Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents

Self- and staff-reported pain in relation to contextual isolation in long-term nursing home residents with Alzheimer's disease and related dementias

We evaluated the degree to which contextual isolation in nursing home residents with Alzheimer's disease and related dementias is associated with documented pain using the Minimum Data Set 3.0, a comprehensive resident assessment required of all nursing home residents in the United States. Contextual isolation was defined as having a socially salient characteristic (demographics, habits and interests, and clinical and care dimensions) shared by fewer than 20% of other residents in the same nursing home. Thirteen percent were contextually isolated on multiple characteristics. Among residents self-reporting pain, residents contextually isolated with respect to multiple characteristics were 8% more likely (95% confidence interval: 7% to 9%) to have pain relative to residents who were not contextually isolated on any characteristics. Long-stay nursing home residents with ADRD who live in settings where they were contextually isolated were more likely to have pain relative to those without contextually isolation on any characteristic.

Correlates of Opioid Use Among Ontario Long-Term Care Residents and Variation by Pain Frequency and Intensity: A Cross-sectional Analysis

Background

Chronic non-cancer pain is common among older residents of long-term care (LTC) homes and often poorly recognized and treated. With heightened concerns regarding opioid prescribing in recent years, it is important to examine the current prevalence of opioid use and its association with resident characteristics to help identify those potentially at risk of medication harms as well as suboptimal pain management.

Objectives

The aims were to estimate the prevalence and correlates of opioid use among non-palliative LTC residents and explore variation in opioid prevalence and correlates across strata defined by pain frequency and intensity.

Methods

We conducted a population-based cross-sectional study of all older (aged > 65 years) LTC residents (excluding those with cancer or receiving palliative care) in Ontario, Canada during 2018–2019. Health administrative databases were linked with standardized clinical assessment data to ascertain residents’ health and pain characteristics and their opioid and other medication use. Modified Poisson regression models estimated unadjusted and adjusted associations between residents’ characteristics and opioid use, overall and across strata capturing pain frequency and intensity.

Results

Among 75,020 eligible residents (mean age 85.1 years; 70% female), the prevalence of opioid use was 18.5% and pain was 29.4%. Opioid use ranged from 12.2% for residents with no current pain to 55.7% for those with severe pain. In adjusted models, residents newly admitted to LTC (adjusted risk ratio [aRR] = 0.60, 95% confidence interval [CI] 0.57–0.62) and with moderate to severe cognitive impairment (aRR = 0.69, 95% CI 0.66–0.72) or dementia (aRR = 0.76, 95% CI 0.74–0.79) were significantly less likely to receive an opioid, whereas residents with select conditions (e.g., arthritis, aRR = 1.37, 95% CI 1.32–1.41) and concurrently using gabapentinoids (aRR = 1.80, 95% CI 1.74–1.86), benzodiazepines (aRR = 1.33, 95% CI 1.28–1.38), or antidepressants (aRR = 1.31, 95% CI 1.27–1.35) were significantly more likely to receive an opioid. The associations observed for residents newly admitted, with dementia, and concurrently using gabapentinoids, benzodiazepines, or antidepressants were largely consistent across all pain strata.

Conclusions

Our findings describe resident sub-groups at potentially higher risk of adverse health outcomes in relation to both opioid use and non-use. LTC clinical and policy changes informed by research are required to ensure the appropriate recognition and management of non-cancer pain in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-022-00972-9.