Mental health disorder, pain, and pain treatment among long-term care residents: Evidence from the Minimum Data Set 3.0

Pilot testing implementation of the pain management clinical practice guideline in nursing homes

Pain is a common symptom for older adults living with dementia in nursing homes. Unfortunately, there are many challenges to pain assessment, diagnosis and management for these individuals. The purpose of this study was to pilot test the implementation of the newly published Pain Management Clinical Practice Guideline from AMDA: The Society of Post Acute and Long-Term Care using our theoretically based Pain-CPG-EIT approach. Implementation was provided by a research nurse facilitator and included four components: Component I: Establishing and working with a stakeholder team monthly; Component II: Education of the staff; Component III: Mentoring and motivating the staff; and Component IV: Ongoing monitoring of pain assessment, diagnosis and management for residents. Findings provide some preliminary support for the feasibility and effectiveness of our implementation approach.

Pain and Associated Factors in Nursing Home Residents

BACKGROUND

Understanding factors associated with risk of pain allows residents and clinicians to plan care and set priorities, however, factors associated with pain in nursing home residents has not been conclusively studied.

AIM

To evaluate the association between pain and nursing home (NH) resident demographic and clinical characteristics.

DESIGN

Retrospective analysis of Minimum Data Set 3.0 records of nursing home residents residing in 44 Indiana NHs between September 27, 2011 and December 27, 2019 (N = 9,060).

RESULTS

Pain prevalence in this sample of NH residents was 23.7%. Of those with pain, 28.0% experienced moderate to severe/frequent pain and 54.6% experienced persistent pain. Risk factors for moderate to severe/frequent pain include female sex; living in a rural setting; intact, mildly, or moderately impaired cognition; arthritis; contracture; anxiety; and depression. In contrast, stroke and Alzheimer's disease and Alzheimer's-disease related dementias (AD/ADRD) were associated with decreased risk of reporting moderate to severe/frequent pain, likely representing both the under-assessment and under-reporting of pain among cognitively impaired NH residents. Risk factors for persistent pain included age <70, Black race, living in a rural location, intact cognition, contracture, and depression.

CONCLUSIONS

Pain remains a pressing problem for NH residents. In this study, we identified demographic and clinical factors associated with moderate to severe frequent pain and persistent pain. Residents with a diagnosis of AD/ADRD were less likely to report pain, likely representing the difficulty of evaluating pain in these residents. It is important to note that those with cognitive impairment may not experience any less pain, but assessment and reporting difficulties may make them appear to have less pain. Knowledge of factors associated with pain for NH residents has the potential for improving the ability to predict, prevent, and provide better pain care in NH residents.

Trends in Risk-Adjusted Initiation and Reduction of Opioid Use among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers

OBJECTIVE

Proper initiation and reduction of opioids is important in providing effective and safe pain relief to Veterans with dementia, including in Community Living Centers (CLCs). We examined the trends in aggregated monthly risk-adjusted opioid administration days and dosage over 3 opioid safety regulatory periods: pre-Opioid Safety Initiative period (October 1, 2012-June 30, 2013; period 1), pre-CDC Clinical Practice Guideline period (January 1, 2014-November 30, 2015, period 2) and post-Veterans Affairs Clinical Practice Guideline period (March 1, 2017-September 30, 2018; period 3).

DESIGN

A retrospective study between October 1, 2012, and September 30, 2018.

SETTINGS AND PARTICIPANTS

4995 long-stay CLC residents with dementia who had incident (incident cohort, n = 2609) or continued (continued opioid cohort, n = 2386) opioid administration in CLCs.

METHODS

CLC Minimum Data Set (MDS) assessments data and bar-code medication administration data were used. Opioid initiation was examined for incident opioid cohort and reduction was examined using continued opioid cohort. We first computed aggregated monthly risk-adjusted opioid administration days, opioid with benzodiazepine administration days and opioid dosage, and then examined risk-adjusted incident and continued opioid administration trends over the regulatory periods controlling for facility-level characteristics.

