Nonpharmacologic Pain Management Interventions in German Nursing Homes: A Cluster Randomized Trial

The use of nonpharmacological interventions for chronic pain treatment in community-dwelling older adults with a certified need for care

BACKGROUND

Chronic pain is a major health issue and rapid population ageing exacerbates the burden to health systems in countries like Germany. Nonpharmacological interventions (NPIs) are essential in pain care and the prioritization of active NPIs is emphasized in guidelines. This paper examines the utilization of NPIs for chronic pain management in community-dwelling older adults with a certified need of care in Berlin, Germany.

METHODS

Cross-sectional data was collected through standardized face-to-face surveys with older adults (≥65 years), using validated instruments (e.g., Brief Pain Inventory), and structured lists for NPI utilization. Categorization into active and passive NPIs was performed through a literature-based, iterative process by an interdisciplinary team. For not normally distributed data, non-parametric tests were used as appropriate. Logistic regression was conducted for multivariate analysis.

RESULTS

In total, 250 participants were included in this analysis (aged 65-104, x̅ = 81.8, 68.8% female). Most (92%) use NPIs for chronic pain management: 85.6% use active NPIs, 50.4% active movement and only 5.6% use solely passive approaches. Most common NPIs are distraction, thermotherapy/compresses, and physiotherapy. The odds of utilizing physiotherapy are three times higher for those with high educational status when compared to those with low education while those with low educational status had higher odds of using thermotherapy/compresses.

CONCLUSIONS

In our sample, most community-dwelling older adults with a certified need of care use active NPIs for chronic pain management with about half using active movement approaches. Considering the high vulnerability of this population, physiotherapy (in the form of therapeutic exercise) is a particularly appropriate intervention, and it was the third most frequent NPI in our sample. However, there is a social gradient in the utilization of physiotherapy for chronic pain management which might be rooted in issues around awareness, appeal, and access to such measures. It is important to take socioeconomic differences into account when planning the care for older chronic pain patients but also when designing research or user-friendly guidelines for this target group.

TRIAL REGISTRATION

Ethical approval from the Ethics Committee of Charité - Universitätsmedizin Berlin (EA1/368/14) and study registration with the Central Study Register (ZSR no. 20009093).

Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Pain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents.

DESIGN

A Cochrane-style systematic review and meta-analysis using PRISMA guidelines.

SETTING AND PARTICIPANTS

Randomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60 years receiving interventions to reduce chronic pain.

METHODS

Six databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0.

RESULTS

We included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD -0.80; 95% CI -1.47 to -0.12; P = .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD -0.70; 95% CI -0.95 to -0.45; P < .001), combined interventions (SMD -0.37; 95% CI -0.60 to -0.13; P = .002), and education interventions (SMD -0.31; 95% CI -0.48 to -0.15; P < .001).

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.

Use and effects of implementation strategies for practice guidelines in nursing: a systematic review

BACKGROUND

Practice guidelines can reduce variations in nursing practice and improve patient care. However, implementation of guidelines is complex and inconsistent in practice. It is unclear which strategies are effective at implementing guidelines in nursing. This review aimed to describe the use and effects of implementation strategies to facilitate the uptake of guidelines focused on nursing care.

METHODS

We conducted a systematic review of five electronic databases in addition to the Cochrane Effective Practice and Organization of Care (EPOC) Group specialized registry. Studies were included if implementation of a practice guideline in nursing and process or outcome of care provided by nurses were reported. Two reviewers independently screened studies, assessed study quality, extracted data, and coded data using the EPOC taxonomy of implementation strategies. For those strategies not included in the EPOC taxonomy, we inductively categorized these strategies and generated additional categories. We conducted a narrative synthesis to analyze results.

RESULTS

The search identified 46 papers reporting on 41 studies. Thirty-six studies used a combination of educational materials and educational meetings. Review findings show that multicomponent implementation strategies that include educational meetings, in combination with other educational strategies, report positive effects on professional practice outcomes, professional knowledge outcomes, patient health status outcomes, and resource use/expenditures. Twenty-three of the 41 studies employed implementation strategies not listed within the EPOC taxonomy, including adaptation of practice guidelines to local context (n = 9), external facilitation (n = 14), and changes to organizational policy (n = 3). These implementation strategies also corresponded with positive trends in patient, provider, and health system outcomes.

