Nursing home resident barriers to effective pain management: why nursing home residents may not seek pain medication

Pain trajectories of nursing home residents

BACKGROUND

Understanding changes in nursing home (NH) resident pain over time would provide a more informed perspective, allowing opportunities to alter the course of illness, plan care, and set priorities. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents.

METHODS

Retrospective longitudinal analysis of NH resident pain scores with a length of stay >100 days (N = 4864). Group-based trajectory modeling was applied to Minimum Data Set 3.0 assessments to identify pain trajectories. Trajectories were then characterized using unadjusted and adjusted cross-sectional associations between residents' demographic and clinical characteristics and their pain trajectory.

RESULTS

We identified four distinct trajectories: (1) consistent pain absence (48.9%), (2) decreasing-increasing pain presence (21.8%), (3) increasing-decreasing pain presence (15.3%), and (4) persistent pain presence (14.0%). Demographics of younger age and living in a rural area were associated with the persistent pain presence trajectory. Clinical variables of obesity and intact cognition were associated with being in the persistent pain presence trajectory. A smaller proportion of residents with moderately or severely impaired cognition were in any of the trajectory groups with pain.

CONCLUSIONS

We identified and characterized four pain trajectories among NH residents, including persistent pain presence which was associated with demographic characteristics (younger, female, rural) and clinical factors (obese, fracture, contracture). Moreover, residents with a diagnosis of Alzheimer's disease or dementia were less likely to be in any of the three trajectories with pain, likely representing the difficulty in evaluating pain in these residents. It is important that NH staff understand, recognize, and respond to the factors associated with the identified pain trajectories to improve mitigation of potentially persistent pain (e.g., hip fracture, contracture) or improve proxy pain assessment skills for residents at risk for under reporting of pain (e.g., Alzheimer's Disease).

A retrospective review of pain management in Tasmanian residential aged care facilities

Background

The management of pain by GPs for residents of aged care facilities (ACFs) is very common.

Aim

To measure the prevalence and assess the management of pain in ACF residents, particularly those with dementia.

Design & setting

A retrospective review of ACF residents' medical records was undertaken at five southern Tasmanian (Australia) ACFs.

Method

Data extracted included results of the most recent assessment of pain and its management, frequency and treatment of pain incidents in the previous 7 days, demographics, and medical and medication history. Univariate analysis was used to identify variables associated with increased frequency of pain episodes.

Results

The final analysis included 477 residents. At least one episode of pain in the preceding 7 days was documented in 25.6% (n = 122) of residents' notes. Pain episodes were most commonly managed by analgesics (45.5%), massage (40.7%), and heatpacks (13.8%). Residents with dementia were not less likely to have pain identified during the past week (14% versus 20%; P = 0.09), but they were much less likely to have pain identified on their most recent pain assessment (P = 0.03).

Conclusion

GPs should carefully consider the suitability of using 'as required' analgesics. Furthermore, on admission to an ACF, GPs need to ensure a patient's medical history includes all pain or potentially pain-causing conditions, to ensure that a resident's pain assessment is complete. This is especially necessary for those with dementia, to ensure that staff remain vigilant about the possibility of the resident experiencing pain.

Validation of the Rotterdam Elderly Pain Observation Scale in the Hospital Setting

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has been proven useful to assess pain in noncommunicative and cognitively impaired nursing home residents. We evaluated whether the REPOS is also reliable and valid for pain assessment in the hospital setting.

METHODS

In this prospective multicenter observational study, surgical patients were observed perioperatively at bedside and internal medicine patients were filmed during a possible painful moment and at rest. Pain behavior was assessed from the video recordings with the REPOS and the Pain Assessment Checklist for seniors with Severe Dementia-Dutch language (PACSLAC-D). Longitudinal associations between REPOS score and numeric rating scale pain ratings from observers and nurses (NRS_obs and NRS_proxy ) corrected for patients' gender were assessed with linear mixed models.

RESULTS

In total, 72 patients were included; 118 observations of surgical and 68 observations of internal medicine patients were analyzed. Interobserver reliability between the researcher and 2 other observers was good, with Cohen's kappa values of 0.71 (confidence interval [CI] 0.59 to 0.83) and 0.84 (CI 0.74 to 0.94), respectively. The intraobserver reliability of the principal investigator was good, with Cohen's kappa 0.82 (CI 0.67 to 0.91). Linear mixed modeling revealed correlation values between the REPOS and NRS_obs of 0.67 and the REPOS and NRS_proxy of 0.73. Optimal sensitivity (78%) and specificity (90%) for the detection of pain were found with a REPOS cutoff score of ≥3, using an NRS score of ≥4 as the reference value.

CONCLUSIONS

The REPOS is reliable and valid for the assessment of postoperative and chronic pain in hospital patients who cannot self-report pain.

