An Exploration of Pain Documentation for People Living with Dementia in Aged Care Services

Analgesic stewardship in Australian residential aged care facilities: Retrospective audit of a collaborative approach to optimising opioid use

OBJECTIVE

To evaluate retrospectively an analgesic stewardship role of a non-dispensing pharmacist as part of a general practice team providing primary care services to residential aged care facilities (RACF).

METHODS

Our general practice implemented an analgesic stewardship program to optimise and monitor opioid usage for our patients located across 12 RACF in Canberra from March 2019 to September 2020. The primary objective was the development of a multidisciplinary chronic pain care plan to document treatment and monitoring strategies for optimising pain control. The pharmacist reviewed and documented existing pain management strategies in a care plan for each patient and discussed recommendations for optimisation with the general practitioner. The general practitioner implemented accepted recommendations and distributed finalised care plans to the RACF. A retrospective audit of care plans was undertaken to assess the outcomes: mean daily oral morphine equivalence to monitor opioid usage, and pain scores to monitor for any potential harm associated with analgesic stewardship.

RESULTS

One hundred and sixty-seven residents received an initial care plan. Residents were scheduled for a follow-up care plan after 6 months, which was achieved for 100 residents (60%). Scope for optimising opioid therapy was identified for 47 residents (28%) at baseline and 23 residents (23%) at follow-up. Mean opioid usage and pain scores were reduced at follow-up; 19.4 mg (SD 40.8) versus 13.4 mg (SD 22.8), and 4.2 (SD 2.3) versus 3.9 (SD 2.0), respectively.

CONCLUSIONS

A systematic, multidisciplinary analgesic stewardship approach may optimise pain management plans and reduce opioid usage in RACF residents.

A systematic review of prevalence of pain in nursing home residents with dementia

BACKGROUND

The prevalence of dementia in nursing home (NH) residents is high, and pain is a troublesome symptom for them. Several studies since 2010 have focused on pain in NH residents with dementia, but there is a lack of systematic reviews on the prevalence of pain in NH residents with dementia.

AIM

To systematically review observational studies published from 2010 to 2023 on how pain is assessed and prevalence of pain found in NH residents with dementia.

METHODS

A systematic search was conducted in the MEDLINE, PubMed, PsycINFO, Embase, CINAHL, AgeLine, and Cochrane databases for studies published from January 2010 to August 2023. Studies were included if they were observational studies with a quantitative design where self-report, staff assessment, and/or chart review were used to define the prevalence of pain in samples or subsamples of NH residents with dementia.

RESULTS

Of 184 studies considered, 25 were included. The studies assessed pain as daily, present, clinically relevant, chronic, intermittent, persistent pain and/or if pain affected quality of life. The prevalence of pain was high in most studies of NH residents with dementia independent of whether pain was reported as presence of pain or clinically relevant pain, but the prevalence varied from 8.6% to 79.6%. This prevalence was quite stable across the NH stay, but higher towards the end of life (up to 80.4%). Study designs and methodologies differed considerably. About half relied on an observational assessment inventory.

CONCLUSION

The number of studies focusing on pain in NH residents with dementia was restricted and methodologies differed considerably. Relatively few studies used an observational assessment inventory. In view of the fact that residents with dementia may have difficulties communicating pain, clinicians should pay attention to pain in these residents, systematically and reliably uncover pain by use of observational inventories, and subsequently treat pain to secure high quality care.

Barriers and enablers to leisure provision in residential aged care: personal care attendant perspectives

This exploratory descriptive study investigated barriers and enablers to the provision of leisure activities for people living in three Australian residential aged care facilities (RACFs) that operated under a household model of care. This research is unique in the international context, as few studies have explored the understandings and experiences of personal care attendants' (PCAs) perceptions of what impacts leisure provision for people living in RACFs. Qualitative data were collected from 17 PCAs via four focus groups. Barriers to leisure provision were identified as PCA–resident ratios, competing demands of the PCA role and a prioritisation of physical care tasks over leisure-related activities. The severity of residents' dementia (cognitive and functional deficits) as well as behavioural and psychological symptoms of dementia were also framed as barriers to participation in and the provision of leisure. Participants identified enablers of leisure provision as related to perceptions of leisure, the experiential knowledge of staff, organisational support and resourcing. The study findings suggest that enhancing leisure provision for people living with dementia will require attention to system issues (i.e. staffing levels, ratios, PCA role demands) as well as PCA knowledge and capability to facilitate person-centred leisure.

Are nurse`s needs assessment methods robust enough to recognise palliative care needs in people with dementia? A scoping review

BACKGROUND

People with dementia are most at risk of experiencing serious health related suffering, if they do not have a palliative care approach introduced early enough in the illness. It can be challenging for nurses to assess experienced needs of people, who are thought no longer able to self-report such as people with dementia. Assessment help to understand the care the patient and their family need promptly. It is unknown how nurses recognise holistic palliative care needs in people with dementia during routine care.

METHODS

Scoping review where EMBASE, MEDLINE, CINAHL, PsycInfo databases, and references were searched with an advanced search strategy, which was built on three concepts (nurses, dementia, and nursing assessment) using corresponding Medical Subject Headings. Data were charted in a piloted extraction form, based on the assessment domains within the nursing process followed by summarise and synthesise results narratively.

