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

The use of nonpharmacological interventions for chronic pain treatment in community-dwelling older adults with a certified need for care

BACKGROUND

Chronic pain is a major health issue and rapid population ageing exacerbates the burden to health systems in countries like Germany. Nonpharmacological interventions (NPIs) are essential in pain care and the prioritization of active NPIs is emphasized in guidelines. This paper examines the utilization of NPIs for chronic pain management in community-dwelling older adults with a certified need of care in Berlin, Germany.

METHODS

Cross-sectional data was collected through standardized face-to-face surveys with older adults (≥65 years), using validated instruments (e.g., Brief Pain Inventory), and structured lists for NPI utilization. Categorization into active and passive NPIs was performed through a literature-based, iterative process by an interdisciplinary team. For not normally distributed data, non-parametric tests were used as appropriate. Logistic regression was conducted for multivariate analysis.

RESULTS

In total, 250 participants were included in this analysis (aged 65-104, x̅ = 81.8, 68.8% female). Most (92%) use NPIs for chronic pain management: 85.6% use active NPIs, 50.4% active movement and only 5.6% use solely passive approaches. Most common NPIs are distraction, thermotherapy/compresses, and physiotherapy. The odds of utilizing physiotherapy are three times higher for those with high educational status when compared to those with low education while those with low educational status had higher odds of using thermotherapy/compresses.

CONCLUSIONS

In our sample, most community-dwelling older adults with a certified need of care use active NPIs for chronic pain management with about half using active movement approaches. Considering the high vulnerability of this population, physiotherapy (in the form of therapeutic exercise) is a particularly appropriate intervention, and it was the third most frequent NPI in our sample. However, there is a social gradient in the utilization of physiotherapy for chronic pain management which might be rooted in issues around awareness, appeal, and access to such measures. It is important to take socioeconomic differences into account when planning the care for older chronic pain patients but also when designing research or user-friendly guidelines for this target group.

TRIAL REGISTRATION

Ethical approval from the Ethics Committee of Charité - Universitätsmedizin Berlin (EA1/368/14) and study registration with the Central Study Register (ZSR no. 20009093).

Prevalence of falls, incontinence, malnutrition, pain, pressure injury and restraints in home care: A narrative review

Global demographic changes and the strategy of 'ageing in place' will increase the importance of home care in the future. To deliver safe and high-quality care, clinical data on nursing-sensitive indicators and transparency are needed. A comprehensive narrative review of the literature was conducted to describe the prevalence and incidence of nursing-sensitive indicators, namely, falls, incontinence, malnutrition, pain, pressure injury and restraints in home care. A literature search was carried out in May 2021 in PubMed and CINAHL, and 28 studies were included. Data were extracted using two extraction tables designed for this review. Prevalence and incidence rates varied widely and internationally within each indicator. The prevalence range for falls was 4.8%-48%; urinary incontinence, 33.7%-62.5%; malnutrition, 20%-57.6%; pain, 6.5%-68.5%; pressure injury, 16%-17.4% and physical restraints, 5%-24.7%. Due to various measurements and different instruments, the rates are not comparable. The use of standardised measurement and risk assessment tools to assess nursing-sensitive indicators in home care is needed to implement suitable interventions and to prevent these indicators.

Pain-coping types among older community-dwelling care receivers with chronic pain

OBJECTIVES

There is a lack of knowledge on coping with pain and sub-group specific pain-coping profiles among older home care receivers with chronic pain. To describe pain-coping strategies, identify subgroups based on cognitive and behavioral pain-coping strategies and pain-related psychological impairment and to compare these groups with regard to socio-demographic, medical, pharmacological and psychological characteristics.

METHOD

Data of 212 care receivers were examined using the German pain-coping questionnaire (FESV) to determine how they cope with pain. Subgroups were identified using hierarchic agglomerative cluster analysis, using Ward's algorithm and squared Euclidean distance, and characterized using socio-demographic, medical, pharmacological and psychological parameters. Multinomial logistic regression was used to identify variables associated with the subgroups.

