Do Nursing Home Residents With Dementia Receive Pain Interventions?

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.

The influence of Alzheimer's disease stigma on pain assessment in older persons

INTRODUCTION

Pain of nursing homes residents with Alzheimer's disease remains under detected compared to their cognitively intact counterparts. Communication difficulties may partly explain this poor quality of care but the influence of stigmatization on pain assessment has never been explored.

RESEARCH QUESTION

The objective of this research was to analyze whether a diagnosis label of Alzheimer's disease or the stage of the disease may bias pain assessment scores and empathic reactions of health care staff in nursing homes.

METHODS

Two studies were conducted based on a similar experimental between-subjects design with a video showing an older adult woman experiencing undefined pain. Different labels and vignettes were manipulated to characterize the subject of the video. In the first study, 84 certified nursing assistants were asked to watch the video and then to assess the pain intensity and their empathic reaction. Participants were randomized in two conditions that varied the disease label (Alzheimer's disease vs no diagnosis). In the second study, 67 certified nursing assistants were enrolled who did not participate in the first study. They watched the same video as in the first study and assessed the pain intensity and their empathic reaction. They were randomized in two conditions that varied the stage of the Alzheimer's disease (mild stage vs severe stage).

RESULTS

Alzheimer's disease label had no influence on assessment scores. In contrast, the stage of the disease had a significant effect on the health care staff assessments with severe stage associated with lower pain intensity scores and empathic reactions.

CONCLUSION

These results confirm that the Alzheimer's disease stigma is a real phenomenon that tends to be mainly elicited by the symptoms of the acute phase of the disease. These findings are crucial to better understand the stigma related to Alzheimer's disease and to enhance the pain management of this frail population.

The use of analgesics and associated factors among nursing home residents

Aim: This study examined the use of analgesics and associated factors among nursing home residents (NHRs). Materials & methods: A descriptive correlational design and a convenience sample of 209 NHRs receiving analgesics was used in this study. Results: Higher use of analgesics was noted among NHRs without cognitive impairment (p < 0.001), those with higher anticholinergic burden scores (p = 0.002) and those with a higher average number of oral pills taken daily (p = 0.045). Conclusion: These findings contribute to a better understanding of the prevalence and associated factors of analgesic use, which will inform the development and application of evidence-based pain practice and guidelines in nursing homes in Jordan and beyond.

Comparative differences in musculoskeletal pain consultation and analgesic prescription for people with dementia: a UK-wide matched cohort study

ABSTRACT

Painful musculoskeletal conditions are common in older adults; however, pain identification, assessment, and management are reported to be suboptimal for people with dementia. Adequate pain management is an integral aspect of care for people with dementia to prevent or delay negative outcomes, such as behavioural and psychological changes, emergency department attendance, and premature nursing home admission. This study aims to examine musculoskeletal consultations and analgesic prescriptions for people with dementia compared with those for people without dementia. A dementia cohort (n = 36,582) and matched cohort were identified in the Clinical Practice Research Datalink (a UK-wide primary care database). Period prevalence for musculoskeletal consultations and analgesic prescriptions was described, and logistic regression applied to estimate associations between dementia and musculoskeletal consultation or analgesic prescription from the time of dementia diagnosis to 5 years after diagnosis. People with dementia had a consistently (over time) lower prevalence and odds of musculoskeletal consultation and analgesic prescription compared with people without dementia. The evidence suggests that pain management may be suboptimal for people with dementia. These results highlight the need to increase awareness of pain and use better methods of pain assessment, evaluation of treatment response, and acceptable and effective management for people with dementia, in primary care.

Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Background

Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them.

Objectives

The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes.

Design

This was a mixed-methods study.

Setting

The setting was care homes for older adults in England.

Participants

Care home residents participated.

Results

Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%.

Limitations

No care homes rated as inadequate were recruited to the study.

Conclusions

The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents.

Future work

Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. 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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02333-4.

Cognition-Enhancing, Antipsychotic, and Opioid Medication Use Among Assisted Living and Residential Care Residents in Oregon

OBJECTIVES

Explore community- and resident-level characteristics associated with polypharmacy and use of cognition-enhancing, antipsychotic, and opioid medications among a statewide representative sample of assisted living and residential care (AL/RC) residents.

DESIGN

Cross-sectional, descriptive.

SETTING AND PARTICIPANTS

A total of 1135 AL/RC residents living in 387 licensed communities in Oregon were recruited. One-third of residents lived in communities certified to provide memory care to residents with dementia.

METHODS

All licensed AL/RC communities received a mail survey with questions about 3 randomly selected residents' demographic, health service use, health conditions, medication use, and payment information. We estimated bivariate and multiple logistic regression models, resulting in unadjusted and adjusted odds ratios of resident- and community-level characteristics associated with each medication use indicator.

RESULTS

One in 5 residents took a cognition-enhancing medication (20%) in the prior 7 days. Just more than one-fifth (22%) and one-quarter (25%) of residents took opioid or antipsychotic medications, on a scheduled or as-needed basis in the prior 7 days, respectively. Residents with Alzheimer's disease or related dementia (ADRD) living in rural communities were half as likely to take cognitive-enhancing medications compared with their urban counterparts. When controlling for all resident and community covariates, residents with ADRD were almost 3 times as likely to receive an antipsychotic and half as likely to receive an opioid compared to residents without an ADRD diagnosis.

CONCLUSIONS AND IMPLICATIONS

Understanding variation in the use of medications associated with behavioral expressions of ADRD in AL/RC residents is a crucial clinical and policy area.