Assessing Pain and Falls Risk in Residents With Cognitive Impairment: Associated Problems With Overlooked Assessments

Allison H. Burfield, RN, MSN, PhD, is assistant professor, School of Nursing, College of Health and Human Services, and affiliate faculty in Gerontology and Robert Wood Johnson Foundation Nurse Faculty Scholar (2013-2016), University of North Carolina, Charlotte. She can be reached at aburfiel@uncc.edu.

James W. Cooper, RPh, PhD, BCPS, is emeritus professor of pharmacy and a consultant pharmacist, The University of Georgia College of Pharmacy, Athens, and formerly clinical assistant professor of family medicine, The Medical College of Georgia (now Georgia Health Sciences University), Augusta. He can be reached at jwcooper@uga.edu.
__________________________________________________________________________________________________________________________________________

According to the American Geriatrics Society Panel on Persistent Pain in Older Persons, approximately 45% to 80% of long-term care (LTC) residents experience substantial pain.¹ The literature indicates that approximately 25% of LTC residents who experience daily pain receive no pain interventions (ie, analgesics, nonpharmacologic treatments),² indicating more needs to be done to better recognize pain in this population. When pain remains undiagnosed and uncontrolled, it can lead to a variety of adverse outcomes, including falls. In fact, the prevalence of falls in nursing homes is similar to that of pain, with 50% to 75% of residents falling each year.³ Even more troubling is that nursing home residents older than 65 years account for 20% of all fall-related deaths.⁴ As these data show, pain and falls are major challenges in LTC settings, making comprehensive pain and fall assessments essential; however, these assessments can pose a particular challenge in cognitively impaired persons, as these

individuals may not be able to fully communicate their experiences. In this column, we describe two original tools, under development, that LTC providers can use to more thoroughly assess pain and falls risk in their cognitively impaired residents. It is important to note, however, that these instruments have not been validated in large-scale studies.

Assessing Pain in the Cognitively Impaired

Pain recognition remains a challenge in the LTC setting. When examining Minimum Data Set 2.0 data for 52,996 residents (mean age, 83.7 years) from Medicare-certified LTC facilities throughout the United States, we found that residents with mild to severe cognitive impairment and those unable to report pain verbally had the highest risk of experiencing pain.⁵ Using pain frequency and intensity as the only indicators of pain revealed an overall pain prevalence of 31%; however, when taking cognitive status into account, 48% of the intact group had pain, compared with 40% of those with mild cognitive impairment, 30% of those with moderate cognitive impairment, and 18% of those with severe cognitive impairment. These data indicate that pain recognition and reporting decreases with decreasing cognition. Therefore, regularly scheduled pain assessments are necessary for adequate pain recognition in the cognitively impaired.

Although healthcare providers may question whether pain assessment scales are useful in cognitively impaired persons, there is some evidence that they can be effective. In one study, which included 129 older adults with severe dementia, 61% of participants demonstrated comprehension of at least one pain scale.⁶ We observed similar results in an unpublished follow-up study that we conducted. Of the 155 cognitively impaired skilled nursing facility (SNF) senior care recipients included in the study, one-third could use a visual analog pain scale (ie, 0-10 scale) to characterize their pain, whereas two-thirds required a nonverbal pain scale due to cognitive impairment. Based on this study, we developed a checklist that healthcare providers can use to identify nonverbal cues of chronic pain in elderly residents. The use of such an instrument may serve to better identify those cognitively impaired persons who may benefit from a pain management plan. Download this resource by clicking here, or on the right-hand image.

