settings. Comprehensive, individualized, and ongoing assessment provides the information necessary so that clinicians can develop interventions to relieve patients' pain and improve their quality of life. Nurses have the knowledge, skills, and tools to adequately screen and comprehensively assess pain in older adult patients, including those with cognitive impairment. By using this knowledge, nurses can change systems and practices, have a significant effect on improving pain care, and increase quality of life and function of older adults with pain.

Psychological treatment of chronic pain

Psychological treatment has emerged as a common component of a multidimensional and interdisciplinary plan of pain care for many persons with persistent pain. Treatments are informed by a biopsychosocial model of pain and a long history of psychological research that has identified the central role of behavioral, cognitive, and emotional factors that are believed to contribute to the perpetuation, if not the development, of chronic pain and pain-related disability and emotional distress. Empirically supported self-regulatory, behavioral, cognitive-behavioral, and acceptance and commitment interventions are reviewed, and current and future interventions are highlighted. Important issues related to individual differences and disparities in the experience of pain and pain treatment are discussed. In particular, race and ethnicity are considered, and special considerations for the management of pain in children and older adults are discussed.

The epidemiology of pain during the last 2 years of life

BACKGROUND

The epidemiology of pain during the last years of life has not been well described.

OBJECTIVE

To describe the prevalence and correlates of pain during the last 2 years of life.

DESIGN

Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status.

SETTING

The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006).

PARTICIPANTS

Older adult decedents.

MEASUREMENTS

Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity.

RESULTS

The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195).

LIMITATION

Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available.

CONCLUSION

Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life.

PRIMARY FUNDING SOURCE

National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.

Is pain assessment feasible as a performance indicator for Dutch nursing homes? A cross-sectional approach

Quality of care gains transparency with the help of performance indicators. For Dutch nursing homes, the current set of performance indicators does not include pain. To determine the feasibility of pain assessment as performance indicator, information about pain prevalence and analgesic prescription in one nursing home was collected. Within the time span of 3 days, pain intensity was measured in 91% of the residents (201 out of 221), either with a numeric rating scale, a verbal rating scale, or the Rotterdam Elderly Pain Observation Scale (REPOS). Numerical rating was used for 72%, verbal rating for 3%, and REPOS observation for 25% of the residents. Pain was substantial in 65 residents (32%), who received the following analgesic prescription: World Health Organization (WHO) step 1, 45%; WHO step 3, 12%; and neuroactive agents, 5%. Thirty-eight percent of these residents were in pain and received no analgesics. Residents with substantial pain significantly more often received analgesics (p = .007). Results suggest that pain assessment is feasible in a nursing home and would stimulate staff attention to pain. Further investigation is necessary to find out if a pain algorithm is feasible and will lead to improved pain treatment.

Practice guidelines for assessing pain in older persons with dementia residing in long-term care facilities

PURPOSE

Frail patients with dementia most frequently present with musculoskeletal pain and mobility concerns; therefore, physiotherapy interventions for this population are likely to be of great benefit. However, physiotherapists who work with older adults with dementia confront a considerable challenge: the communication impairments that characterize dementia make it difficult to assess pain and determine its source. For an effective physiotherapy programme to be implemented, valid pain assessment is necessary. This paper is intended to provide practice guidelines for pain assessment among older persons with dementia.

SUMMARY OF KEY POINTS

Over the last several years, there has been tremendous research progress in this area. While more research is needed, several promising assessment methodologies are available. These methodologies most often involve the use of observational checklists to record specific pain behaviours.

RECOMMENDATIONS

We encourage the ongoing and regular evidence-based pain assessment of older persons with dementia, using standardized procedures. Without regular and systematic assessment, pain problems will often go undetected in this population. Given the need for systematic pain assessment and intervention for long-term care populations with mobility concerns and muculoskeletal pain problems, we call for increased involvement of physical therapists in long-term care facilities.

Frequency and type of chronic pain care approaches used for elderly residents in Japan and the factors influencing these approaches

AIM

To assess the frequency at which various chronic pain care (CPC) approaches were used while managing older residents of the Health Service Facilities for the Elderly Requiring Care (HSFERC) in Japan and to assess the factors related to nurses and care workers that influence this care.

METHODS

A descriptive study design was used. The population comprised 31 nurses, 92 care workers, and 18 residents with chronic pain in eight HSFERC centers located in three provincial cities in Japan. A questionnaire was formulated by using the data collected by a literature review to assess the frequencies at which various CPC approaches were applied and the factors that might influence this care.

RESULTS

The most frequently preferred CPC approaches were gentle handling and support while providing daily care, listening attentively, and providing a recreational activity. The factors that affected the provision of CPC were the qualifications, years of experience of aged care, and experience of studying about chronic pain. The nurses tended to have a misconception regarding the manner in which the residents complained of pain and their pain sensitivity. Furthermore, organizational strategies for pain management were not reported by the nurses and care workers.

