Pain and Associated Factors in Nursing Home Residents

Effectiveness of Short-Acting Opioid Escalation vs Initiation of a Long-Acting Opioid in Nursing Home Residents

OBJECTIVES

Modifications to opioid regimens for persistent pain are typically made after an initial period of short-acting opioid (SAO) use. Regimen changes may include an escalation of the SAO dosage or an initiation of a long-acting opioid (LAO) as a switch or add-on therapy. This study evaluates the comparative effectiveness between these alternative regimens in nursing home residents.

DESIGN

A retrospective observational cohort analysis of US long-stay nursing home residents.

SETTING AND PARTICIPANTS

Nursing home resident data were obtained from the national Minimum Dataset (MDS) version 3.0 and linked Medicare data, 2011-2016.

METHODS

Opioid regimen changes were identified using Part D dispensing claims to identify dosage escalation of SAOs, initiation of an LAO, or a switch to an LAO. Outcomes included indices of pain occurrence, frequency, and severity reported on the earliest MDS assessment within 3 months following the opioid regimen change. Resident attributes were described by opioid regimen cohort. Prevalence ratios of pain and depression indices were quantified using doubly robust inverse probability of treatment (IPT)-weighted log-binomial regression.

RESULTS

The study cohorts included 2072 SAO dose escalations, 575 LAO add-on initiations, and 247 LAO switch initiations. After IPT weighting, we observed comparable effects on pain and mood across the opioid regimen cohorts. A substantial number of residents continued to report frequent/constant pain (36% in SAO Escalation Cohort, 42% in LAO Add-on Cohort, 42% in the LAO Switch Cohort). The distribution of depressive symptoms was similar regardless of the opioid regimen change.

CONCLUSIONS AND IMPLICATIONS

Initiation of an LAO as an add-on to SAO or a switch from SAO had comparable effects on pain and mood to SAO dose escalation without initiation of an LAO. Although fewer residents reported any pain after the regimen change, persistent pain was reported by most residents.

Pain in Canadian Long-Term Care Homes: A Call for Action

Navigating the evaluation and management of pain in long-term care homes is a complex task. Despite an extensive body of literature advocating for a paradigm shift in pain assessment and management within long-term care homes, much more remains to be done. The assessment of pain in long-term care is particularly challenging, given that a substantial proportion of residents live with some degree of cognitive impairment. Individuals living with dementia may encounter difficulties articulating the frequency and intensity of their pain, potentially resulting in an underestimation of their pain. In Canada and in the United States, the interRAI Minimum Data Set 2.0, Minimum Data Set 3.0, and the interRAI Long-Term Care Facilities assessments are administered to capture the presence and intensity of pain. These assessment instruments are used both on admission and quarterly, offering a reliable and validated method for comprehensive assessment. Nonetheless, the daily assessment and documentation of pain across long-term care homes, which is used to inform the interRAI Pain Scale, is not always consistent. The reality is that assessing pain can be inaccurate for several reasons, including the fact that it is rated by long-term care staff with diverse levels of expertise, resources, and education. This call for action explores the current approaches used in pain assessment and management within long-term care homes. The authors not only bring attention to the existing challenges but also emphasize the necessity of considering a more comprehensive assessment approach.

Nursing Students' Perceptions on a Pain Management E- Learning Module: An Exploratory Quantitative Study

BACKGROUND

Nursing students are graduating ill-prepared to assess and manage pain in older adults. To address this gap, we developed an e-learning module on the topic.

AIM

To examine nursing students' perceptions on a pain management e-learning module focused on older adults.

METHODS

Utilizing an exploratory quantitative design, we assessed nursing students' perceptions of the e-learning module. We used a feedback survey (four 5-point, Likert-type items) and one open-ended question to assess students' perceptions. Descriptive statistics were used to summarize students' perceptions and demographic characteristics. Responses to the open-ended question were content analyzed.

RESULTS

A total of 181 of 249 students completed the module, of whom two-thirds were female. Students perceived that the module enhanced their knowledge, confidence, and perception in working with older people. Students also found the method of instruction interactive and enjoyable.

CONCLUSIONS

The e-learning module on pain management was viewed by nursing students to be helpful and its interactive method of learning improved their knowledge, confidence, and perceptions of working with older adults in pain.