RESULTS

Older care receivers apply cognitive and behavioral strategies to manage pain. Three subgroups were identified: Cluster 1 (25.9%) with good coping competences and little psychological impairment, Cluster 2 (40.1%) with poor coping competences and high psychological impairment, and Cluster 3 (34%) with good coping competences and high psychological impairment. Significant differences between the clusters were observed for age, pain intensity, pain-related interference, daily activities, depression and resilience. Logistic regression demonstrated that belonging to Cluster 2 was associated with the number of pain-reducing medications, depression and resilience. Belonging to Cluster 3 was significantly linked to daily activities, the number of pain medications, depression and the level of care required.

CONCLUSION

Differentiating between pain-coping profiles in the group of older care receivers with chronic pain necessitates target group-specific pain-oriented psychotherapeutic interventions, which can result in improved pain management.

[Older care receivers with chronic pain : Cross-sectional study of gender-specific pain intensity and home-care provision in the city environment]

BACKGROUND

Pain prevalence rates of up to 53% are found among older home-care recipients (aged ≥ 60 years). Of people affected by pain in Germany, care recipients comprise a relevant group with prevalence rates of around 70%. The available information on gender-specific pain experience shows a range of differing findings.

OBJECTIVE

Our objective was to determine pain parameters of older care receivers in the big city environment who are capable of self-reporting, taking into account gender differences and relevant aspects of medical care and medication.

MATERIAL AND METHODS

A cross-sectional study (structured interviews) was carried out among older (≥65 years) home-care recipients (German Social Security Code SGB XI) in Berlin, with chronic pain (n = 225), capable of self-reporting (MMST ≥ 18). Pain parameters were determined using the German version of the brief pain inventory (BPI-NHR). Multiple regression analysis was applied to test and explain how the severest pain was influenced by sociodemographic and medical parameters, mental and physical restrictions, and analgesic provision.

RESULTS

Analyses showed an average pain intensity of 5.3 (SD ± 2.0). The severest pain averaged 7.0 (SD ± 2.2). Few indications of significant gender-based differences were found (e.g. pain location, number of medications). The final model identified the number of pain locations (≥14), everyday abilities, and pain medication (as needed, none) as being associated with the severest pain. Treatment achieved pain relief of over 70% in only 24.6% of cases among pain-affected care receivers.

CONCLUSION

The findings indicate a significant level of pain experienced by older home-care recipients. Interdisciplinary care concepts are urgently needed.

[Pain management for older care receivers in the ambulatory care setting]

PAIN AND PAIN IMPACTS

Chronic pain experienced by care receivers who live in their own homes is an issue of great importance, due to its frequency and intensity. The impacts of pain in this vulnerable group are manifested particularly in the form of marked adverse effects on mobility and activity.

COMMUNICATING ABOUT PAIN IN AMBULATORY CARE SERVICES

Both physicians and staff of the ambulatory care services involved communicate too rarely about pain, its intensity and duration, with the pain-affected care receiver.

MEDICATION-BASED PAIN THERAPY

The deficient pain therapy provided by ambulatory care services for pain-affected care receivers needs to be checked to ensure that medication is appropriate, that the simultaneous prescription of continuous and acute medication, and the clear information on dosage and dosing intervals is given on binding medication charts.

INTERDISCIPLINARY RESOURCES

Too little attention has been paid up to now to the challenges of interdisciplinary care for older care receivers in the ambulatory care setting, although interdisciplinarity in pain management has long been a stated requirement. Multidisciplinary action based on agreed guidelines and standards is the key to appropriate pain management. The interface communication between professional groups needs to be optimized in order to provide adequate care for the care receiver.

Pain-Associated Clusters Among Nursing Home Residents and Older Adults Receiving Home Care in Germany

CONTEXT

There are no available data regarding pain-associated clusters among nursing home residents (NHRs) and older adults receiving home care with chronic pain.