CONCLUSIONS

In order to provide effective and active CPC, ongoing education about pain and cooperation between nurses and care workers to manage residents' pain are highly recommended.

Racial and ethnic disparities in pain: causes and consequences of unequal care

The purpose of our review is to evaluate critically the recent literature on racial and ethnic disparities in pain and to determine how far we have come toward reducing and eliminating disparities in pain. We examined peer-reviewed research articles published between 1990 and early 2009 that focused on racial and ethnic disparities in pain in the United States. The databases used were PubMed, Medline, Scopus, CINAHL, and PsycInfo. The probable causes of minority group disparities in pain are discussed, along with suggested strategies for eliminating pain-related disparities. This review reveals the persistence of racial and ethnic disparities in acute, chronic, cancer, and palliative pain care across the lifespan and treatment settings, with minorities receiving lesser quality pain care than non-Hispanic whites. Although health and health care disparities attract local, state, and federal attention, disparities in pain care continue to be missing from publicized public health agendas and health care reform plans. Ensuring optimal pain care for all is critically important from a public health and policy perspective. A robust research program on disparities in pain is needed, and the results must be successfully translated into practices and policies specifically designed to reduce and eliminate disparities in care.

PERSPECTIVE

This review evaluates the recent literature on racial and ethnic disparities in pain and pain treatment. Racial and ethnic disparities in acute pain, chronic cancer pain, and palliative pain care continue to persist. Rigorous research is needed to develop interventions, practices, and policies for eliminating disparities in pain.

Pain in European long-term care facilities: cross-national study in Finland, Italy and The Netherlands

There have been very few and limited cross-national comparisons concerning pain among residents of long-term care facilities in Europe. The aim of the present cross-sectional study has been to document the prevalence of pain, its frequency and severity as well as its correlates in three European countries: Finland (north), Italy (south) and the Netherlands (western central). Patients (aged 65years or above) were assessed with the Minimum Data Set 2.0 (MDS).The final sample comprised 5761 patients from 64 facilities in Finland, 2295 patients from 8 facilities in the Netherlands and 1959 patients from 31 facilities in Italy. The prevalence of pain - defined as any type of pain - varied between 32% in Italy, 43% in the Netherlands and 57% in Finland. In nearly 50% of cases, pain was present daily; there were no significant differences in pain prevalence between patients with cancer diagnosis and those with non-cancer diagnosis. Regardless of the different prevalence estimates, pain was moderate-to-severe in over 50% of cases in all the countries. In multivariate logistic regression models, clinical correlates of pain were substantially similar across countries: pain was positively correlated with more severe physical disability (ADL impairment), clinical depression and a diagnosis of osteoporosis. Pain was negatively correlated with a diagnosis of dementia and more severe degrees of cognitive deterioration. We conclude that pain is frequently encountered in long-term care facilities in Europe and that, despite cultural and case-mix differences, pain speaks one language.

Paramedic assessment of pain in the cognitively impaired adult patient

Background

Paramedics are often a first point of contact for people experiencing pain in the community. Wherever possible the patient's self report of pain should be sought to guide the assessment and management of this complaint. Communication difficulty or disability such as cognitive impairment associated with dementia may limit the patient's ability to report their pain experience, and this has the potential to affect the quality of care. The primary objective of this study was to systematically locate evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults and to identify those that have been recommended for use by paramedics.

Methods

A systematic search of health databases for evidence relating to the use of pain assessment tools that have been validated for use with cognitively impaired adults was undertaken using specific search criteria. An extended search included position statements and clinical practice guidelines developed by health agencies to identify evidence-based recommendations regarding pain assessment in older adults.

Results

Two systematic reviews met study inclusion criteria. Weaknesses in tools evaluated by these studies limited their application in assessing pain in the population of interest. Only one tool was designed to assess pain in acute care settings. No tools were located that are designed for paramedic use.

Conclusion

The reviews of pain assessment tools found that the majority were developed to assess chronic pain in aged care, hospital or hospice settings. An analysis of the characteristics of these pain assessment tools identified attributes that may limit their use in paramedic practice. One tool - the Abbey Pain Scale - may have application in paramedic assessment of pain, but clinical evaluation is required to validate this tool in the paramedic practice setting. Further research is recommended to evaluate the Abbey Pain Scale and to evaluate the effectiveness of paramedic pain management practice in older adults to ensure that the care of all patients is unaffected by age or disability.