CONCLUSIONS

Nursing guideline implementation may benefit from using the identified implementation strategies described in this review, including participatory approaches such as facilitation, adaptation of guidelines, and organizational policy changes. Further research is needed to understand how different implementation strategy components work in a nursing context and to what effect. As the field is still emerging, future reviews should also explore guideline implementation strategies in nursing in quasi or non-experimental research designs and qualitative research studies.

An intervention to increase physical activity in care home residents: results of a cluster-randomised, controlled feasibility trial (the REACH trial)

BACKGROUND

Care home (CH) residents are mainly inactive, leading to increased dependency and low mood. Strategies to improve activity are required.

DESIGN AND SETTING

Cluster randomised controlled feasibility trial with embedded process and health economic evaluations. Twelve residential CHs in Yorkshire, United Kingdom, were randomised to the MoveMore intervention plus usual care (UC) (n = 5) or UC only (n = 7).

PARTICIPANTS

Permanent residents aged ≥65 years.

INTERVENTION

MoveMore: a whole home intervention involving all CH staff designed to encourage and support increase in movement of residents.

OBJECTIVES AND MEASUREMENTS

Feasibility objectives relating to recruitment, intervention delivery, data collection and follow-up and safety concerns informed the feasibility of progression to a definitive trial. Data collection at baseline, 3, 6 and 9 months included: participants' physical function and mobility, perceived health, mood, quality of life, cognitive impairment questionnaires; accelerometry; safety data; intervention implementation.

RESULTS

300 residents were screened; 153 were registered (62 MoveMore; 91 UC). Average cluster size: MoveMore: 12.4 CHs; UC: 13.0 CHs. There were no CH/resident withdrawals. Forty (26.1%) participants were unavailable for follow-up: 28 died (12 MoveMore; 16 UC); 12 moved from the CH. Staff informant/proxy data collection for participants was >80%; data collection from participants was <75%; at 9 months, 65.6% of residents provided valid accelerometer data; two CHs fully, two partially and one failed to implement the intervention. There were no safety concerns.

CONCLUSIONS

Recruiting CHs and residents was feasible. Intervention implementation and data collection methods need refinement before a definitive trial. There were no safety concerns.

Strategies to enhance routine physical activity in care home residents: the REACH research programme including a cluster feasibility RCT

Background

Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity.

Objectives

The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams.

Design

This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5).

Setting

The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK.

Participants

The participants were elderly residents, carers, managers and staff of care homes.

Intervention

The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines.

Main outcome measures

The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5).

Results

Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green).

Limitations

Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial.

Conclusions

A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting.

Future work

The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population.

Trial registration

Current Controlled Trials ISRCTN16076575.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research programme and will be published in full in Programme Grant for Applied Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Pain assessment and management in care homes: understanding the context through a scoping review

BACKGROUND

Internationally, 2-5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management.

METHODS

Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective.

RESULTS

Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment - including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes. Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia.

CONCLUSIONS

Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

A Systematic Review and Meta-Analysis of the Effects of Biopsychosocial Pain Education upon Health Care Professional Pain Attitudes, Knowledge, Behavior and Patient Outcomes