OBJECTIVES

To identify and describe pain-associated clusters in NHRs and older adults receiving home care with chronic pain and to explore associations with clusters in both settings.

METHODS

We surveyed 137 NHRs and 205 older adults receiving home care. Clusters were identified using hierarchical agglomerative cluster analysis, using Ward's method with squared Euclidean distances in the proximities matrix. The clusters were characterized based on sociodemographic and clinical characteristics. Multinomial logistic regression was used to identify variables associated with different clusters.

RESULTS

In each setting, we identified three clusters: pain relieved, pain impaired, and suffering severe pain. In the nursing home study and home care study, respectively, the participant distributions were 46.72% and 11.71% in the pain-relieved cluster, 22.63% and 33.66% in the pain-impaired cluster, and 30.66% and 54.63% in the severe-pain cluster. Appropriate pain medication was only detected among pain-relieved NHRs.

CONCLUSION

Overall, differences in pain management exist within the two care settings presented here. There is potential for improvement in both settings. Moreover, there exists a need for clinical interventions aiming at shifting from pain-affected clusters to pain-relieved status.

Sex-specific differences in prevention and treatment of institutional-acquired pressure ulcers in hospitals and nursing homes

INTRODUCTION

Gender and/or sex have a major impact on staying healthy, becoming ill, or care dependent. Differences between men and women have been described for socioeconomic positions, health behaviors, courses and severities of diseases and mortality rates. Consequently, sex and/or gender need to be adequately taken into account while developing and implementing evidence-based healthcare. Evidence regarding differences between men and women in pressure ulcer care is limited. Our research aim was to measure possible differences between male and female hospital patients and nursing home residents in prevention and treatment of institutional-acquired pressure ulcers.

METHODS

A secondary data analysis was conducted including data sets collected in nursing homes and hospitals in Germany annually from 2001 to 2016. Relevant variables were compared according to biological sex (men/woman).

RESULTS

The study included 38,655 nursing home residents (mean age 85.4 years women, 77.3 years men) and 58,760 hospital patients (mean age 66.7 years women, 63.4 years men). More women were underweight and at pressure ulcer risk in both settings. The proportion of institutional-acquired pressure ulcers was higher for men in hospitals. Slightly more men had a PU category 2 to 4 (OR 0.87, 95% CI 0.76 to 0.99) in nursing homes or developed an institutional-acquired pressure ulcers category 2 to 4 in both settings (OR 0.85, 95% CI 0.76 to 0.95). Special mattresses were more often used by women at PU risk. More men with an institutional-acquired pressure ulcer in hospitals received counseling of relatives (OR 0.53, 95% CI 0.39 to 0.72).

CONCLUSION

Although slightly more men had institutional-acquired pressure ulcers than women, overall differences regarding pressure ulcer occurrence were minor. Gender and/or sex can rather not be considered as an independent risk factor for pressure ulcer development and differences regarding pressure ulcer prevention interventions seem to be minor.

[Pain management in nursing care in outpatient older adults in need of care]

Pain management in nursing care in outpatient older adults in need of care Abstract. Background: International data report a prevalence rate for chronic pain of up to 50 % in community dwelling older adults (> 65 years). A national study reported a prevalence rate of 68,5 % among outpatient adults (≥ 18 years). Nursing care has an important meaning in pain management. However, previous research on the quality of pain management in nursing care is insufficient. Aim: The aim of this study is to evaluate the appropriateness of pain management in nursing care in our target group. Method: The cross-sectional study is based on data from ACHE. The study comprises 219 patients. Information on subjective pain experience and pain management were obtained by face-to-face interviews and nursing documentation. Results: Our findings indicate considerable deficits in terms of pain management in nursing care. Results show a lack of systematic pain assessment as well as missing documentation of therapeutic aims and pain management in nursing care. Conclusions: The identified deficits might be the result of current framework conditions that separate nursing pain treatment in Volume V and Volume XI of the German Social Security Code services. Appropriateness in pain management in nursing care can only be ensured if framework conditions are optimized.