RESULTS

Among the incident opioid cohort, compared to period 1, there were 1.9 and 2.1 fewer risk-adjusted opioid administration days per month in periods 2 and 3, respectively; 1.5 fewer risk-adjusted days per month with opioid and benzodiazepine administration in both periods 2 and 3; and 2.2 and 3.7 morphine milligrams equivalent per day (MMED) lower risk-adjusted dosage in periods 2 and 3, respectively. Among the continued opioid cohort, compared to period 1, there were 1.6 and 2.9 fewer risk-adjusted days with opioid and benzodiazepine administration days per month in periods 2 and 3, respectively, and 5.3 MMED lower risk-adjusted dosage per month in period 3.

CONCLUSIONS AND IMPLICATIONS

CLC providers initiated and reduced opioid administration in fewer days and at lower dosage among Veterans with dementia across the regulatory periods. The result was likely due to systemic efforts from health care professionals, CLC administrators, and policy makers or VA central office, aiming to reduce opioid misuse and improve quality of care in nursing home residents with dementia. What is still unknown is whether pain was well controlled or nonpharmacologic treatments were utilized.

Program Evaluation: exploring health disparities that impact chronic pain referrals within a VA Health Care System

Introduction

The present Program Evaluation study examines sociodemographic characteristics of Veterans in the Phoenix VA Health Care System who have back pain, and specifically the likelihood of those characteristics being associated with a referral to the Chronic Pain Wellness Center (CPWC) in the year 2021. We examined the following characteristics: Race/ethnicity, gender, age, mental health diagnosis, substance use disorder diagnosis, and service-connected diagnosis.

Methods

Our study used cross sectional data from the Corporate Data Warehouse for 2021. 13624 records had complete data for the variables of interest. Univariate and multivariate logistic regression was used to determine the likelihood of patients' being referred to the Chronic Pain Wellness Center.

Results

The multivariate model found under-referral to be significant for younger adults and for patients who identified as Hispanic/Latinx, Black/African American, or Native American/Alaskan. Those with depressive disorders and opioid use disorders, on the other hand, were found to be more likely to be referred to the pain clinic. Other sociodemographic characteristics were not found to be significant.

Discussion

Study limitations include the use of cross-sectional data, which cannot determine causality, and the inclusion of patients only if the ICD-10 codes of interest were recorded for an encounter in 2021 (i.e., a prior history of a particular diagnosis was not captured). In future efforts, we plan to examine, implement, and track the impact of interventions designed to mitigate these identified disparities in access to chronic pain specialty care.

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 Systematic Review of Barriers and Facilitators of Pain Management in Persons with Dementia

Approximately 50% of persons living with dementia experience pain, yet it is frequently undetected and inadequately managed resulting in adverse consequences. This review aims to synthesize evidence on the barriers and facilitators of pain management in persons living with dementia. PubMed, CINAHL, PsycINFO, and Web of Science datasets were used for article searching. Inclusion criteria were peer-reviewed original articles written in English that examined the barriers and facilitators of pain management for persons living with dementia. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies. A total of 26 studies were selected, including 18 qualitative and 3 quantitative (all high quality), as well as 5 mixed methods studies (low-to-high quality). Results were categorized into intrapersonal, interpersonal, environmental, and policy categories. Factors that impact pain management in dementia include cognitive and functional impairment, healthcare workers' knowledge, collaboration and communication, healthcare workers' understanding of patients' baseline behaviors, observation of behaviors, pain assessment tool use, pain management consistency, staffing level, pain guideline/policy, and training. Overall, pain management is challenging in persons living with dementia. The results indicate that there is a need for multi-component interventions that involves multidisciplinary teams to improve pain management in persons living with dementia at the intrapersonal, interpersonal, environmental, and policy levels. PERSPECTIVES: This review systematically synthesized barriers and facilitators of providing pain management in persons living with dementia. Results were presented in intrapersonal, interpersonal, environmental, and policy categories and suggests that multicomponent interventions involving multidisciplinary teams are needed to systematically improve pain management in persons living with dementia.

Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature

OBJECTIVES

To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.

DESIGN

Systematic review of descriptive studies.

SETTING AND PARTICIPANTS

Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.

RESULTS

Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.

CONCLUSION AND IMPLICATIONS

This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Opioid administration trends among long-stay community living centers residents with dementia

BACKGROUND

Pain assessment and management of Veterans with Alzheimer's disease and Related Dementia (ADRD) living in Community Living Centers (CLCs) is challenging. Safe and effective use of opioids in the treatment of pain is of great concern to patients and providers promulgating national policies and guidelines.

