An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons

Evaluation of a Pain Assessment Procedure in Long-Term Care Residents With Pain and Dementia

BACKGROUND

The management of pain in long-term care (LTC) residents with dementia is complex. A prospective exploratory study was conducted to describe the course of pain and pain management strategies following a guideline-based pain assessment procedure in LTC residents with pain and dementia.

MEASURES

Pain observations with the Mobilization Observation Behaviour Intensity Dementia (MOBID-2) Pain Scale, a review of the electronic patient file and pharmacy files and physical examination of LTC residents with pain and dementia.

INTERVENTION

Communication of the assessment results to the attending physician including guideline-based treatment recommendations.

OUTCOMES

After three months, complete follow-up data were obtained for 64 residents. Pain intensity was significantly reduced (P < 0.001). The proportion of residents with persistent pain was 58% and the total number of analgesic prescriptions did not change significantly.

CONCLUSIONS

There is room for improvement regarding pain management in LTC residents with pain and dementia, and performance feedback seems a promising strategy to explore further.

Self-report pain assessment tools for cognitively intact older adults: Integrative review

BACKGROUND

Pain is common in older adults, but it is often underreported or undertreated partly because many consider pain to be a normal consequence of ageing. Among the plethora of available self-report pain assessment tools, there is no synthetised evidence which tools are indicated for use among cognitively intact older adults.

PURPOSE OF THE STUDY

To understand documented self-report pain assessment tools that have been used among cognitively intact older adults, and to describe their characteristics including overall performance as well as studies demonstrating their use.

METHODS

A systematic search of the indexed databases PubMed, PsycINFO and Cumulative Index to Nursing and Allied Health Literature (CINAHL Plus) was conducted to identify documented self-report pain assessment tools through peer-reviewed papers, including citations from January 1990 to December 2015. Thirty-five percentage of abstracts were independently evaluated by two raters according to specific criteria.

RESULTS

Among identified tools, the Iowa Pain Thermometer, the 6-point Verbal Descriptor Scale, the Numeric Rating Scale, the short form Brief Pain Inventory (BPI) and the Geriatric Pain Measure (GPM) may be suitable tools for self-reported pain by cognitively intact older adults based on the statement of the literature. Only two self-report tools (the GPM and the Geriatric Painful Events Inventory) were designed specifically for older adults.

CONCLUSIONS

More studies are needed to evaluate pain measures' psychometric performance across different settings, racial/ethnic groups and disease categories. Since 80% of older adults have at least one chronic disease, multidimensional tools such as the GPM may need to be used more often for accurate self-report of pain.

IMPLICATIONS FOR PRACTICE

Examining the psychometric properties of comprehensive self-report pain assessment tools informs recommendations for the selection of tools to be used in clinical practice.

Pain Management in Older Adults

Treating pain in older adults can be complex because of the age-related physiologic changes, comorbidities, and polypharmacy. Thus, an individualized, multimodal treatment approach is recommended. Treatment plans should include pharmacologic and nonpharmacologic strategies. Several important clinical guidelines and expert panel statements are available to guide health care providers in the best practices for treating pain in older adults. This article provides evidence-based recommendations for pharmacological and non-pharmacological pain management in older adults.

Clinical Evaluation of a Skin Protectant for the Management of Incontinence-Associated Dermatitis: An Open-Label, Nonrandomized, Prospective Study

PURPOSE:

The purpose of this study was to evaluate the efficacy of an investigational skin protectant product at managing severe skin breakdown associated with incontinence.

DESIGN:

Open-label, nonrandomized, prospective study.

SUBJECTS AND SETTING:

The sample comprised 16 patients; inclusion criteria were: patients older than 18 years, cared for in the intensive care unit of a level I trauma center hospital or in long-term care facilities in the northeast region of the United States, and had incontinence-associated dermatitis (IAD). Twelve of the patients had epidermal skin loss and 4 had severe redness.

METHODS:

The investigational product is a formulation based on acrylate chemistry. The skin protectant application schedule was twice weekly for up to 3 weeks for a maximum of 6 applications during the study period. The skin was evaluated via a skin assessment instrument specifically designed for use in this study; this instrument has not undergone validation studies. The main outcome measure was changes in the instrument score over time. In addition, complete reepithelialization was recorded when observed, and pain scores (associated with IAD) were noted in participants who were able to report pain.

RESULTS:

The IAD score improved in 13 of 16 patients, remained unchanged in 1 patient, and deteriorated in 2 patients. The median percent improvement in the skin assessment instrument was 96% (P = .013). Four of the patients with epidermal skin loss had complete reepithelialization of the skin surface with 4 to 6 applications of the skin protectant, and 5 had substantial improvement. The 4 patients with severe red skin returned to healthy normal skin with 2 to 4 skin protectant applications. Substantial pain reduction was reported by all 9 patients who reported pain at enrollment. No adverse events associated with the skin protectant application were reported during data collection.

CONCLUSION:

Results of this study suggest that an acrylate-based product, evaluated here for the first time in patients, may be effective as a protective barrier in the presence of continued incontinence. Additional research is needed to confirm these findings.