Pain is a significant health burden globally and its management frequently fails to comply with evidence based, biopsychosocial guidelines. This may be partly attributable to inadequate biopsychosocial focussed pain education for students and clinicians. We aimed to undertake a systematic review, using Cochrane methodology, of randomized controlled trials with meta-analysis to quantify the effects of biopsychosocial education strategies in changing student/qualified health care professionals (HCPs) pain related attitudes, knowledge, clinical behaviour or patient outcomes. A systematic search of the literature was undertaken using CINAHL, AMED, PEDro, Cochrane Central Library, MEDLINE, ScienceDirect, Rehabdata, SportDiscus, EMBASE, ASSIA, Dentistry and Oral Science, Psycinfo, Education Research Complete and OpenGrey from 1977 to November 2020. Pooled effect sizes were quantified in random effects meta-analyses for attitudes, knowledge, and clinical behaviors. From a sample of 1812 records, 6 were narratively analysed and 15 were included in the meta-analyses. These studies represented 3022 patients and 3163 HCPs and students. Education improved attitudes by 11.3% (95% confidence interval: 2.2-20.4%, P = .02), and knowledge by 18.8% (12.4-25.3%, P = .01). The effects of education on clinical behavior favoured a clinically relevant improvement (OR = 2.4, 0.9-5.9, P = .06). Narrative analysis of the effect of biopsychosocial education for student HCPs/HCPs upon patient outcomes was inconclusive. These findings demonstrate that biopsychosocial focussed pain education strategies can improve student/qualified HCPs' pain related knowledge and attitudes and increase the likelihood that they will behave more in keeping with evidence-based practice. This should result in improved patient outcomes, however, evidence to support or refute this is lacking. PROSPERO systematic review record number, CRD42018082251. Perspective: We outline the effectiveness of biopsychosocial pain education for health care professionals and students in improving pain knowledge, attitudes, and evidence-based behaviors. These improvements should enhance clinical outcomes in patients with pain but further evidence is needed to confirm this.

A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial)

BACKGROUND

provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff.

DESIGN AND SETTING

a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC).

PARTICIPANTS

residents who were not independently mobile.

INTERVENTION

SCTP-delivered by physiotherapists to care staff.

OBJECTIVES AND MEASUREMENTS

key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety.

RESULTS

a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable-staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns.

CONCLUSION

care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

Pain-Associated Clusters Among Nursing Home Residents and Older Adults Receiving Home Care in Germany

CONTEXT

There are no available data regarding pain-associated clusters among nursing home residents (NHRs) and older adults receiving home care with chronic pain.

OBJECTIVES

To identify and describe pain-associated clusters in NHRs and older adults receiving home care with chronic pain and to explore associations with clusters in both settings.

METHODS

We surveyed 137 NHRs and 205 older adults receiving home care. Clusters were identified using hierarchical agglomerative cluster analysis, using Ward's method with squared Euclidean distances in the proximities matrix. The clusters were characterized based on sociodemographic and clinical characteristics. Multinomial logistic regression was used to identify variables associated with different clusters.

RESULTS

In each setting, we identified three clusters: pain relieved, pain impaired, and suffering severe pain. In the nursing home study and home care study, respectively, the participant distributions were 46.72% and 11.71% in the pain-relieved cluster, 22.63% and 33.66% in the pain-impaired cluster, and 30.66% and 54.63% in the severe-pain cluster. Appropriate pain medication was only detected among pain-relieved NHRs.

CONCLUSION

Overall, differences in pain management exist within the two care settings presented here. There is potential for improvement in both settings. Moreover, there exists a need for clinical interventions aiming at shifting from pain-affected clusters to pain-relieved status.

Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment

OBJECTIVES

To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity.

DESIGN

Prospective individual data were collected over 1 to 3 days for each participant.

SETTING

Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years).

MEASUREMENTS

A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep).

RESULTS

Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week.

CONCLUSION

Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial

PURPOSE

Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018).

PARTICIPANTS

Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included.

INTERVENTION

In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses.

METHODS

Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD).

RESULTS

Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05).

CONCLUSION

While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

[Pain management in nursing care in outpatient older adults in need of care]

Pain management in nursing care in outpatient older adults in need of care Abstract. Background: International data report a prevalence rate for chronic pain of up to 50 % in community dwelling older adults (> 65 years). A national study reported a prevalence rate of 68,5 % among outpatient adults (≥ 18 years). Nursing care has an important meaning in pain management. However, previous research on the quality of pain management in nursing care is insufficient. Aim: The aim of this study is to evaluate the appropriateness of pain management in nursing care in our target group. Method: The cross-sectional study is based on data from ACHE. The study comprises 219 patients. Information on subjective pain experience and pain management were obtained by face-to-face interviews and nursing documentation. Results: Our findings indicate considerable deficits in terms of pain management in nursing care. Results show a lack of systematic pain assessment as well as missing documentation of therapeutic aims and pain management in nursing care. Conclusions: The identified deficits might be the result of current framework conditions that separate nursing pain treatment in Volume V and Volume XI of the German Social Security Code services. Appropriateness in pain management in nursing care can only be ensured if framework conditions are optimized.