Pain management interventions in the nursing home: a structured review of the literature

Residents in nursing homes (NHs) experience pain that is underrecognized and undertreated. This pain contributes to a decline in quality of life. Although descriptive studies of pain assessment and management have been conducted, few have been published that critically evaluate interventions to improve pain management. Identification of the strengths and gaps in the current literature is required. A literature search was conducted of clinical trials that evaluated prospective interventions to improve pain management. Information on the intervention type, resident sample and setting, endpoints, and study design were extracted. Studies were classified based on a modification of Donabedian's model of healthcare quality. Four categories of interventions were identified: actor, decision support, treatment, and systems. The search strategy and selection criteria yielded 21 articles. Eleven studies used an actor intervention; of these, eight also employed a systems intervention, and one also used a treatment intervention. Two studies used a decision support intervention, seven used a treatment intervention, and one used a systems intervention. The overall quality of research was uneven in several areas: research design--nine studies were quasi-experimental in nature, endpoints measures were not consistent--three did not perform statistical analysis, and characteristics of the resident samples varied dramatically. In conclusion, the number of high-quality studies of pain management in NHs remains limited. Process endpoints are used as surrogate measures for resident endpoints. Systematic approaches are needed to understand how each type of intervention improves the quality of pain management at the resident level.

Healthcare proxies of nursing home residents with advanced dementia: decisions they confront and their satisfaction with decision-making

OBJECTIVES

To describe the medical decisions confronting healthcare proxies (HCPs) of nursing home (NH) residents with advanced dementia and to identify factors associated with greater decision-making satisfaction.

DESIGN

Prospective cohort study.

SETTING

Twenty-two Boston-area NHs.

PARTICIPANTS

Three hundred twenty-three NH residents with advanced dementia and their HCPs.

MEASUREMENTS

Decisions made by HCPs over 18 months were ascertained quarterly. After making a decision, HCPs completed the Decision Satisfaction Inventory (DSI) (range 0-100). Independent variables included HCP and resident sociodemographic characteristics, health status, and advance care planning. Multivariable linear regression identified factors associated with higher DSI scores (greater satisfaction).

RESULTS

Of 323 HCPs, 123 (38.1%) recalled making at least one medical decision; 232 decisions were made, concerning feeding problems (27.2%), infections (20.7%), pain (12.9%), dyspnea (8.2%), behavior problems (6.9%), hospitalizations (3.9%), cancer (3.0%), and other complications (17.2%). Mean DSI score +/- standard deviation was 78.4 +/- 19.5, indicating high overall satisfaction. NH provider involvement in shared decision-making was the area of least satisfaction. In adjusted analysis, greater decision-making satisfaction was associated with the resident living on a special care dementia unit (P=.002), greater resident comfort (P=.004), and the HCP not being the resident's child (P=.02).

CONCLUSION

HCPs of NH patients with advanced dementia can most commonly expect to encounter medical decisions relating to feeding problems, infections, and pain. Inadequate support from NH providers is the greatest source of HCP dissatisfaction with decision-making. Greater resident comfort and care in a special care dementia unit are potentially modifiable factors associated with greater decision-making satisfaction.

Transforming long-term care pain management in north america: the policy-clinical interface

BACKGROUND

The undertreatment of pain in older adults who reside in long-term care (LTC) facilities has been well documented, leading to clinical guideline development and professional educational programs designed to foster better pain assessment and management in this population. Despite these efforts, little improvement has occurred, and we postulate that focused attention to public policy and cost implications of systemic change is required to create positive pain-related outcomes.

OBJECTIVE

Our goal was to outline feasible and cost-effective clinical and public policy recommendations designed to address the undermanagement of pain in LTC facilities.

METHODS

We arranged a 2-day consensus meeting of prominent United States and Canadian pain and public policy experts. An initial document describing the problem of pain undermanagement in LTC was developed and circulated prior to the meeting. Participants were also asked to respond to a list of relevant questions before arriving. Following formal presentations of a variety of proposals and extensive discussion among clinicians and policy experts, a set of recommendations was developed.

RESULTS AND CONCLUSIONS

We outline key elements of a transformational model of pain management in LTC for the United States and Canada. Consistent with previously formulated clinical guidelines but with attention to readily implementable public policy change in both countries, this transformational model of LTC has important implications for LTC managers and policy makers as well as major quality of life implications for LTC residents.

Pain in patients living in Norwegian nursing homes

The aims of this study were to describe the pain and use of pain medication in nursing home patients and examine which variables that were associated with pain. Inpatients (n = 307) older than 64 years from nursing homes were included. Pain was measured with a 4-point verbal rating scale in the self-reported group (SRG) and Doloplus-2 in the proxy-rated group (PRG). The mean age was 86 years (SD, 7), and more than two-thirds were female. A total of 128 (60%) patients were able to self-report their pain. Approximately 50% of the SRG reported 'pain now', and of these, nearly 50% reported moderate or severe pain intensity. Better cognitive function was associated with higher pain and receiving more potent pain medication in the SRG. The pain prevalence in the PRG was higher than in the SRG (67.5% vs 51%), but no variable was associated with proxy-rated pain. Nearly 30% in the SRG and 40% in the PRG did not receive pain medication in spite of pain. Pain is still a huge problem in the nursing homes, and more research is needed on pain management in nursing home residents.