Nursing Home Resident Barriers to Effective Pain Management: Why Nursing Home Residents May Not Seek Pain Medication

The prevalence and intensity of pain in older people living in retirement villages in Auckland, New Zealand

Chronic pain is common in older people. However, little is known about how pain is experienced in residents of retirement villages ('villages'), and how pain intensity and associations are experienced in relation to characteristics of residents and village living. We thus aimed to examine pain levels, prevalence and associated factors in village residents. The current paper is a cross-sectional analysis of baseline data from the 'Older People in Retirement Villages' study in Auckland, New Zealand. Between July 2016 and August 2018, 578 village residents were interviewed face-to-face by gerontology nurse specialists, using interRAI Community Health Assessment (CHA) and customised survey. We used a validated pain scale and multivariable logistic regression analyses adjusted for pre-specified confounders. Residents' median age was 82 years; 420 (73%) were female; 270 (47%) exhibited/reported daily pain, and in 11% this was severe. After controlling for confounders, daily pain was positively associated with self-reported arthritis (OR = 3.88, 95% CI = 2.57-5.87), poor/fair self-reported health (OR = 3.19, 95% CI = 1.29-7.93), having no health clinic on-site (OR = 1.76, 95% CI = 1.10-2.83), and minimal fatigue (diminished energy but completes normal day-to-day activities) (OR = 1.77, 95% CI = 1.11-2.81). Similar associations were observed for levels of pain. We conclude that levels of pain and prevalence of daily pain are high in village residents. Self-reported arthritis, self-reported poor/fair health, no health clinic on-site and minimal fatigue are all independently associated with a higher risk of daily pain and with levels of pain. This study suggests potential opportunities for villages to better provide on-site support to decrease prevalence and severity of pain for their residents, and thus potentially increase wellbeing and quality-of-life, though as we cannot prove causality, more research is needed.

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness-Implementation Study

OBJECTIVES

To evaluate the effectiveness and implementation of a multilevel pain management intervention in nursing homes (NHs) comprising a pain management guideline, care worker training, and pain champions.

DESIGN

An implementation science pilot study using a quasi-experimental effectiveness-implementation (hybrid II) design.

SETTING

Four NHs in Switzerland.

PARTICIPANTS

All consenting long-term residents aged 65 years and older with pain at baseline (N = 62) and all registered and licensed practical nurses (N = 61).

INTERVENTION

Implementation of a contextually adapted pain management guideline, interactive training workshops for all care workers, and specifically trained pain champions.

MEASUREMENTS

Interference from pain, worst and average pain intensity over the previous 24 hours; proxy ratings of pain with the Pain Assessment in Advanced Dementia scale; and care workers' appraisal of the guideline's reach, acceptability, and adoption.

RESULTS

Pain-related outcomes improved for self-reporting residents (n = 43) and residents with proxy rating (n = 19). Significant improvements of average pain from baseline to T1 (P = .006), and in worst pain from baseline to T1 (P = .003) and T2 (P = .004). No significant changes in interference from pain (P = .18). With regard to the implementation efforts, about 76% of care workers indicated they were familiar with the guideline; 70.4% agreed that the guideline is practical and matches their ideas of good pain assessment (75.9%) and treatment (79.7%).

CONCLUSION

Implementation of a multilevel pain management intervention did significantly improve average and worst pain intensity in NH residents. However, to effect clinical meaningful changes in interference from pain, a more comprehensive approach involving other disciplines may be necessary. J Am Geriatr Soc 67:2574-2580, 2019.

Normalizing suffering: A meta-synthesis of experiences of and perspectives on pain and pain management in nursing homes

Older people who live in nursing homes commonly suffer from pain. Therefore, relieving suffering among older people that stems from pain demands knowledge improvement through an integration of international knowledge. This study aimed to integrate current international findings and strengthen the understanding of older people's experiences of and perspectives on pain and pain management in nursing homes. A meta-synthesis study using Noblit and Hare's interpretative meta-ethnography approach was conducted. Empirical research papers from journals were collected from various databases. The search process and appraisal determined six articles for inclusion. Two studies were conducted in the US and one each in Iceland, Norway, the UK, and Australia. The older people's experiences of pain as well as perspectives on pain management from all involved (older people, their family members, and healthcare staff) were integrated into a theoretical model using three themes of "identity of pain," "recognition of pain," and "response to pain." The metaphor of "normalizing suffering" was devised to illustrate the meaning of pain experiences and pain management in nursing homes. Society's common attitude that pain is unavoidable and therefore acceptable in old age in society-among older people themselves as well as those who are responsible for reporting, acknowledging, and relieving pain-must change. The article emphasizes that pain as a primary source of suffering can be relieved, provided that older people are encouraged to report their pain. In addition, healthcare staff require sufficient training to take a person-centered approach towards assessment and management of pain that considers all elements of pain.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial

OBJECTIVE

To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies.

DESIGN

A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only.

SETTING

Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership.

PARTICIPANTS

Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group.

MEASUREMENTS

Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later.

RESULTS

Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention.

CONCLUSIONS

Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

Pain and persistent pain in nursing home residents in Norway

The objective of this study was to examine the nature of pain and persistence of pain in nursing home residents. The study was carried out with 201 participants drawn from six nursing homes in Norway. The participants rated their pain on 5 different days within a 14-day period on the modified McGill Pain Questionnaire regarding the intensity and location of pain. Four patterns in the persistence of pain were extracted, with the results showing approximately 50% of the participants experiencing persistent pain of a moderate to intense level. Pain ratings and persistent pain were significantly associated with number of body areas with pain, sleeping problems, number of medical diagnoses, and number of medications. The findings of this study suggest that both persistence and fluctuation of pain within short time periods may be related to inadequacy in pain management in nursing home residents, and fill the gap in the literature regarding patterns of persistent pain in nursing home residents.