Mental Health and Pain in Older Adults: Findings from Urban HEART-2

Pain is an important component of disability problems, and plays a key role in mental health of older adults. This study aims to investigate the relationship between mental health and pain in older adults of Tehran, Iran. This was a cross-sectional study using data on 5326 older adults aged ≥60 years old from a large population-based survey (Urban HEART-2). A multistage cluster random sampling method was used to select the participants in Tehran, Iran, in 2011. General Health Questionnaire (GHQ-28), pain questionnaire, and socioeconomic questionnaires were used to collect the data. A total of 5326 older adults, 3811 (71.6%) married and 2797 (52.5%) female, were included into the study. The mean age of the participants was 68.92 ± 7.02 years. Mean of GHQ-28 scores in the sample was 51.08 ± 10.94, which indicates of a good level of mental health. The majority of the older adults had knee and back pain (more than 50%). Regardless of the chronicity, time, and the mode of reaction to it, knee and back pain were the highly reported pains among the participants. There was a statistically significant difference between two groups of older adults, with and without pain, in terms of GHQ-28 scores. Multiple regression analysis revealed that there was a relationship between mental health and the following factors: pain in head, shoulder, teeth, upper and lower limbs, education, gender, age, and marital status. Whatever the explanation, the relation of lowered health status to pain in all body parts among older people is considerable. This renders this matter as a top priority in health policy making.

Pain and pharmacologic pain management in long-stay nursing home residents

Previous studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after the important initiatives of (1) prevalence and correlates of persistent pain; and (2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in U.S. NHs between 2011 and 2012 with 2 Minimum Data Set assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios (APRs) estimates and 95% confidence intervals (CIs). The prevalence of persistent and intermittent pain was 19.5% and 19.2%, respectively, but varied substantially by age, sex, race and ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated and undertreated, respectively. Racial and ethnic minorities (non-Hispanic blacks vs whites, APR = 1.19, 95% CI: 1.13-1.25) and severely cognitively impaired residents (severe vs no/mild APR = 1.51, 95% CI: 1.44-1.57) had an increased prevalence of untreated and undertreated pain. One in 5 NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Associations between Pain and Quality of Life in Severe Dementia: A Norwegian Cross-Sectional Study

Background/Aims

Many variables influence the quality of life in older adults with dementia. We aim to quantify how the relationship between pain and quality of life in nursing home residents with severe dementia can be explained by neuropsychiatric symptoms, depressive symptoms, and activities of daily living.

Methods

This article presents cross-sectional baseline data from a cluster randomised controlled trial.

Results

The total and direct effects of pain on quality of life were statistically significant. Both neuropsychiatric and depressive symptoms partially mediated the relationship between pain and quality of life. Activities of daily living acted as a mediator only when modelled together with depressive symptoms.

Conclusion

Pain, neuropsychiatric symptoms, and depressive symptoms appear to be important factors that influence the quality of life for nursing home residents with severe dementia. Therefore, multidimensional interventions may be beneficial for maintaining or improving quality of life in this population.

Differences in psychosocial responses to pain between sufficiently and insufficiently active adults with arthritis

OBJECTIVE

Adults with arthritis struggle to meet the physical activity recommendation for disease self-management. Identifying psychosocial factors that differentiate adults who meet (sufficiently active) or do not meet (insufficiently active) the recommendation is needed. This study sought to examine differences in psychosocial responses to arthritis pain among adults who were sufficiently or insufficiently active.

DESIGN

This prospective study included adults with medically diagnosed arthritis (N = 136, M_age = 49.75 ± 13.88 years) who completed two online surveys: (1) baseline: pain and psychosocial responses to pain and (2) two weeks later: physical activity.

MAIN OUTCOME MEASURES

Psychosocial responses examined in this study were psychological flexibility in response to pain, pain anxiety and maladaptive responses to pain anxiety.

RESULTS

A between-groups MANCOVA comparing sufficiently active (n = 87) to insufficiently active (n = 49) participants on psychosocial responses, after controlling for pain intensity, was significant (p = .005). Follow-up ANOVA's revealed that sufficiently active participants reported significantly higher psychological flexibility and used maladaptive responses less often compared to insufficiently active participants (p's < .05).

CONCLUSIONS

These findings provide preliminary insight into the psychosocial profile of adults at risk for nonadherence due to their responses to arthritis pain.

The determinants of coping with pain in chronically ill geriatric patients - the role of a sense of coherence

BACKGROUND

Given the rising population of the elderly in modern societies, the concern for their good functioning poses a challenge for the 21st century medicine and social services. Senior citizens are at an increased risk of developing chronic conditions, which in turn increase discomfort associated with physiological processes of aging. Sensations of pain have a particular influence on the mentioned discomfort, and pain is prevalent among older people. Therefore, from the perspective of an elderly person and senior care, it is crucial to identify determinants of effective coping with chronic pain.

OBJECTIVES

The aim of the research was to assess the relationship between a sense of coherence (SOC) and pain-coping strategies in chronically ill seniors. A total number of 188 individuals were included in the study, of whom 117 were female subjects and 71 were male subjects, with a mean age of 68.38 (standard deviation [SD] =6.35) years in the studied group. Subjects were sampled based on a diagnosis of a chronic medical illness with chronic pain as one of the major symptoms.

METHODS

The Polish adaptation of the Orientation to Life Questionnaire (SOC-29) to assess an SOC, the Coping Strategies Questionnaire (CSQ) to assess pain-coping strategies, and the visual analog scale (VAS) to assess pain intensity were used in the study.

RESULTS AND CONCLUSION

The mean score of respondents' SOC was 133.44 (SD =24.35). Among most common pain-coping strategies used by the respondents were prayer and hope, and the declaration of coping with pain while redefining pain was the least often used coping strategy in the studied group. Individuals with stronger SOC were less prone to catastrophizing and more often declared that they were coping with and could control and reduce pain.