Deficits in pain medication in older adults with chronic pain receiving home care: A cross-sectional study in Germany

OBJECTIVE

To analyze the pattern and appropriateness of pain medications in older adults receiving home care.

METHODS

We performed a prospective cross-sectional study in patients ≥65 years old having chronic pain and receiving home care in Berlin, Germany. Data on prescribed pain medications were collected using self-reported information, nursing documents, and medication plans during interviews at home. Pain intensity was determined with the numeric rating scale (NRS) and the Pain Assessment In Advanced dementia (PAINAD) scale. The Pain Medication Appropriateness Scale score (SPMAS) was applied to evaluate inappropriateness (i.e. a score ≤67) of pain medication.

RESULTS

Overall 322 patients with a mean age of 82.1 ± 7.4 years (71.4% females) were evaluated. The average pain intensity scores during the last 24 hours were 5.3 ± 2.1 and 2.3 ± 2.3 on NRS and PAINAD scale (range 0-10, respectively). Sixty (18.6%) patients did not receive any pain medication. Among the treated patients, dipyrone was the most frequently prescribed analgesic (71.4%), while 50.8% and 19.1% received systemic treatment with opioids and non-steroidal anti-inflammatory drugs, respectively. The observed median SPMAS was 47.6 (range 0-100) with 58 (18.0%) of patients achieving appropriate values. Half of the patients were treated with scheduled, while 29.9% were only treated with on-demand medications. Cognitive status had no effect on appropriateness of pain treatment.

CONCLUSIONS

We observed substantial deficits in dosing patterns and appropriateness of pain medication in older adults with pain receiving home care. This applied to both patients with and without severe cognitive impairment.

[painApp-mobile pain monitoring in the home care setting]

BACKGROUND

The use of a scientifically developed App for pain management in the home care setting is not yet established in Germany. The documentation of pain-specific data by the patients and the transfer into a web portal to be examined by the attending physician can help close the existing communication gap in pain management between consultations.

OBJECTIVES

The aim of the study was to develop a mobile health (mHealth) solution for optimizing pain management in the home care setting. The research questions focus on design and technical issues concerning layout and navigation of the painApp as well as user-relevant questions concerning pain management, such as pain at rest and pain during movement, taking pain medication and patient satisfaction with their pain situation.

MATERIALS AND METHODS

Within a 12-month period, the user-centered development and practice-based testing of the application painApp involved patients aged ≥ 65 years. Within a formative evaluation, a total of four data collections and a final survey took place. During the same period, a web portal was developed and tested the documentation of the patient pain-specific data from the painApp with the participation of general practitioners.

RESULTS AND CONCLUSIONS

The development of the painApp as a prototype was realized in the study with high acceptability by the patients. The painApp is able to establish digital communication with the general practitioner without any technical problems and allows the physician access to patient data in real time.

Urinary incontinence in home care: a representative multicenter study on prevalence, severity, impact on quality of life, and risk factors

OBJECTIVES

The objective of the study was to determine the prevalence and severity of urinary incontinence and associated factors in patients receiving home care nursing service.

METHODS

From June to September 2015, a multicenter cross-sectional study was conducted in 923 patients from 102 home care services throughout Germany. The ICIQ-SF was used to determine the characteristics of UI and its impact on QoL. To determine the risks for UI, demographic and social risks, the Barthel Index and medical diagnoses were determined in descriptive and logistic regression analysis.

RESULTS

The prevalence of UI was 62.5% (95% CI 59.3-65.6). The most common reasons for UI were before getting to the toilet 27.6% and when coughing or sneezing 27.3%. If the amount of leakage was medium (high), the mean of the impact on QoL was 4.9, SD 2.7 (5.0, SD 3.6). If the frequency of UI was higher than once a day (permanent), the mean of the impact on QoL was 4.2, SD 2.7 (4.8, SD 3.2). The results of the logistic regression analysis show the highest odds ratios for mobility-inability to walk (4.49), presence of dementia (2.59), and female sex (1.81). The metric variables age (1.02), Barthel Index (0.93), and BMI (1.05) were also statistically significant.