METHODS

This study examined long-stay CLC Veterans with ADRD identified in three regulatory periods (period 1: 10/2012-6/2013, n = 3347; period 2: 1/2014-11/2015, n = 4426; period 3: 1/2017-9/2018, n = 4444; Total N = 12,217).This population-based observational study used CLC Minimum Data Set (MDS) data in Fiscal Years (FYs) 2013-2018 and VA bar-code medication administration (BCMA) data. Opioid administration measures included: any opioids, long-term opioids, high-dose opioids, and co-administration with benzodiazepine. Measures were modeled using negative binomial regression with length of stay in CLC as offset adjusting for Veteran predisposing, enabling and need measures from the MDS.

RESULTS

Compared to period 1, any opioid administration was 26% lower in period 2, and 34% lower in period 3. Among Veterans who received any opioid medications over the three regulatory periods, high-dose and long-term opioid administration were more than 40% lower in periods 2 and 3 compared to period 1. Co-administration of opioid with benzodiazepine versus no opioid was 11% lower in period 2 and 34% lower in period 3 after adjusting for patient level covariates.

CONCLUSIONS

All patterns of opioid administration decreased over the four opioid regulations periods when guidelines were promulgated across the VA health system. Further research should clarify whether decreasing opioids among patients with ADRD impacted health outcomes.

The Relationship Between Pain, Function, Behavioral, and Psychological Symptoms of Dementia and Quality of Life

BACKGROUND

This study evaluated the association between age, sex, comorbidities, cognition, and administration of opioids with pain and the impact of all of these variables plus function, agitation, resistiveness to care, and depression on quality of life among residents in nursing home with severe dementia.

DESIGN

This was a descriptive study using baseline data from the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia implementation study.

METHODS

Model testing was done using structural equation modeling. The sample included 553 residents from 55 nursing homes with a mean age of 83.88 (standard deviation = 10.44) and mean Brief Interview of Mental Status of 4.30 (standard deviation = 3.50).

RESULTS

There were significant associations showing those who were older, male, had fewer comorbidities, better cognition, and were black were more likely to have pain. Pain, in combination with the demographic and descriptive variables, explained 32% of the variance in function, 75% of the variance in depression, 88% of the variance in agitation, 98% of the variance in resistiveness to care, and 92% of the variance in quality of life. The model however did not show a good fit to the data.

SETTING

The study was done in 55 nursing homes in Maryland and Pennsylvania.

PARTICIPANTS/SUBJECTS

A total of 553 residents were included in the study.

CONCLUSIONS

The model did not have a good fit with the data which likely was due to the lack of variance in outcomes. The hypothesized paths, with the exception of opioid use, were significant.

Preparing Long-Term Care Staff to Meet the Needs of Aging Persons With Serious Mental Illness

OBJECTIVES

Individuals with serious mental illness (SMI; schizophrenia spectrum disorders and affective psychoses) are increasingly aging into older adulthood and are overrepresented in residential long-term care settings. The present study aimed to examine the preparedness of staff in these settings to care for individuals with SMI.

DESIGN

A multidisciplinary US Department of Veterans Affairs (VA) workgroup of professionals with expertise in geriatric mental health collected voluntary feedback via online questionnaire as part of a quality improvement project.

SETTING AND PARTICIPANTS

Respondents were mental health providers (N=51) embedded in VA nursing homes called Community Living Centers (CLCs).

MEASURES

The questionnaire contained multiple-choice, Likert-type scale, and open-ended questions regarding the opportunities and challenges associated with caring for Veterans with SMI in CLCs.

RESULTS

Respondents identified a lack of training of front-line staff as a key challenge in providing high-quality care to residents with SMI. Specifically, respondents indicated a need to increase staff knowledge about SMI symptoms and diagnoses, to improve staff communication and interactions with residents with SMI, and to decrease mental illness stigma among staff.

CONCLUSIONS/IMPLICATIONS

The present study revealed significant areas of training need for front-line staff in nursing homes. Many perceived staff training needs overlap with the knowledge and skill set required to provide high-quality dementia care. Integrating training regarding the care of residents with SMI into dementia care training efforts may be a fruitful future direction. Strategies for this and a suggested curriculum are provided.