Barriers to Optimal Pain Management in Aged Care Facilities: An Australian Qualitative Study

Up to 80% of residents in aged care facilities (ACFs) experience pain, which is often suboptimally managed. The purpose of this study was to characterize pain management in ACFs and identify the barriers to optimal pain management. This exploratory descriptive qualitative study used semistructured interviews in five Southern Tasmania, Australian ACFs. Interviewees included 23 staff members (18 nurses and 5 facility managers) and were conducted from September to November 2015. Interviews included questions about how pain was measured or assessed, what happened if pain was identified, barriers to pain management, and potential ways to overcome these barriers. Interviewees noted that there were no formal requirements regarding pain assessment at the ACFs reviewed; however, pain was often informally assessed. Staff noted the importance of adequate pain management for the residents' quality of life and employed both nonpharmacologic and pharmacologic techniques to reduce pain when identified. The barriers to optimal pain management included difficulty identifying and assessing pain, residents' resistance to reporting pain and/or taking medications, and communication barriers between the nursing staff and GPs. Staff interviewed were dedicated to managing residents' pain effectively; however, actions in a number of areas could improve resident outcomes. These include a more consistent approach to documenting pain in residents' progress notes and improving nurse-GP communications to ensure that new or escalating pain is identified and expedient changes can be made to the resident's management. Additionally, resident, family, nurse, and carer education, conducted within the facilities on a regular basis, could help improve the pain management of residents.

Measuring Family Members' Satisfaction with End-of-Life Care in Long-Term Care: Adaptation of the CANHELP Lite Questionnaire

RATIONALE

Improving end-of-life care (EOLC) in long-term care (LTC) homes requires quality measurement tools that assess families' satisfaction with care. This research adapted and pilot-tested an EOLC satisfaction measure (Canadian Health Care Evaluation Project (CANHELP) Lite Questionnaire) for use in LTC to measure families' perceptions of the EOLC experience and to be self-administered.

METHODS AND RESULTS

Phase 1. A literature review identified key domains of satisfaction with EOLC in LTC, and original survey items were assessed for inclusiveness and relevance. Items were modified, and one item was added.

PHASE 2

The revised questionnaire was administered to 118 LTC family members and cognitive interviews were conducted. Further modifications were made including reformatting to be self-administered.

PHASE 3

The new instrument was pilot-tested with 134 family members. Importance ratings indicated good content and face validity. Cronbach's alpha coefficients (range: .88-.94) indicated internal consistency.

CONCLUSION

This research adapted and pilot-tested the CANHELP for use in LTC. This paper introduces the new, valid, internally consistent, self-administered tool (CANHELP Lite Family Caregiver LTC) that can be used to measure families' perceptions of and satisfaction with EOLC. Future research should further validate the instrument and test its usefulness for quality improvement and care planning.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial

OBJECTIVE

To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.

DESIGN

A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.

SETTING

Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.

PARTICIPANTS

Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.

MEASUREMENTS

Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.

RESULTS

Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.

CONCLUSIONS

Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Managing pain medications in long-term care: nurses' views

The purpose of this study was to explore nurses' perceptions of their current practices related to administering pain medications to long-term care (LTC) residents. A cross-sectional survey design was used, including both quantitative and open-ended questions. Data were collected from 165 nurses (59% response rate) at nine LTC homes in southern Ontario, Canada. The majority (85%) felt that the medication administration system was adequate to help them manage residents' pain and 98% felt comfortable administering narcotics. In deciding to administer a narcotic, nurses were influenced by pain assessments, physician orders, diagnosis, past history, effectiveness of non-narcotics and fear of making dosage miscalculations or developing addictions. Finally, most nurses stated that they trusted the physicians and pharmacists to ensure orders were safe. These findings highlight nurses' perceptions of managing pain medications in LTC and related areas where continuing education initiatives for nurses are needed.

Older people and barriers to self-reporting of chronic pain

Too many older adults live with the negative consequences of chronic pain and its detrimental impact on quality of life. To explore this, an extended literature review was conducted to identify barriers the older person encountered in the self-reporting of their chronic pain. Four themes were found to mediate help-seeking behaviour. Attitudes such as stoicism, beliefs such as pain being a necessary part of ageing, and the external barriers generated by health professionals, all have a multidimensional relationship with the 'decision' to seek help for pain. Personality and the perceived importance of independence were found to influence these responses. The findings imply that communication between the health professional and patient needs to improve during the more comprehensive assessment of chronic pain. To achieve such improvements, it is first necessary to eradicate ageist attitudes held both by the elderly and within health care.

A mixed-methods approach to investigating the adoption of evidence-based pain practices in nursing homes

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses' judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care.

