Quality Pain Care for Older Adults in an Era of Suspicion and Scrutiny

Improving Pain Self-Management Among Rural Older Adults With Cancer

Importance

Undertreated cancer pain is a major public health concern among older adults in rural communities. Interventions to improve pain management among this vulnerable population are needed.

Objective

To test the feasibility, acceptability, and changes in pain outcomes from exposure to an adapted intervention, Cancer Health Empowerment for Living without Pain (CA-HELP), to improve patients' communication about pain to their clinicians.

Design, Setting, and Participants

Older adults with cancer (aged ≥65 years) who were residing in a noninstitutional rural setting and receiving outpatient care at a rural-based clinic in Tennessee were enrolled in the study, in which everyone received the intervention, in May 2022. All patients were given assessments at baseline and 1 week after intervention. Mean score differences were analyzed using 1-tailed paired sample t tests (α = .05). Data were analyzed in June 2022.

Exposure

The adapted version of CA-HELP included an 18-page patient-facing workbook and a 30-minute telephone coaching call with a registered nurse to coach patients on pain education and communication techniques to discuss pain with their medical team.

Main Outcomes and Measures

Feasibility was examined through accrual and completion rates. Acceptability was measured by helpfulness, difficulty, and satisfaction with the intervention. Changes in outcomes were measured using mean score differences from pre-post assessments of pain self-management, self-efficacy for communicating with clinicians about pain, patient-reported pain, and misconceptions about pain.

Results

Among the 30 total participants, the mean (SD) age was 73.0 (5.1) years; 17 participants (56.7%) were female, 5 (16.7%) were Black or African American, 30 (100%) were non-Hispanic or non-Latino, 24 (80.0%) were White, 16 (53.3%) had less than a high school education, and 15 (50.0%) reported income less than $21 000 per year. Based on accrual and completion rates of 100%, this intervention was highly feasible. Fidelity rates for delivering intervention components (100%) and communication competence (27 participants [90%]) were also high. Regarding acceptability, all patients rated the intervention as helpful, with the majority (24 participants [80%]) rating it as "very helpful." Most patients rated the intervention as "not at all difficult" (27 participants [90%]), enjoyed participating (21 participants [70%]), and reported being "very satisfied" (25 participants [83.3%]). Pre-post changes in outcomes suggested significant improvements in pain self-management and self-efficacy for communicating with clinicians about pain, as well as significant reductions in patient-reported pain and pain misconceptions.

Conclusions and Relevance

In this case-series study of CA-HELP, results suggested the adapted version of CA-HELP was feasible and acceptable and showed changes in pain-related outcome measures among older adults with cancer in a rural setting.

What do older adults want from spine care?

Introduction

Older adults comprise a large portion of back pain (BP) sufferers but are under-represented in the literature. Patients over age 65 present with different clinical characteristics and psychosocial needs than younger patients. Therefore, recommended patient-centered outcomes for BP may not be relevant to older patients.

Research question

What treatment outcomes are most important to adults over 65 years of age?

Materials and methods

We queried older adults seeking treatment for BP using qualitative methods. Participants were asked about their goals and expectations of treatment in an audio-taped interview. Audiotapes were transcribed, coded and analyzed by the investigators. Using thematic analysis, main themes and constructs were extracted and interpreted by the investigators. From there we were able to generate hypotheses about what older patients want from spine treatment.

Results

For all participants, age played a role in their treatment goals as a moderator or motivator. They were most concerned with returning to usual activities and preventing further physical limitations to maintain independence. Goals that reflect important outcomes such as increasing walking tolerance and improving balance were of particular importance. Confidence in the provider acted as a facilitator of goals.

Discussion and conclusion

Unlike their younger cohorts, they did not emphasize work-related outcomes and pain relief. These findings can be tested in future quantitative studies and will help to develop protocols for outcomes assessment in older adults. This study is a first step towards understanding and improving the quality of care for older patients with back pain.

A historical review of pain disparities research: Advancing toward health equity and empowerment

BACKGROUND AND PURPOSE

This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research.

METHODS

Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society.

DISCUSSION

Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus.

CONCLUSION

We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Pain Assessment Clinical Practice Improvement: An Educational Approach in the Home Healthcare Setting

In the 2 decades since The Joint Commission on Accreditation of Healthcare Organizations designated pain as the fifth vital sign, practitioners have become increasingly aware of the numerous challenges associated with the assessment and management of pain in older adults. Comprehensive pain assessment relies not only on the availability of assessment tools, but also on a clinician's knowledge, training, prior experience, and keen awareness of their own implicit bias and how it may influence their assessment and decisions. The purpose of this project was to develop, implement, and evaluate outcomes of a two-part online learning module on home healthcare clinicians' knowledge of pain. A quasi-experimental, one-group pretest posttest design was used. Of the 94 clinicians who volunteered, 54 participants completed all modules and surveys. Mean posttest scores (58.7%) were significantly higher than pretest scores (50.7%; n = 54, T = 3.08, p-value = 0.003). The strongest gains in learning occurred for those with lower pretest scores. The mean difference between posttest and pretest scores did not vary among job titles. There was no significant difference in posttest scores among job titles. A higher mean pretest score was associated with greater years of clinical experience, but did not significantly affect mean posttest scores. These findings suggest elearning is an effective educational approach to improve home healthcare clinicians' pain knowledge, particularly those who lack a sufficient knowledge base at the outset.