[Patients with pain in outpatient care. A nationwide cross-sectional survey with path model]

BACKGROUND

There is limited knowledge on the degree of pain and pain-related impairments in home care clients. This study was carried out to provide data on the prevalence of pain and pain-related impairments in home care patients and to investigate the impact on activities of daily living and on classification into the three levels of care as defined by the statutory German long-term care insurance.

MATERIAL AND METHODS

In 2012 a representative cross-sectional multicenter study was conducted among clients of 100 German home care services. The stepwise sampling procedure included a random selection of 9 home care services in each of the 16 federal states and a randomized sampling among the clients of the participating home care services. The total sample consisted of 878 home care clients (inclusion criteria ≥ 18 years). The subjective pain intensity was measured using an 11-step Likert scale ranging from 0 (no pain) to 10 (most severe pain). Pain-related impairments were rated on a 6-step Likert scale (0 = no impairments to 5 = complete impairment) assessing the level of independence in household chores, mobility, personal hygiene, dressing and social participation. Furthermore, multimorbidity (number of diagnoses) and level of care according to the current classification in the German long-term care insurance were registered. The predictive significance of latent variables was determined by structural equation modelling.

RESULTS

Of the subjects surveyed 68.5 % (n = 672) reported suffering from pain. The average intensity of pain was 2.9 (standard deviation SD 2.8) and pain-related impairments had the greatest effect on mobility (78.2 %). Path analysis revealed that a higher degree of pain-related impairments (β = + 0.31) and a higher number of diagnoses (β = + 0.19) were associated with classification to higher levels of care as defined in the German long-term care insurance. However, stronger pain and higher age were related to a classification to a lower level of care (β = - 0.21). No relevant gender differences were identified except for the finding that old age in women had no significant effect on the classification to the level of care, whereas in men both old age and pain intensity did have an impact.

CONCLUSION

Even though the majority of home care clients in this representative study suffered from pain, the degree of pain intensity only becomes an issue in home care if it concurs with impairments in daily living and a corresponding classification to higher levels of care dependency. These findings suggest that pain and pain management should receive more attention in home care, irrespective of observable impairments in daily living. In practice, nurses in home care services should regularly assess the level of pain intensity among home care clients and the results of these regular pain assessments should be taken into account for the identification of individual care needs.

Somatosensory function in old age

Sensory decline is viewed as an inevitable consequence of the ageing process. However, reports of declines have not been a consistent finding across the sensory systems. Reports from psychophysical studies indicate that the most common declines with ageing are in vision and audition and, to a lesser degree, olfaction and gustation. Findings for the somatosensory system (mechanoreception, warming and cooling thermoreception and pain) are less conclusive. Factors that contribute to individual differences in sensory ratings beyond chronological ageing include stimulus factors including stimulus type and body location, response measures and instructions, systemic disease that may affect the peripheral or central nervous system and environmental factors that may affect the skin integrity.

Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

OBJECTIVE

To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development.

DESIGN

Multicentre prospective cohort study.

SETTING

UK hospital and community settings.

PARTICIPANTS INCLUSION

Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU).

EXCLUSION

Patients too unwell, unable to report pain, 2 or more category ≥2 PUs.

FOLLOW-UP

Twice weekly for 30 days.

PRIMARY AND SECONDARY OUTCOME MEASURES

Development and time to development of one or more category ≥2 PUs.

RESULTS

Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001).

CONCLUSIONS

This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development.

Exploring healthcare assistants' role and experience in pain assessment and management for people with advanced dementia towards the end of life: a qualitative study

BACKGROUND

Pain assessment and management are key aspects in the care of people with dementia approaching the end of life but become challenging when patient self-report is impaired or unavailable. Best practice recommends the use of observational pain assessments for these patients; however, difficulties have been documented with health professionals' use of these tools in the absence of additional collateral patient knowledge. No studies have explored the role, perspectives and experiences of healthcare assistants in pain assessment and management in dementia; this study provides insight into this important area.

METHODS

A qualitative approach was adopted, using key informant interviews with healthcare assistants caring for people with advanced dementia approaching the end of life in hospice, nursing home and acute care settings. Thematic analysis was the analytic approach taken to interpretation of interview data. Data were collected between June 2014 and September 2015.

RESULTS

Fourteen participants took part in the study. Participants' average length of caring experience was 15.4 years and most were female. Three key themes emerged: recognising pain, reporting pain, and upskilling. Participants were often the first to notice obvious causes of pain and to detect changes in patient norms which signified hidden causes of pain. Comprehensive knowledge of resident norms enabled participants to observe for behavioural and nonverbal indicators of pain and distinguish these from non-pain related behaviours. Pain reporting was heavily impacted by relationships with professional staff and the extent to which participants felt valued in their role. Positive relationships resulted in comprehensive pain reports; negative relationships led to perfunctory or ambiguous reporting. Participants emphasised a desire for further training and upskilling, including in the use and reporting of basic pain tools.

CONCLUSIONS

Healthcare assistants are frontline staff who have a key role in direct patient care, spending a considerable amount of time with patients in comparison to other health professionals. These staff are often first to notice changes in patients that may signify pain and to alert professional staff. However, to ensure the quality of these reports, further efforts must be made in reversing stigma attached to this role and in upskilling these members of the healthcare team.

Acceptance and Commitment Therapy and Selective Optimization with Compensation for Institutionalized Older People with Chronic Pain

OBJECTIVE

Recent studies support the efficacy of Acceptance and Commitment Therapy (ACT) with people with chronic pain. In addition, Selective Optimization with Compensation strategies (SOC) can help the elderly with chronic pain to accept their chronic condition and increase functional autonomy. Our aim was to analyze the efficacy of an ACT treatment program combined with training in SOC strategies for elderly people with chronic pain living in nursing homes.