A controlled investigation of continuing pain education for long-term care staff

BACKGROUND

The underassessment and undertreatment of pain in residents of long-term care (LTC) facilities has been well documented. Gaps in staff knowledge and inaccurate beliefs have been identified as contributors.

OBJECTIVES

To investigate the effectiveness of an expert-based continuing education program in pain assessment⁄management for LTC staff.

METHODS

Participants included 131 LTC staff members who were randomly assigned to either an interactive pain education (PE) program, which addressed gaps in knowledge such as medication management, or an interactive control program consisting of general dementia education without a specific clinical focus. Participants attended three sessions, each lasting 3 h, and completed measures of pain-related knowledge and attitudes⁄beliefs before, immediately after and two weeks following the program. Focus groups were conducted with a subset of participants to gauge perception of the training program and barriers to implementing pain-related strategies.

RESULTS

Analysis using ANOVA revealed that PE participants demonstrated larger gains compared with control participants with regard to pain knowledge and pain beliefs. Barriers to implementing pain-related strategies certainly exist. Nonetheless, qualitative analyses demonstrated that PE participants reported that they overcame many of these barriers and used pain management strategies four times more frequently than control participants.

CONCLUSIONS

Contrary to previous research, the present study found that the interactive PE program was effective in changing pain beliefs and improving knowledge. Continuing PE in LTC has the potential to address knowledge gaps among front-line LTC providers.

Chronic pain: the help-seeking behavior, attitudes, and beliefs of older adults living in the community

Psychologic variables such as attitudes and beliefs may account for patients choosing not to seek treatment for pain; however, there is a dearth of empirical research to support this contention. The aim of this study was to explore the help-seeking behavior, individual characteristics, attitudes, and beliefs of older adults with chronic pain in an Irish community setting. A descriptive correlational design was used. A convenience sample of 72 older adults with chronic pain were recruited through two primary care practices. The research instruments used were a demographic questionnaire, the Level of Expressed Need Questionnaire, which measured help-seeking behavior, the Pain Attitudes Questionnaire, and the Pain Beliefs Questionnaire. Results revealed that individual characteristics associated with help-seeking behavior were female gender, increasing age, higher education, living alone, and severe pain. High levels of stoicism were reported, indicating that participants were more likely to believe they had superior pain control and courage in the face of pain and were not willing to disclose their pain to others. These attitudes were significantly associated with lower levels of expressed need for treatment. Participants had moderate age-related beliefs about the origin of pain, but those who believed pain had an organic cause were more likely to seek help.

Vulnerability in clinical research with patients in pain: a risk analysis

Some have characterized patients living with intractable pain as a vulnerable population in both clinical and research settings. Labeling the population as vulnerable, however, does not provide clarity regarding the potential risks that they face when they participate in research. Instead, research vulnerability for patients in pain is a function of an interaction between their pain conditions and elements of the research enterprise. Therefore, the identification of potential risks requires consideration not only of characteristics of patients with chronic pain, but also consideration of features of researchers, the quality of institutional oversight, and the medical/social environment within which the research is conducted. This paper provides an analysis of those risks and provides some suggestions as to how the risks might be better managed.

Unmet symptom management needs of nursing home residents with cancer

Nursing home residents living with cancer have unacceptably high percentages of unrelieved pain and other symptoms. However, residents with cancer have received relatively little attention in the literature to date. This article provides an overview of previous symptom research for residents with cancer, explores clinical and organizational factors that impede effective symptom management, and proposes an agenda for future research and clinical practice. Residents with cancer have numerous symptoms that tend to be different from the symptoms of other nursing home residents. Symptom management for residents with cancer is often complicated by cognitive impairment, declining physical functioning, and comorbid illnesses. Barriers to symptom management include underuse of analgesics and hospice, nursing home staffing patterns, and lack of resources. Additional research is necessary to provide a more comprehensive understanding of residents with cancer, explore how organizational factors affect the care of residents with cancer, and evaluate interventions for effective symptom assessment and management. Collaboration of oncology nurses with clinicians and researchers in nursing home settings is needed to improve care for residents with cancer.

Opiates and elderly: use and side effects

The evaluation of pain and the subsequent issue of pain control is a clinical challenge that all healthcare providers face. Pain in the elderly population is especially difficult given the myriad of physiological, pharmacological, and psychological aspects of caring for the geriatric patient. Opiates are the mainstay of pain treatment throughout all age groups but special attention must be paid to the efficacy and side effects of these powerful drugs when prescribing to a population with impaired metabolism, excretion and physical reserve. In a random chart review of 300 US veterans, 44% of those receiving an analgesic also received opioids. The increasing use of opiates for pain management by healthcare practitioners requires that those prescribing opioids be aware of the special considerations for treating the elderly. This article will address the precautions one must take when using opiates in the geriatric population, as well as the side effects and ways to minimize them.