Non-Pharmacological Approaches to Pain Management in Residential Aged Care: a Pre-Post-Test Study

OBJECTIVES

The project aimed to evaluate a pain management program (PMP) using non-pharmacological approaches at five residential aged care facilities (RACFs) in Australia.

METHODS

The PMP involved a physiotherapist implementing four sessions per week of treatments (massage therapy, TENS, exercises and stretching, or combinations of these). Ninety-five participants were recruited (average age, 83 years; SD = 7.6; 38% men, 62% women; 56% with dementia). Sessions lasted approximately 10 minutes, and residents' levels of pain were recorded using a 5-point scale before and after each treatment. The intervention period for each participant was the first consecutive 8 weeks in which they received the intervention.

RESULTS

Data analyses showed: (1) a small but statistically significant decrease in the number of as required (PRN) medications; and (2) a decrease in average pain ratings from pre-session to post-session from 2.4 (some to moderate pain) to 1.1 (a little pain). Notably, residents with dementia received lower pain ratings than those without.

CONCLUSIONS

Non-pharmacological approaches to pain in residential care settings are effective, especially when two or more are combined. Staff working in residential care settings should rely on best practice to recognise pain in residents with dementia.

CLINICAL IMPLICATIONS

Non-pharmacological interventions may be effective in reducing pain and reliance on PRN medications in residential care settings, especially when two or more are used. Staff working in residential aged care settings should be provided with training in pain assessment and management, with particular attention to residents with dementia.

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.

Nonpharmacological interventions for persistent, noncancer pain in elders residing in long-term care facilities: An integrative review of the literature

Elders residing in long-term care facilities experience ongoing moderate to severe pain, relief from and increased comfort remain relevant healthcare concerns. However, persistent, noncancer pain may not have been properly addressed due to insufficient attention to research that exists to support the utilization and efficacy of nonpharmacological intervention(s) for elders in long-term care facilities. Our aim of this integrated review was to evaluate the current state of the science on nonpharmacological intervention(s) for pain that are currently utilized in elders who reside in long-term care facilities. Exercise, massage, heat therapy, and relaxation/rest were identified as significant nonpharmacological interventions for persistent pain in elder residents living in long-term care facilities.

Pain management intervention targeting nursing staff and general practitioners: Pain intensity, consequences and clinical relevance for nursing home residents

AIM

Although chronic pain is common in older adults, its treatment is frequently inappropriate. This problem is particularly prevalent in nursing home residents. We therefore developed an intervention to optimize pain management and evaluated its effects on pain intensity and pain interference with function in nursing home residents in Germany.

METHODS

In a cluster-randomized controlled intervention, 195 residents of 12 Berlin nursing homes who were affected by pain were surveyed at three points of measurement. A modified German version of the Brief Pain Inventory was used to assess pain sites, pain intensity and pain interference with function in various domains of life. The intervention consisted of separate training measures for nursing staff and treating physicians.

RESULTS

The primary objective of reducing the mean pain intensity by 2 points was not achieved, partly because the mean pain intensity at baseline was relatively low. However, marginal reductions in pain were observed in the longitudinal assessment at 6-month follow up. The intervention and control groups differed significantly in the intensity sum score and in the domain of walking. Furthermore, the proportion of respondents with pain scores >0 on three pain intensity items decreased significantly.

CONCLUSIONS

Given the multifocal nature of the pain experienced by nursing home residents, improving the pain situation of this vulnerable group is a major challenge. To achieve meaningful effects not only in pain intensity, but especially in pain interference with function, training measures for nursing staff and physicians need to be intensified, and long-term implementation appears necessary. Geriatr Gerontol Int 2017; 17: 1534-1543.