METHODS

101 participants (mean age = 82.26; SD = 10.00; 78.6% female) were randomized to the intervention condition (ACT-SOC) or to a minimal support group (MS). Complete data are available for 53 participants (ACT-SOC: n = 27; MS: n = 26). Assessments of functional performance, pain intensity, pain acceptance, SOC strategies, emotional well being and catastrophizing beliefs were done preintervention and postintervention.

RESULTS

Significant time by intervention changes (P = 0.05) were found in acceptance, pain related anxiety, compensation strategies, and pain interference in walking ability. Simple effects changes were found in acceptance (P = 0.01), selection strategies (P = 0.05), catastrophizing beliefs (P = 0.03), depressive symptoms (P = 0.05), pain anxiety (P = 0.01) and pain interference in mood and walking ability (P = 0.03) in the ACT-SOC group. No significant changes were found in the MS group.

CONCLUSIONS

These results suggest that an ACT intervention combined with training in SOC strategies could help older people with pain to improve their emotional well being and their functional capability.

Experiencing Pain in the Presence of Others: A Structured Experimental Investigation of Older Adults

The role of various forms of social support (including the mere presence of another person) in pain has been studied in children and younger adults, but parallel studies involving older persons have not been conducted. In this investigation, older adults (N = 100) took part in a series of experimental pain tasks in each of the following conditions: alone, in the presence of a stranger, and in the presence of a family member. Indices of pain (threshold, tolerance, intensity, unpleasantness, facial expressions) and facial expressions of emotion were analyzed. Facial expressions of pain and happiness were more prominent when a family member was present. In the presence of a stranger, pain was reported as less unpleasant and facial expressions of fear were more frequent. In examining sex differences, male participants reported higher pain tolerance and female participants displayed more prominent facial expressions of pain. Moreover, facial expressions of neutral states and happiness were more frequent among female participants, whereas facial expressions of anger were more frequent among male participants. Results show that the presence of others influences the experience and expression of pain in older persons.

PERSPECTIVE

We showed that the presence of others influences the experience and expression of pain in older adults. The presence of a family member increases nonverbal pain expressiveness whereas the presence of a stranger results in decreased self-reported pain unpleasantness.

Polypharmacy and inappropriate medication use in patients with dementia: an underresearched problem

Multimorbidity and polypharmacy are increasingly prevalent across healthcare systems and settings as global demographic trends shift towards increased proportions of older people in populations. Numerous studies have demonstrated an association between polypharmacy and potentially inappropriate prescribing (PIP), and have reported high prevalence of PIP across settings of care in Europe and North America and, as a consequence, increased risk of adverse drug reactions, healthcare utilization, morbidity and mortality. These studies have not focused specifically on people with dementia, despite the high risk of adverse drug reactions and PIP in this patient cohort. This narrative review considers the evidence currently available in the area, including studies examining prevalence of PIP in older people with dementia, how appropriateness of prescribing is assessed, the medications most commonly implicated, the clinical consequences, and research priorities to optimize prescribing for this vulnerable patient group. Although there has been a considerable research effort to develop criteria to assess medication appropriateness in older people in recent years, the majority of tools do not focus on people with dementia. Of the limited number of tools available, most focus on the advanced stages of dementia in which life expectancy is limited. The development of tools to assess medication appropriateness in people with mild to moderate dementia or across the full spectrum of disease severity represents an important gap in the research literature and is beginning to attract research interest, with recent studies considering the medication regimen as a whole, or misprescribing, overprescribing or underprescribing of certain medications/medication classes, including anticholinergics, psychotropics, antibiotics and analgesics. Further work is required in development and validation of criteria to assess prescribing appropriateness in this vulnerable patient population, to determine prevalence of PIP in large cohorts of people with the full spectrum of dementia variants and severities, and to examine the impact of PIP on health outcomes.

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

In two decades, the pendulum has swung from focusing on the undertreatment of pain by prescribers who fail to use medically necessary opioid agents to an intense focus on overprescribing opioid medications and the harms they cause. Within these two extremes rests the older adult with pain and in need of safe and effective care. Today, health care providers are practicing in an era of scrutiny, with new guidelines and regulations superseding their compassion and clinical judgment about the best treatment options when older adults have pain across the care continuum. Media depicting opioid medications as lethal, unnecessary, and highly addictive that do not distinguish non-medical from therapeutic use or legitimately versus illegally obtained drugs are widely reported. These reports and legislative focus on treating addiction have silenced and further stigmatized older adults with persistent pain. Patients and professionals treating pain need to provide balance of multimodal pain management strategies to safely manage persistent pain based on a comprehensive assessment and personalized approach. [Journal of Gerontological Nursing, 42(12), 31-39.].

Pain assessment tools for older adults with dementia in long-term care facilities: a systematic review

AIM

The aim of this review is to document pain assessment tools used primarily for older adults in long-term care facilities and compare self-report and observer-rated tools.

METHODS

A literature search was conducted in Ovid MEDLINE^®, Embase, Cochrane and PsycINFO. Keywords included 'dementia', 'pain management' and 'managing pain'.

RESULTS

Of 1033 references, 23 articles were selected for inclusion. Six tools were self-rated and 18 tools were administered by an observer. 13 studies evaluated the reliability/validity of their scales; four studies compared different scales against each other.

CONCLUSION

Self-report should be the first-line approach when possible, with observational assessment used as a supplementary tool. Reliable observational tools have been shortened, and shown to maintain high reliability/validity, and positive psychometric properties.