The pain of residents with terminal cancer in USA nursing homes: family members' perspectives

Cancer pain continues to be poorly treated despite efforts aimed at improvement. This causes considerable distress to both patients and their families. The purpose of this research is to explore the perspectives of family members of nursing home residents with terminal cancer, about pain and pain management. Participants who believed their pain could be better managed viewed their family member's pain and illness differently than those who believed the pain could not be managed better. The family members who believed better pain management was possible often took on the role of advocate and saw to it that the pain was addressed. Those who believed that their relative did not have adequate pain relief, but felt better management was not possible, expressed no concerns about this aspect of their relatives' care; they could not separate their relatives' pain from their illness. The interpretation and presence of adequate pain management is critical for family members to construct meaning around their relative's pain. When family members do not believe that the pain can be managed any better, this acts as a barrier to the resident's access to adequate pain management.

Efficacy of the World Health Organization Analgesic Ladder to Treat Pain in End-Stage Renal Disease

Pain is the one of the most common symptoms experienced by patients with ESRD; it impairs their quality of life and is undertreated. Most pain clinicians believe that the pain management approach of the World Health Organization (WHO) three-step analgesic ladder is applicable to the treatment of patients with ESRD, but this approach has not been validated for them. A cohort of 45 hemodialysis patients were assessed for type and severity of pain using the Short-Form McGill Pain Questionnaire and then treated during a 4-wk period according to the WHO analgesic ladder. Mean age was 65 +/- 12.5 yr, and 22 (49%) patients had diabetic nephropathy as the cause of ESRD. Initial pain was rated severe by 34 (76%) patients. There was no difference in initial pain rating by gender, age, race, or type of pain. Forty percent of patients reported nociceptive pain, 31% neuropathic, and 29% both. Adequate analgesia was achieved in 43 (96%) of 45 patients. The mean pain score decreased from 7.8 +/- 1.2 to 1.6 +/- 1.3 (P < 0.001). Patients who were 65 yr and older had higher posttreatment scores than those who were younger than 65 (2.1 +/- 1.4 versus 0.94 +/- 0.93; P = 0.002) and more medication adverse effects. It is concluded that the use of the WHO three-step analgesic ladder leads to effective pain relief in hemodialysis patients. Older patients will need more careful pain management to achieve the same results as younger patients. Further studies are needed to confirm these results in a larger, more diverse dialysis population.

Nurses' reflections on pain management in a nursing home setting

Achieving optimal and safe pain-management practices in the nursing home setting continues to challenge administrators, nurses, physicians, and other health care providers. Several factors in nursing home settings complicate the conduct of clinical process improvement research. The purpose of this qualitative study was to explore the perceptions of a sample of Colorado nursing home staff who participated in a study to develop and evaluate a multifaceted pain-management intervention. Semistructured interviews were conducted with 103 staff from treatment and control nursing homes, audiotaped, and content analyzed. Staff identified changes in their knowledge and attitudes about pain and their pain-assessment and management practices. Progressive solutions and suggestions for changing practice include establishing an internal pain team and incorporating nursing assistants into the care planning process. Quality improvement strategies can accommodate the special circumstances of nursing home care and build the capacity of the nursing homes to initiate and monitor their own process-improvement programs using a participatory research approach.

Effective Pain Management: Lessons from a Nursing Home Research Study

Persistent pain affects at least half of all older adults. The negative consequences of persistent pain are numerous and include depression, anxiety, and lower overall quality of life: However, pain is often underrecognized, underreported, underassessed, and undertreated, and multiple barriers to optimal pain practices exist. Although a solid evidence base exists for optimal pain practices, little progress has been made. This article reviews a study that developed and implemented a multifaceted intervention to improve pain practices in nursing homes and then examines the implications of those study findings for the home healthcare setting.

Measuring pain intensity in nursing home residents

Assessing pain intensity in nursing home residents remains a challenge. As part of a multifaceted intervention study to improve pain practices in nursing homes, quarterly pain assessments were conducted in 12 Colorado nursing homes. Residents who reported pain or discomfort of any kind in the past 24 hours were asked to choose one of three pain intensity scales to quantify their current and highest level of pain intensity. They were also observed for pain behaviors using Feldt's Checklist of Nonverbal Pain Indicators. Residents preferred the Verbal Descriptor Scale almost 2:1 over the 11-point Verbal Numeric Rating Scale and the Faces Pain Scale. Sex and ethnicity were associated with differences in scale preference. More than one-half of residents reporting pain had an observable pain indicator. There was a monotonic relationship between reported pain intensity and number of observed pain indicators. To improve pain assessment and management in nursing homes, residents should be given a choice of pain intensity scales and observed for possible pain behaviors.