RESULTS

37 out of 2,028 qualitative and quantitative articles published between 2000 and 2021, and relating to 2600 + nurses, were identified. Pain was sole focus of assessment in 29 articles, leaving 8 articles to describe assessment of additional needs (e.g., discomfort). Nurses working in a nursing home assess pain and other needs by observing the persons with dementia behaviour during routine care. Nurses in the acute care setting are more likely to assess symptoms with standard assessment tools at admission and evaluate symptoms by observational methods. Across settings, about one third of pain assessments are supported by person-centred pain assessment tools. Assessments were mostly triggered when the person with dementia vocalised discomfort or a change in usual behaviour was observed. Nurses rely on family members and colleagues to gain more information about needs experienced by people with dementia.

CONCLUSION

There is a scarcity of evidence about techniques and methods used by nurses to assess needs other than pain experienced by people with dementia. A holistic, person-centred screening tool to aid real-time observations at the bedside and used in conversations with health care professionals and families/friends, may improve need recognition other than pain, to ensure holistic needs could then be addressed timely to improve care in people with dementia.

Pain management nursing practice assessment in older adults with dementia

Aim

To assess pain management nursing practice in older adults with dementia through electronic health records (EHR).

Design

Retrospective study.

Methods

Data were collected from EHR related to pain management in older adults with dementia treated at the Acute Geriatrics Unit (AGU) of a university hospital in early 2018.

Results

EHR related to the pain of 111 patients were reviewed. Pain intensity was assessed at admission in 88% of patients and a median of 1.9 times per day of stay. A disproportionate number of the assessments (39%) occurred during the late shift. A median of 1 drug per day was administered. Pain was recorded in 28% of patients’ care plans, and non‐pharmacological interventions were recorded in 12%.

In conclusion, exist variability in pain management nursing practice in older adults with dementia. Admission diagnosis correlated with the analgesic administration schedule, the number of drugs administered and the number of pain nursing annotations.

Facilitators, Barriers, and Solutions in Pain Management for Older Adults with Dementia

BACKGROUND

Although qualitative studies have been conducted to identify barriers and facilitators that influence the pain management of older adults with dementia, as far as we know, only a very recent study (Andrews et al., 2019) has used participatory action research (PAR) as a methodology for studying pain management. It allows nurses to examine and improve their practice based on their realities and within their context.

AIM

To reflect on nursing practice and identify facilitators and barriers in the management of pain in older adults with dementia and to propose actions for improvement.

DESIGN

We used qualitative participatory action research.

PARTICIPANTS/SETTINGS

Ten nurses from the geriatric acute care unit of a university hospital in Spain were recruited through convenience sampling.

METHODS

Data were generated through a written questionnaire and three focus groups.

RESULTS

One of the main facilitators the participants identified was professional experience. The main barriers they identified were lack of knowledge and skills and lack of time. The participants proposed two main improvements: (1) a training program consisting of three courses (pain evaluation and management, dementia and pain, and pharmacology) and (2) the creation of a specific register for nurses to record patients' pain.

CONCLUSIONS

Involving nurses directly in research on their practices can result in precise proposals for improvements based on their needs and oriented toward improving the quality of care. Moreover, our results confirm previous findings in other countries.

The Effect of Using PARO for People Living With Dementia and Chronic Pain: A Pilot Randomized Controlled Trial

OBJECTIVES

To evaluate the effect of interaction with a robotic seal (PARO) on pain and behavioral and psychological symptoms of people with dementia and chronic pain.

DESIGN

A parallel pilot randomized controlled trial conducted between January 2018 and January 2019.

SETTING

Three long-term care facilities in Australia.

PARTICIPANTS

Forty-three participants aged ≥65 years living with dementia and chronic pain.

INTERVENTION

Participants were randomized to the PARO group (individual, nonfacilitated, 30-minute sessions, 5 days per week for 6 weeks) or a usual care group using a computer-generated random number.

MEASUREMENTS

The primary outcome was researcher-rated observational pain behaviors before and after each session. Secondary outcomes were staff-rated pain level, agitation, depression, and anxiety measured at baseline and the end of week 6. Medications regularly prescribed and as needed were recorded weekly. Analyses followed intention-to-treat, using the generalized estimating equation model. Australian New Zealand Clinical Trials Registry (ACTRN12618000082202).

RESULTS

Participants in the PARO group had a significantly lowered level of observed pain [-0.514, 95% confidence interval (CI) -0.774 to -0.254, P < .001] and used fewer pro re nata medications (-1.175, 95% CI -2.205 to -0.145, P = .025) than those in usual care after controlling for age, sex, cognitive function and medications. There were no significant differences in staff-rated pain, agitation, anxiety, and depression, nor regularly scheduled medications between intervention and control group.

CONCLUSIONS AND IMPLICATIONS

PARO shows promise in reducing pain and medications for individuals with dementia and chronic pain in long-term care facilities. This intervention might be incorporated into daily practice as an alternative to manage pain in people with dementia. Larger randomized controlled trials with longer time frames are needed to identify further and test the use of PARO in long-term care settings.