Pharmacotherapies in Geriatric Chronic Pain Management

Pharmacologic management of chronic pain in older adults is one component of the multimodal, interdisciplinary management of this complex condition. In this article, we summarize several of the key barriers to effective pharmacologic management in older adults and review the existing (albeit limited) evidence for its effectiveness and safety, especially in a medically complex population with multimorbidity. This review covers topical formulations, acetaminophen, oral nonsteroidal antiinflammatory drugs, and adjuvant therapies. The article concludes with a suggested approach to managing chronic pain in the older patient, incorporating goals and expectations for treatment as well as careful monitoring of medication adjustments.

Assessment and Measurement of Pain in Adults in Later Life

Pain in aging adults is a global health problem requiring a proactive and consistent assessment approach. Pain assessment is critical to detecting pain and developing a collaborative and adaptive pain management plan. Getting health providers to assess and measure pain even in older adults who are communicative and can self-report remains a challenge. Self-report is the best method for identifying pain. Using a validated pain assessment scale is key to evaluate pain intensity. This article discusses techniques to obtain self-report and describe appropriate self-report pain tools for a focused pain assessment and reassessment in adults in later life.

Gaps in Aging Research as it Applies to Rheumatologic Clinical Care

The incidence and prevalence of rheumatologic conditions are increasing and the rheumatology workforce must be aware of aging-specific issues. This article reviews specific barriers to understanding the biology of aging and aging-related mechanisms that may underlie development of rheumatologic diseases in older adults. It summarizes gaps in the assessment, outcomes measurement, and treatment of these diseases in this unique population. It also highlights potential solutions to these barriers and suggests possible ways to bridge the gap, from a research and education standpoint, so that clinicians can be better prepared to effectively manage older adults with rheumatologic conditions.

Towards improved decision support in the assessment and management of pain for people with dementia in hospital: a systematic meta-review and observational study

Background

Pain and dementia are common in older people, and impaired cognitive abilities make it difficult for them to communicate their pain. Pain, if poorly managed, impairs health and well-being. Accurate pain assessment in this vulnerable group is challenging for hospital staff, but essential for appropriate management. Robust methods for identifying, assessing and managing pain are needed.

Aims and objectives

Two studies were undertaken to inform the development of a decision support tool to aid hospital staff in the recognition, assessment and management of pain. The first was a meta-review of systematic reviews of observational pain assessment instruments with three objectives: (1) to identify the tools available to assess pain in adults with dementia; (2) to identify in which settings they were used and with what patient populations; and (3) to assess their reliability, validity and clinical utility. The second was a multisite observational study in hospitals with four objectives: (1) to identify information currently used by clinicians when detecting and managing pain in patients with dementia; (2) to explore existing processes for detecting and managing pain in these patients; (3) to identify the role (actual/potential) of carers in this process; and (4) to explore the organisational context in which health professionals operate. Findings also informed development of health economics data collection forms to evaluate the implementation of a new decision support intervention in hospitals.

Methods

For the meta-review of systematic reviews, 12 databases were searched. Reviews of observational pain assessment instruments that provided psychometric data were included. Papers were quality assessed and data combined using narrative synthesis. The observational study used an ethnographic approach in 11 wards in four UK hospitals. This included non-participant observation of 31 patients, audits of patient records, semistructured interviews with 52 staff and four carers, informal conversations with staff and carers and analysis of ward documents and policies. Thematic analysis of the data was undertaken by the project team.

Results

Data from eight systematic reviews including 28 tools were included in the meta-review. Most tools showed moderate to good reliability, but information about validity, feasibility and clinical utility was scarce. The observational study showed complex ward cultures and routines, with variations in time spent with patients, communication patterns and management practices. Carer involvement was rare. No pain decision support tools were observed in practice. Information about pain was elicited in different ways, at different times, by different health-care staff and recorded in separate documents. Individual staff made sense of patients’ pain by creating their own ‘overall picture’ from available information.

Limitations

Grey literature and non-English-language papers were excluded from the meta-review. Sample sizes in the observational study were smaller than planned owing to poor documentation of patients’ dementia diagnoses, gatekeeping by staff and difficulties in gaining consent/assent. Many patients had no or geographically distant carers, or a spouse who was too unwell and/or reluctant to participate.

Conclusions

No single observational pain scale was clearly superior to any other. The traditional linear concept of pain being assessed, treated and reassessed by single individuals did not ‘fit’ with clinical reality. A new approach enabling effective communication among patients, carers and staff, centralised recording of pain-related information, and an extended range of pain management interventions is proposed [Pain And Dementia Decision Support (PADDS)]. This was not tested with users, but a follow-on study aims to codesign PADDS with carers and clinicians, then introduce education on staff/patient/carer communications and use of PADDS within a structured implementation plan. PADDS will need to be tested in differing ward contexts.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Assessment of Chronic Pain: Domains, Methods, and Mechanisms

Accurate classification of chronic pain conditions requires reliable and valid pain assessment. Moreover, pain assessment serves several additional functions, including documenting the severity of the pain condition, tracking the longitudinal course of pain, and providing mechanistic information. Thorough pain assessment must address multiple domains of pain, including the sensory and affective qualities of pain, temporal dimensions of pain, and the location and bodily distribution of pain. Where possible, pain assessment should also incorporate methods to identify pathophysiological mechanisms underlying the pain. This article discusses assessment of chronic pain, including approaches available for assessing multiple pain domains and for addressing pathophysiological mechanisms. We conclude with recommendations for optimal pain assessment.