Assessing Falls Risk in the Cognitively Impaired

A recently published article in Annals of Long-Term Care by Willy and Osterberg⁷ provides an excellent overview of fall risk considerations, and as this article and others^8,9 demonstrate, all nursing home residents are at risk for falls. However, the risks are amplified in cognitively impaired residents. One study reported that elderly nursing home residents with dementia are four to five times more likely to experience falls than elderly residents without significant cognitive impairment.¹⁰ Although these residents were no more likely to experience injuries than their cognitively intact counterparts, their risk of sustaining injurious falls was significantly higher due to their increased propensity to fall, highlighting the need to implement fall prevention programs for this population.¹⁰

A crucial aspect of any fall prevention program is conducting regular fall risk assessments, as they can provide important insights on how to reduce fall risks. To maximize the benefit of these assessments, they should be completed within 24 hours of admission, quarterly, whenever there is a significant change in a resident’s cognitive or physical status, and following any fall. In approximately 33% of cases, a single potential cause can be identified, whereas in approximately 66% of cases, more than one risk factor is involved.¹¹ To assess the multifactorial cause of falls, we highly encourage healthcare providers to consider using the falls risk assessment instrument provided by clicking here or on the right-hand image. This instrument was developed based on our long-term observations and numerous published reports^9,12-14 regarding falls in the LTC environment. Our assessment instrument takes into account the inability of many residents to complete common fall risk assessment tests, such as the timed Get Up and Go test, due to their cognitive and motor impairment(s).

Psychotropics and Uncontrolled Pain as Precursors to Falls: Reducing Risks

As previously noted, cognitively impaired residents have an increased risk of falls compared with their cognitively intact counterparts. Although there are numerous reasons for this, the behavioral and psychological symptoms of dementia, which may develop as cognitive impairment progresses, may play a considerable role. In many cases, when such behaviors manifest (eg, agitation, aggression), these patients are placed on antipsychotics and other psychotropic medications, which have been associated with a variety of adverse drug reactions, including falls.^12,15,16 One study found an up to 3.5-fold increased risk of falls across all psychotropic drug classes examined, including antidementia medications, antidepressants, antipsychotics, anxiolytics, hypnotics, and short-acting benzodiazepines.¹⁷

When examining a resident’s medication regimen with a goal to reduce falls risk, the total psychoactive drug load needs to be carefully considered.^13,14 Psychoactives include all psychotropics, sedatives/hypnotics, central nervous system stimulants, antiparkinson agents, anticonvulsants, metoclopramide, muscle relaxants, opioid analgesics, and antihistamines, and any drug that has primary or secondary anticholinergic side effects, which can include a variety of agents used for gastrointestinal, urinary tract, and pulmonary diseases. Appropriate tapering that accounts for adverse drug withdrawal effects may improve cognition and reduce the frequency of falls, emergency department visits, and hospitalizations.       

However, evidence also suggests that pain may be the cause of these behavioral manifestations in some cases,^8,9 and a pain evaluation may be warranted before any psychotropic medications are administered. In 1998, a study published in Annals of Long-Term Care reported that a regular schedule of acetaminophen 3 g daily decreased behavioral symptoms of agitation, inappropriate outbursts, and aggression by 63%, and enabled a 75% discontinuation rate of all psychotropics; however, the study did not address the effect on falls.⁸ Subsequently, we conducted a similar study that included SNF residents with dementia and agitation who were treated with conventional psychotropics. We found that tapering psychotropics and then converting these residents to buspirone (ie, an anxiolytic that is not chemically or pharmacologically related to the benzodiazepines, barbiturates, or other sedative/anxiolytic drugs) decreased the number of agitation and fall episodes by 75% and improved cognition over the 6-month study period.⁹

In a previously unpublished subset analysis of the aforementioned study,⁹ which included 12 of the 57 patients who were treated with acetaminophen 2.6 g to 3 g daily before psychotropic tapering and discontinuance, we observed less agitation (10 of 12 patients), fewer total episodes of agitation, and an 80% decrease in the number of falls for 3 months thereafter, as compared with the 3-month period preceding the addition of regularly scheduled acetaminophen.