CONCLUSIONS

The prevalence of UI in home care in Germany is high. Since UI is strongest associated with (im-) mobility, preserving or regaining patients' mobility should play a central role in providing care to avoid/minimize UI.

[Challenges for home care services in the pain management of cancer patients : A qualitative study]

BACKGROUND

People with cancer are increasingly supported by home care services. Pain is a relevant symptom of these diseases and nurses of home care services are involved in the treatment. The German National Expert Standard "Pain management in nursing" includes evidence-based recommendations for the implementation of adequate pain management. Considering the given structural conditions of home care services, nurses describe both barriers and challenges with the implementation.

METHODS

By means of five guideline-based discussion groups, nurses of 14 home care services were questioned about the challenges they had experienced in pain management. The questioning focuses on the level of implementation of the recommendation for each aspect: pain assessment, pharmacological pain therapy, non-pharmacological pain therapy, pain-related side effects, information, training, and counseling in the care of people with cancer. A qualitative content analysis was conducted.

RESULTS

On the one hand, the results illustrate a need for further knowledge and possibilities, e.g., for the assessment of pain as a multidimensional phenomenon and, on the other hand, that the conditions for continuous pain monitoring of cancer patients in home care services are limited. The need for short-term reconciliation with the treatment team and the practitioners proved to be more difficult than the cooperation with the palliative care network. Involvement of family members is important to ensure uninterrupted treatment.

CONCLUSIONS

Beside knowledge and competencies regarding nursing care, structures and processes for interprofessional pain management need further development and research.

[Developing a framework for a public health monitoring of the population aged 65 years and older : Results of the IMOA workshop on concepts and indicators]

Main goal of the Improving Health Monitoring in Older Age (IMOA) project is to provide a framework for an indicator-based public health monitoring of the population aged 65 years and older. The workshop served as a forum to discuss and agree upon relevant concepts with gerontologists, nursing care and public health scientists.

[Frequency of falls among clients of home care services : The importance of care-related and social risk factors]

BACKGROUND

Among the elderly falls frequently result in injuries, increase the need for long-term care and pose a challenge for the quality assurance in nursing care. We describe the frequency and risk factors of falls among care-dependent persons using home care services in Germany.

METHODS

The participants of the study "Nursing-related health problems in home care" (n = 880) were recruited based on a list of the officially accredited nursing services. Data collection followed a standardized study protocol. Proportions were calculated and adjusted odds ratios and predicted probabilities were estimated using binary logistic regression.

RESULTS

Falls are a frequent occurrence among care-dependent persons who are cared for by home care services: Almost every tenth care-dependent person suffers from a fall within a period of 2 weeks. Falls are mainly associated with social and care-related factors. Besides a low educational status this comprises certain living and care arrangements: People living alone or having infrequent contact to their nursing service as well as clients that, according to their carers, should receive more support have a significantly higher chance of falling. Multimorbidity is a medical risk factor while neurological diseases as well as polypharmacy present increased risks only in interaction with living and care arrangements.

CONCLUSION

Nursing staff and physicians should maintain an overview of the social and health conditions of people in need of long-term care. If care-dependent persons live alone or are infrequently cared for, additional medical problems considerably increase the risk for falling; therefore, preventive interventions and follow-up assessments of actual need levels should be promptly considered if health conditions or living arrangements change.

Regional Anesthesia for Painful Injuries after Disasters (RAPID): study protocol for a randomized controlled trial

Background

Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting.

Methods/design

The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction.

Discussion

Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma.

Trial registration

ClinicalTrials.gov (NCT02698228), registered on 16 February 2016.