Challenges of Pain Management in Long-Term Care
Farless LB, Ritchie CS. Challenges of pain management in long-term care. Annals of Long-Term Care: Clinical Care and Aging. 2012;20(5):32-38.
Persistent pain is known to be common among older persons residing in long-term care (LTC) facilities, yet it continues to go unrecognized and undertreated despite pain guidelines, such as those put forth by the American Geriatrics Society (AGS) and AMDA–Dedicated to Long Term Care Medicine (previously known as the American Medical Directors Association [AMDA]), having been in existence for more than a decade. In 1998, the AGS published its first clinical practice guidelines on the management of persistent pain in older adults,1 which were revised in 2002 and 2009.2,3 Compared with the 1998 guidelines, the 2002 guidelines offer a wider range of pain assessment and management strategies, including nonpharmacologic pain management approaches, pharmacologic guidelines, and consideration of cognitively impaired patients. The 2009 update to the AGS pain guidelines focuses on details of pharmacologic management, incorporating newer evidence-based pharmacologic approaches into the protocol. AMDA released its first guidelines on managing chronic pain in the nursing home setting in 1999,4 and they were subsequently revised in 2003, 2009, and 2012.5-7
Our literature review evaluates how guidelines, such as those put forth by the AGS and AMDA, on persistent pain in older persons have been applied in the LTC setting with regard to pain assessment and management protocols, including in cognitively impaired individuals. However, given the relative dearth of data on the application of pain guidelines in the LTC setting, we broadened our review to include an overview of the general literature regarding barriers to effective pain assessment and management in nursing home residents and of strategies that can be employed to improve pain management in this population.
Examining the Scope of Pain in LTC Residents
Documented rates of persistent pain in nursing home residents vary throughout the literature. In a systematic review by Fox and colleagues8 that included six studies with data from self-reporting or chart reviews,the prevalence of pain in US nursing homes and abroad ranged between 49% and 83%. When only the five studies with data on analgesic use were considered, the prevalence of pain ranged between 27% and 44%. In a study by Teno and associates,9 which analyzed the Minimum Data Set (MDS) data for approximately 2.2 million US nursing home residents, the rate ranged between 39.5% and 49.5%.
Untreated pain can impact LTC residents physically, mentally, and socially in many ways, including by interfering with their activities of daily living, sleep, and mobility. Pain can also lead to depression, anxiety, and other physical stresses.10 Among the many barriers to effective pain management in nursing homes are high staff turnover; government regulatory issues; lack of formal pain education for staff, including limited physician involvement; and cognitive impairment, which is seen in many nursing home residents.11-13 Older adults may not report pain to their providers because they think it is a normal consequence of aging, and patients and families may not report it because they fear addiction issues as portrayed in the media.10,14 Furthermore, the pain experience for patients may be complicated by emotional, spiritual, and physical suffering, making it difficult for nursing home staff to adequately quantify or qualify pain.15
There is also likely a gap between the perception of pain management in a given facility and the existence of an actual standardized approach that staff must use for assessment and treatment. In an interview of 49 LTC administrators across Kentucky, all respondents answered “yes” to the question, “Does your staff do a good job of assessing and treating pain in your residents?”13 However, none of the facilities had a formal, routine pain assessment protocol in place that was used on a daily or weekly basis, and only one respondent reported having a pain assessment protocol in place for cognitively impaired residents. Some facilities did have tools for measuring pain intensity, most often the Wong-Baker FACES Pain Rating Scale, but there were no policies requiring staff to use this tool.
Pain Assessment and Management Protocols in LTC
There are marked inconsistencies between pain guidelines and the actual practice of pain assessment and management in LTC facilities, with pain management practices varying widely.16-20 One of the biggest obstacles to optimal pain management facing many nursing homes is the lack of a comprehensive pain assessment protocol that is administered on a frequent basis. Although pain evaluations using the MDS are mandatory upon admission to LTC facilities, a subset of MDS items is administered only quarterly thereafter or when there is a change in a resident’s status.15,21 Pain evaluation between these quarterly assessments may be informal or lacking altogether. One study showed that nursing home staff may rely on relationship-centered daily pain assessments (meaning the staff determines a resident’s pain levels based on their knowledge of the resident’s behavior), rather than on a formal, standardized pain assessment tool.15 This may lead to staff misinterpreting behavior and nonverbal pain cues.15,22
In 2009, Decker and colleagues17 conducted a descriptive study of 215 residents from 13 Iowa nursing homes and found that face-to-face patient interviews involving four yes/no questions about the presence of pain revealed higher rates of pain responses than those documented in the MDS, which at the time used a numerical scale to determine pain levels. The MDS was updated in 2010 to version 3.0 and now includes interview-type questions about pain; however, while MDS 3.0 also includes a pain assessment protocol for nurses to evaluate pain behaviors in residents who are unable to respond to the interview questions, patients with cognitive impairment may still be at a disadvantage if they cannot remember, process, or communicate details of their pain to the nurse assessor.21,23
Cohen-Mansfield and Lipson24 demonstrated the challenge of pain assessment in cognitively impaired individuals in a cross-sectional analysis that evaluated the reliability and validity of geriatricians’ assessments of pain in cognitively impaired nursing home residents. The study included 79 cognitively impaired residents (median age, 87 years), 31 with mild to moderate impairment and 48 with severe impairment, whose pain levels were assessed by two outside geriatricians via a physical examination, completion of a detailed pain assessment, and an evaluation of the residents’ laboratory results. The authors found that the reliability and validity of the pain assessments dropped significantly for the residents with severe cognitive impairment, and they concluded “There is a need for increased awareness of pain in this population and a need for improved methodologies to identify it.”24 A later study by the same authors involving 121 nursing home residents with dementia sought to examine the utility of nine pain assessments in identifying pain and documenting responsiveness to pain medication in cognitively impaired individuals; these assessments included self-report, informant ratings by nursing staff, and direct observations.14 Residents who met the criteria for pain on at least two of the assessment instruments were treated with a medication protocol based on current guidelines. Patients were assessed every 2 weeks and advanced to the next phase of medication if they were still considered to be in moderate pain on at least two assessment instruments. The authors found that using multiple assessments along with a pain medication protocol were effective in reducing pain, particularly when informant ratings and self-report assessment tools were employed.14 This and other studies indicate that specialized assessment tools for cognitively impaired LTC residents are necessary.14,22,24-27
Without adequate pain assessment, it is difficult to determine an appropriate treatment plan. Few studies in the literature detail interventions for pain in the LTC setting. Herman and colleagues28 conducted a structured review in 2009 of prospectively designed intervention studies in managing pain in the LTC setting. Overall, they found uneven quality in the research designs, varying end point measures, and differing characteristics of the resident populations.