These data suggest that a regular schedule of acetaminophen 2.6 g to 3.0 g daily for those with good liver function may both reduce the need for psychoactive drugs and enable easier tapering of any inappropriate psychoactive drugs that are being used. When proceeding with an acetaminophen regimen, healthcare providers need to be cautious about the concurrent use of cold, flu, allergy, and any other medications that may contain acetaminophen, as they can markedly increase the risk of liver toxicity if added to a regular schedule of acetaminophen. In addition, no ingested alcohol in any amount should be allowed in any patient taking any dose of acetaminophen. Concurrent use of alcohol is known to increase the risk of severe liver damage, and it more than doubles the risk of kidney disease per a preliminary study presented at the 2013 American Public Health Association annual meeting.¹⁸

Take-Home Message

Pain and fall risk assessments are crucial in LTC settings, and cognitively impaired residents should not be overlooked when it comes to these assessments. In addition to helping healthcare providers better identify persons who may benefit from pain management strategies, such as regular acetaminophen administration, and fall prevention strategies, such as minimizing psychoactive drug loads, they can enable documentation of the effects of these interventions on both pain scores and falls. By comparing scores, interventions can be fine-tuned to optimize care. It is essential to remember that pain and falls are key quality measures in the nursing home; thus, it behooves all LTC providers to strive to improve care in these areas, which starts with thorough assessments. 

References

1. AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(suppl 6):S205-S224.

2. Won AB, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc. 2004;52(6):867-874.

3. Rubenstein LZ. Preventing falls in the nursing home. JAMA. 1997;278(7):595-596.

4. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442-451. 

5. Burfield AH, Wan TT, Sole ML, Cooper JW. Behavioral cues to expand a pain model of the cognitively impaired elderly in long-term care. Clin Interv Aging. 2012;7:207-223.

6. Pautex S, Michon A, Guedira M, et al. Pain in severe dementia: self-assessment or observational scales? J Am Geriatr Soc. 2006;54(7):1040-1045.

7. Willy B, Osterberg CM. Strategies for reducing falls in long-term care. Annals of Long-Term Care. 2014;22(1):23-32.

8. Douzjian M, Wilson C, Schults M, et al. A program to use pain control medication to reduce psychotropic drug use in residents with difficult behavior. Annals of Long-Term Care. 1998;6(5):174-178.

9. Cooper JW, Cobb HH, Burfield AH. A one year study of psychotropic load reduction and buspirone conversion possible effects on behavioral disturbances and global deterioration in a rural nursing home population. Cons Pharm. 2001;16(4):358-363.

10. van Doorn C, Gruber-Baldini AL, Zimmerman S, et al; Epidemiology of Dementia in Nursing Homes Research Group. Dementia as a risk factor for falls and fall injuries among nursing home residents. J Am Geriatr Soc. 2003;51(9):1213-1218.

11. Briggs Corporation. Resident falls: facts, prevention, responding, tools & references. Accessed April 14, 2014.

12. Perri M 3rd, Menon AM, Deshpande AD, et al. Adverse outcomes associated with inappropriate drug use in nursing homes. Ann Pharmacother. 2005;39(3):405-411.

13. Cooper JW, Freeman MH, Cook CL, Burfield AH. Assessment of psychotropic and psychoactive drug loads and falls in nursing facility residents. Consult Pharm. 2007;22(6):483-489.

14. Cooper JW, Freeman MH, Cook CL, Burfield AH. Psychotropic and psychoactive drugs and hospitalization rates in nursing facility residents. Pharmacy Practice. 2007;5(3):140-144.

15. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716-2724.

16. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-631.

17.  van Strien AM, Koek HL, van Marum RJ, Emmelot-Vonk MH. Psychotropic medications, including short acting benzodiazepines, strongly increase the frequency of falls in elderly. Maturitas. 2013;74(4):357-362. 

18.  Ndetan HT, Rupert R, Jayswal R. Relationship of acetaminophen and alcohol usage to renal dysfunction: an opportunity for health promotion/education in chiropractic. Paper presented at: 141st American Public Health Association Annual Meeting and Expo; November 4, 2013; Boston, MA. Abstract 290307. https://apha.confex.com/apha/141am/webprogram/Paper290307.html. Accessed April 21, 2014.

Disclosures: Dr. Burfield reports no relevant financial relationships. Dr. Cooper has previously served as a speaker, advisory board member, or researcher for buspirone, risperidone, aripiprazole, quetiapine, fluoxetine, sertraline, mirtazapine, citalopram, escitalopram, nefazodone, tolterodine, ipratropium, tiotropium, oxybutynin, donepezil, galantamine, memantine, zolpidem, valproic acid, topiramate, and fentanyl. He has not served in any of these capacities in the past 5 years.