PERSPECTIVE

Pain assessment is a critical prerequisite for accurate pain classification. This article describes important features of pain that should be assessed, and discusses methods that can be used to assess the features and identify pathophysiological mechanisms contributing to pain.

Interdisciplinary Approaches to Managing Pain in Older Adults

An interdisciplinary approach to managing pain has been widely used in managing specific pain conditions (eg, lower back and fibromyalgia) but not reviewed specifically for older adults. Interdisciplinary approaches have been used in primary, residential long-term, and acute care settings, where a variety of health care professionals work on pain teams to manage pain in older adults. Given the multidimensional nature of pain in older adults, interdisciplinary approaches to managing pain are recommended in practice. This article reviews the rationale supporting an interdisciplinary approach to managing pain in older adults and summarizes studies that have evaluated this approach.

Pain assessment in elderly with dementia: Brazilian validation of the PACSLAC scale

Objective

To validate the Pain Assessment Checklist for Seniors with Limited Ability to Communicate – Portuguese in demented elderly and to analyze its measurement properties.

Methods

We evaluated 50 elderly with dementia, residing in a nursing home and with limited communication ability, when exposed to potentially painful situations. The tool was applied at two different moments. First, two interviewers applied it simultaneously, and the intensity of pain was asked based on the caregiver’s opinion. After 14 days, with no analgesic intervention, one of the interviewers applied it again.

Results

The sample comprised more females, aged over 80 years, with dementia due to Alzheimer, presenting musculoskeletal pain of moderate to severe intensity. The psychometric properties of the tool demonstrated appropriate internal consistency (Cronbach’s alpha coefficient of 0.827). The scale had excellent reproducibility, according to the intraclass correlation coefficient, and the tool has been duly validated.

Conclusion

The Pain Assessment Checklist for Seniors with Limited Ability to Communicate – Portuguese had adequate measuring properties for use with elderly presenting limited communication.

Nurses’ Pain Management for Hospitalized Elderly Patients With Postoperative Pain

Using the theory of planned behavior, the study aim was to determine the relationships among nurses’ beliefs, attitudes, perceived norms, perceived behavioral control, intentions, and behavior regarding pain management for hospitalized elderly patients with postoperative pain. A cross-sectional design was used with a convenience sample of 140 nurses working in adult surgical units at three hospitals. Based on path analyses, nurses’ behavioral, normative, and control beliefs, respectively, had direct effects on their attitudes, perceived norms, and perceived behavioral control regarding pain management. Nurses’ attitudes and perceived norms had direct effects on their pain management intentions. However, nurses’ intentions had no direct effect on their behavior (measured by responses to questions about case study vignettes). This study highlights the need for education that enhances nurses’ perceptions of pain management benefits, the influence of normative referents, and their ability to assess pain and administer pro re nata (PRN) opioid analgesics.

Physician Contacts and Their Influence on the Appropriateness of Pain Medication in Nursing Home Residents: A Cross-Sectional Study

OBJECTIVES

This study assessed the frequency of physician contacts for individual nursing home residents (NHRs) and investigated whether the frequency of contacts influences the appropriateness of pain medication in NHRs.

DESIGN

Observational cross-sectional study conducted between March 2009 and April 2010.

SETTING

Forty nursing homes in Berlin and Brandenburg, Germany.

PARTICIPANTS

A total of 560 NHRs.

MEASUREMENTS

The number and type of NHR physician contacts were obtained by face-to-face interviews. To assess the appropriateness of pain medication, the German version of the Pain Medication Appropriateness Scale (PMASD) was used. The influence of physician contacts on the appropriateness of pain medication was calculated with a linear mixed-effect model.

RESULTS

The proportions of NHRs with at least 1 contact with their attending physicians were 61.8% (primary care physicians), 55.2% (general practitioners), 9.6% (neurologists), 9.4% (other), 5.4% (internists), 2.2% (orthopedic surgeons), and 0.7% (psychiatrists). The number of all physician contacts correlated weakly with the appropriateness of pain medication (r = 0.166, P = .039). With every physician contact, the PMASD score rose by about 2 points (P = .056).

CONCLUSIONS

Physician care in German nursing homes is mainly provided by primary care physicians. A higher number of physician contacts had a modest impact on more appropriate pain medication use.

Relationships among pain intensity, pain-related distress, and psychological distress in pre-surgical total knee arthroplasty patients: a secondary analysis

The current study aimed to examine the relationships between movement and resting pain intensity, pain-related distress, and psychological distress in participants scheduled for total knee arthroplasty (TKA). This study examined the impact of anxiety, depression, and pain catastrophizing on the relationship between pain intensity and pain-related distress. Data analyzed for the current study (N = 346) were collected at baseline as part of a larger Randomized Controlled Trial investigating the efficacy of TENS for TKA (TANK Study). Participants provided demographic information, pain intensity and pain-related distress, and completed validated measures of depression, anxiety, and pain catastrophizing. Only 58% of the sample reported resting pain >0 while 92% of the sample reported movement pain >0. Both movement and resting pain intensity correlated significantly with distress (r_s = .86, p < .01 and .79, p < .01, respectively). About three quarters to two thirds of the sample (78% for resting pain and 65% for movement pain) reported different pain intensity and pain-related distress. Both pain intensity and pain-related distress demonstrated significant relationships with anxiety, depression, and catastrophizing. Of participants reporting pain, those reporting higher anxiety reported higher levels of distress compared to pain intensity. These findings suggest that anxious patients may be particularly distressed by movement pain preceding TKA. Future research is needed to investigate the utility of brief psychological interventions for pre-surgical TKA patients.