When pain management strategies do exist, they are not uniform. One study involving 2065 LTC residents across the United States demonstrated that, in addition to a lack of appropriate pain assessments in this population, nonpharmacologic pain interventions were rarely used and prescribing patterns were variable and often included the inappropriate use of analgesics, most commonly propoxyphene.18 The authors concluded that the frequent prescribing of inappropriate pain therapies for older people attests to the urgent need to educate nursing home practitioners on the appropriate use of analgesics.
In 2009, a study including 215 residents from 13 rural Iowa nursing homes sought to identify patients’ musculoskeletal diagnoses associated with pain and then compared pain management strategies in these patients with those outlined in the 1998 AGS evidence-based pain guidelines.17 Again, analgesic medications given for pain were inconsistent, and propoxyphene, which was discouraged in the AGS pain guidelines and taken off the US market in 2010, was used in 10.7% of the study cases. A high percentage (32.9%) of residents expressing daily pain received no analgesics, and nonpharmacologic interventions were used by only 13.5% of the study group, with topical agents being the most common therapy. The authors concluded that the AGS evidence-based guidelines for managing chronic pain were inconsistently implemented in the nursing homes they assessed.17
Pharmacologic and Nonpharmacologic Pain Management Strategies
Clinical trials of analgesic drugs and nonpharmacologic therapies have often excluded older patients, specifically those in the nursing home setting, which is problematic when prescribing treatments for this patient population.2 The few articles looking at specific analgesics recommended by the AGS pain guidelines have shown unclear benefit or have been inconclusive. For example, Buffum and colleagues27 studied the effect of regularly scheduled acetaminophen in 39 LTC residents in California who had dementia and a painful condition. They found that a 2600-mg daily dose of acetaminophen provided inadequate pain control for elderly nursing home patients who had significant discomfort. Chibnall and associates29 also studied the effect of acetaminophen (3000 mg/day) on behavior and well-being in nursing home residents, hypothesizing that scheduled pain medication would improve agitation, which was the primary outcome measure of their study. Although the results were inconclusive, with no effects observed on agitation, emotional well-being, or use of as-needed psychotropic medications, the authors did report that when participants received acetaminophen versus the placebo, they were more prone to engaging in activities and socializing with people, experienced less unattended distress, and were less isolated.29
Finally, Manfredi and colleagues30 performed a trial of scheduled opioids for agitated nursing home patients with advanced dementia. It was presumed that agitation in these residents was related to uncontrolled pain and that reducing pain in these patients would concomitantly reduce their agitation. Although low-dose, long-acting opioids were shown to lessen agitation that is difficult to control in very old patients (≥85 years) with advanced dementia, the study was limited overall by its small size (only 25 completed this two-phase study), as there was a high dropout rate related to issues such as unsteady gait, increased agitation, fecal impaction, infection, and seizures.30
Although the AGS and AMDA pain guidelines state that pharmacologic treatment is the cornerstone of pain management in the LTC setting, they note that a combination approach that includes both pharmacologic and nonpharmacologic pain treatments is often the most effective. According to the 2009 AMDA pain guidelines, nonpharmacologic comfort interventions, such as distraction, relaxation, massage, application of heat or cold, change of position, or exercise, should be the first approach employed to control pain when a patient’s physical examination and history are negative.7 Although nonpharmacologic interventions are generally supported by the various pain guidelines, research on the most effective complementary and alternative therapies to analgesic treatment in the LTC setting are lacking. In 2002, Simmons and colleagues31 conducted a randomized controlled trial to assess the efficacy of controlled exercise to manage pain in 51 nursing home residents. The authors found no significant changes in pain reports attributable to exercise, and while the participants in the exercise intervention group demonstrated improvements in physical performance, there was actually a tendency for pain to increase in this group. This finding led the authors to recommend preemptive analgesia or modified exercise regimens.31