Exploring the prevalence of and factors associated with pain: a cross-sectional study of community-dwelling people with dementia

Few pain studies have made community-dwelling people with dementia (PWD) their focus. The aim of this study was to determine the prevalence of pain among this patient population and to explore medication use. Moreover, we sought to investigate patient and caregiver variables associated with the presence of pain. Community-dwelling PWD and their caregivers were recruited between May 2009 and July 2012 from outpatient memory clinics in Northern Ireland to take part in a face-to-face structured interview with a researcher. Patients' cognitive status and presence of depression were established. A full medication history was taken. Both patients and caregivers were asked to rate patients' pain, at the time of the interview and on an average day, using a 7-point verbal descriptor scale. From the 206 patients who were eligible to take part, 75 patient-caregiver dyads participated in the study (participation rate = 36.4%). The majority of patients (92.0%) had dementia classed as mild or moderate. Pain was commonly reported among the sample, with 57.3% of patients and 70.7% of caregivers reporting patient pain on an average day. Significant differences were found between patients' and caregivers' reports of pain. Two-fifths of patients (40.0%) were prescribed analgesia. Antipsychotic, hypnotic and anxiolytic drug use was low, whereas antidepressant drugs were prescribed more commonly. Presence of pain was unaffected by dementia severity; however, the use of prescribed analgesic medication was a significant predictor of the presence of pain in these patients, whether reported by the patient or their caregiver 'right now' or 'on an average day' (P < 0.001). Patient and caregiver recruitment was challenging, and remains a barrier to research in this area in the future.

Evidence from diverse clinical populations supported clinical validity of PROMIS pain interference and pain behavior

OBJECTIVE

To evaluate clinical validity, including responsiveness, of Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PROMIS-PI) and pain behavior (PROMIS-PB) T-scores.

STUDY DESIGN AND SETTING

Data were aggregated from longitudinal studies of cancer, chronic low back pain (cLBP), rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), and major depressive disorder (MDD). Linear mixed-effects models were used to compare baseline score differences and score changes over time. We calculated standardized response means (SRMs) for subgroups defined by self-reported change in general health and pain.

RESULTS

A total of 1,357 individuals participated at baseline and 1,225 at follow-up. Hypotheses of significant change in PROMIS-PI and PROMIS-PB scores were supported in the intervention groups (cLBP and MDD). Differences in baseline scores for COPD exacerbators compared to stable COPD patients were in the hypothesized direction but were not statistically significant. Subgroups reporting better health showed corresponding negative SRM values supporting responsiveness of T-scores to improvement. Responsiveness to decrements was supported in some but not all clinical groups and varied by anchor. More congruent values were obtained when using a pain-specific anchor.

CONCLUSION

This study provides evidence that PROMIS-PI and PROMIS-PB scores are sensitive to changes in pain in studies of interventions expected to impact pain. The results inform estimation of meaningful change and support power analyses for comparative effectiveness research.

Expanding access to pain care for frail, older people in primary care: a cross-sectional study

Background

Although untreated pain has a negative impact on quality of life and health outcomes, research has shown that older people do not always have access to adequate pain care. Practice nurse-led, comprehensive geriatric assessments (CGAs) may increase access to tailored pain care for frail, older people who live at home. To explore this, we investigated whether new pain cases were identified by practice nurses during CGAs administered as part of an intervention with the Geriatric Care Model, a comprehensive care model based on the Chronic Care Model, and whether the intervention led to tailored pain action plans in care plans of frail, older people.

Methods

We used cross-sectional data from the older Adults: Care in Transition (ACT) study, a 2-year clinical trial carried out in two regions of the Netherlands. Practice nurses proactively visited older people at home and administered an in-home CGA that included an assessment of pain. Pain care-related agreements and actions (pain action plans) based on CGA results were described in a tailored care plan. We analyzed care plans of 781 older people who received a first-time CGA by a practice nurse for the presence of pain, pain location and cause, new pain cases, and pain action plans. We used descriptive statistics to analyze our data.

Results

We found that 315 (40.3 %) older people experienced any type of pain. Practice nurses identified 20 (10.6 %) new pain cases, and 188 (59.7 %) older people with pain formulated at least one therapeutic or non-therapeutic pain action plan together with a practice nurse. More than half of the older people whose pain had already been identified by a primary care physician wanted a pain action plan. Most pain action plans consisted of actions or agreements related to continuity of care.

Discussion and conclusion

Practice nurses in primary care can contribute to expanding older people's access to tailored pain care. Future researchers should continue to direct their focus at ways to overcome the barriers that restrict older people’s access to pain care.

Pain in older adults: development of a tool for measuring knowledge of residential aged care staff

OBJECTIVE

To develop a psychometrically sound tool for measuring the knowledge of nursing and care staff about the experience, assessment and management of pain in older people (including people with dementia) for use in the residential aged care setting.

METHODS

The Pain in Older Adults Knowledge Survey (POAKS) was developed and tested in two phases. Phase 1 involved developing an initial item pool with good content validity based on a review of the research literature and a modified Delphi technique involving national and international experts. A pool of 24 items was developed for testing. Initial testing of the psychometric properties of the POAKS with 30 university employees led to refinement and final wording of items. Phase 2 involved testing of the psychometric properties of the POAKS with 279 respondents, including first year (n = 176) and third year (n = 70) nursing students and staff in a residential aged care service (n = 33).

RESULTS

Results established the content validity and internal consistency of the POAKS and supported its use as an instrument to measure nursing staff knowledge about the experience, assessment and management of pain in older people.

CONCLUSIONS

The POAKS will enable residential aged care facilities to measure the level of knowledge among nursing and care staff about pain in older people (including people with dementia). The measure provides a basis for the development and implementation of educational interventions to address knowledge gaps that may impact on the quality of care provided.

Increasing the Frequency and Timeliness of Pain Assessment and Management in Long-Term Care: Knowledge Transfer and Sustained Implementation

Background. Although feasible protocols for pain assessment and management in long-term care (LTC) have been developed, these have not been implemented on a large-scale basis. Objective. To implement a program of regular pain assessment in two LTC facilities, using implementation science principles, and to evaluate the process and success of doing so. Methods. The implementation protocol included a pain assessment workshop and the establishment of a nurse Pain Champion. Quality indicators were tracked before and after implementation. Focus groups and interviews with staff were also conducted. Results. The implementation effort was successful in increasing and regularizing pain assessments. This was sustained during the follow-up period. Staff members reported enthusiasm about the protocol at baseline and positive results following its implementation. Despite the success in increasing assessments, we did not identify changes in the percentages of patients reported as having moderate-to-severe pain. Discussion. It is our hope that our feasibility demonstration will encourage more facilities to improve their pain assessment/management practices. Conclusions. It is feasible to implement regular and systematic pain assessment in LTC. Future research should focus on ensuring effective clinical practices in response to assessment results, and determination of longer-term sustainability.

Subjective easiness of pain assessment measures in older people

BACKGROUND

Chronic pain is a significant health problem in older people. Easy-to-use measures of pain help detection and assessment of pain in general practice.

OBJECTIVE

To assess the subjective ease of use of self-report tools of pain among older home-dwelling people.

METHODS

Independently living people aged 75, 80 and 85 years subject to communal preventive home visits with chronic pain were invited to a clinical pain examination. At the visit subjects were asked to assess their pain with 4 self-report tools; VAS (visual analog scale), NRS (numerical rating scale), PainDETECT and BPI (brief pain inventory), and at the end report the subjective ease of use for these measures.

RESULTS

Altogether 106 subjects (28 males, 78 females) consented to participate in the clinical study. Musculoskeletal pain was the most common cause of chronic nociceptive pain, being present in 88 (83%) subjects. The most common manifestations were spinal disorders and osteoarthritis of the hip or knee. The multidimensional pain scales (PainDETECT and BPI) were rated easier to use than the unidimensional measures (VAS and NRS), although all the measures were assessed as "quite easy" to use in general. In comparison with the other measures, PainDETECT was significantly easier to use. Low MMSE explained the difficulty of using PainDETECT.

CONCLUSIONS

The VAS, NRS, PainDETECT and the BPI appear to be suitable pain measures to use for older community-dwelling people in general practice.

Identifying and Managing Pain in People with Alzheimer's Disease and Other Types of Dementia: A Systematic Review

BACKGROUND AND OBJECTIVE

Pain in patients with Alzheimer's disease is a complex issue; these patients suffer from the common causes of acute and chronic pain, and some also have neuropathic or nociceptive pain. Whatever the mechanism of pain in these patients, their pain will require careful assessment and management, to insure the correct type and level of analgesia is given. The objective of this systematic review was the identification of studies that have investigated the efficacy of different analgesics on pain intensity or pain-related behavior during nursing home stay and at the end of life.

METHODS

A search using pain, pain treatment, and dementia MESH terms and keywords was conducted (October 15, 2015) in MEDLINE, EMBASE, PsychINFO, CINAHL, and Cochrane libraries.

RESULTS

Our search yielded 3138 unique hits, published between 1990 and October 2015. We read titles and abstracts, identified 124 papers for full-text evaluation, and included 12 papers to reflect and synthesize the following questions: (1) Which pain assessment tools for people with dementia are responsive to change in pain intensity scores? (2) Which analgesics are efficacy-tested by controlled trials including people with dementia living in nursing homes, including at the end of life? (3) Which outcome measures have been used to identify pain, pain behavior, and/or treatment efficacy in people with dementia?

CONCLUSION

Despite increased use of analgesics, pain is still prevalent in people with dementia. Validated pain tools are available but not implemented and not fully tested on responsiveness to treatment. Official guidelines for pain assessment and treatment addressing people with dementia living in a nursing home are lacking. The efficacy of analgesic drug use on pain or neuropsychiatric behavior related to dementia has been hardly investigated.

Perceived success/failure and attributions associated with self-regulatory efficacy to meet physical activity recommendations for women with arthritis

The relationship between attributional dimensions women assign to the cause of their perceived success or failure at meeting the recommended physical activity dose and self-regulatory efficacy for future physical activity was examined among women with arthritis. Women (N = 117) aged 18-84 years, with self-reported medically-diagnosed arthritis, completed on-line questions in the fall of 2013 assessing endurance physical activity, perceived outcome for meeting the recommended levels of endurance activity, attributions for one's success or failure in meeting the recommendations, and self-regulatory efficacy to schedule/plan endurance activity over the next month. The main theoretically-driven finding revealed that the interaction of the stability dimension with perceived success/failure was significantly related to self-regulatory efficacy for scheduling and planning future physical activity (β = 0.35, p = .002). Outcomes attributed to more versus less stable factors accentuated differences in self-regulatory efficacy beliefs following perceived success and failure at being active. It appears that attributional dimensions were associated with self-regulatory efficacy in women with arthritis. This suggests that rather than objectively observed past mastery experience, women's subjective perceptions and explanations of their past experiences were related to efficacy beliefs, especially following a failure experience.