Frequency and Predictors of Analgesic Prescribing in U.S. Nursing Home Residents with Persistent Pain

Registered nurses' knowledge, attitudes and practices of pain management for aged care residents with dementia: an integrative review

AIM

To assess the knowledge, attitudes and practices of Registered Nurses working in residential aged care facilities pertaining to pain management for residents living with dementia.

BACKGROUND

Sub-optimal pain management continues for people living with dementia in residential aged care. Registered Nurses are the pivotal staff responsible for complex assessment and management of people residing in residential aged care facilities.

DESIGN AND METHODS

:This integrative literature review was informed by Whittemore (2005). Searching and screening followed the PRISMA guidelines.

RESULTS

Thirteen papers were identified, the major themes identified were gaps in knowledge and skills, uncertainty of assessment, and delays in treatment.

CONCLUSION

Registered Nurses require education on pain management for people living with dementia in residential aged care. Broader issues in residential aged care contribute to the problem and require examination. Research pertaining to Registered Nurses' roles pain management for residents living with dementia is required.

Prevalence of Opioid Use in Nursing Homes Over the Last Decade: A Systematic Literature Review

Background: Despite global concerns of an opioid epidemic, there is no systematic literature review on how frequently these drugs are used in nursing home (NH) populations, including those living with dementia. Objective: This systematic review aims to describe the prevalence and incidence of opioid use in NHs. A secondary objective is to describe the use of these drugs in a subset of NH residents, namely among persons living with dementia. Methods: A systematic literature review was carried out using MEDLINE and Scopus (PROSPERO registration number CRD42021254210). Screening of title and abstract was carried out by 2 persons independently for studies published between January 1, 2011 and May 19, 2021. The main outcomes were annual prevalence, period prevalence, and duration of opioid use. Results: From a total of 178 identified studies, 29 were considered eligible for inclusion. The annual prevalence of any opioid use among all NH residents without any selection criteria ranged from 6.3% to 50% with a median annual prevalence of 22.9% (Q25-Q75: 19.5%-30.2%), based on 17 studies. Five studies measured the annual prevalence in NH residents living with dementia, finding that this ranged from 10% to 39.6%. Conclusions: More evidence is needed quantifying opioid use in NH, especially among persons living with dementia. Given that opioid use in NH is still a problem, implementation of a pain management protocol in NH or nationally would help improve clinical outcomes.

Pharmacological Prescribing and Satisfaction with Pain Treatment Among Non-Hispanic Black Men with Chronic Pain

Introduction

Pharmacological strategies are often central to chronic pain management; however, pain treatment among non-Hispanic Black men may differ because of their disease profiles and healthcare interactions. However, less is known about pain medication prescribing and patients' satisfaction with pain treatment and management among non-Hispanic Black men with self-reported chronic pain.

Purpose

This study assessed factors associated with non-Hispanic Black men being prescribed/recommended narcotics/opioids for chronic pain and their satisfaction with pain treatment/management.

Methods

Data were analyzed from 286 non-Hispanic Black men with chronic pain who completed an internet-delivered questionnaire. Participants were recruited nationwide using a Qualtrics web-based panel. Logistic regression was used to identify factors associated with being prescribed/recommended narcotics/opioids for pain management treatment. Then, ordinary least squares regression was used to identify factors associated with their satisfaction level with the pain treatment/management received.

Results

On average, participants were 56.2 years old and 48.3% were prescribed/recommended narcotics/opioids for chronic pain. Men with more chronic conditions (Odds Ratio [OR] = 0.57, P = 0.043) and depression/anxiety disorders (OR = 0.53, P = 0.029) were less likely to be prescribed/recommended narcotics/opioids. Men who were more educated (OR = 2.09, P = 0.044), reported more frequent chronic pain (OR = 1.28, P = 0.007), and were allowed to participate more in decisions about their pain treatment/management (OR = 1.11, P = 0.029) were more likely to be prescribed/recommended narcotics/opioids. On average, men with more frequent chronic pain (B = -0.25, P = 0.015) and pain problems (B = -0.16, P = 0.009) were less satisfied with their pain treatment/management. Men who were allowed to participate more in decisions about their pain treatment/management reported higher satisfaction with their pain treatment/management (B = 0.55, P < 0.001).

Conclusion

Playing an active role in pain management can improve non-Hispanic Black men's satisfaction with pain treatment/management. This study illustrates the importance of patient-centered approaches and inclusive patient-provider interactions to improve chronic pain management.

Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause

OBJECTIVE

To provide health care providers with the best evidence on opioid use and women's health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women's health (both positive and negative) to ensure informed decision-making.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women.

TWEETABLE ABSTRACT

Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women's health to ensure informed decision-making.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Identifying Residents Who May Benefit from an Analgesic Review: Applying Analgesic Indicators in Residential Aged Care Services

BACKGROUND

Ensuring safe and effective analgesic use in residential aged care services is important because older adults are susceptible to analgesic-related adverse drug events (ADEs).

OBJECTIVE

The aim of this study was to identify the proportion and characteristics of residents of aged care services who may benefit from analgesic review based on indicators in the 2021 Society for Post-Acute and Long-Term Care Medicine (AMDA) Pain Management Guideline.

METHODS

Cross-sectional analyses of baseline data from the Frailty in Residential Sector over Time (FIRST) study (N = 550 residents) across 12 South Australian residential aged care services in 2019 were conducted. Indicators included the proportion of residents who received > 3000 mg/day of acetaminophen (paracetamol), regular opioids without a documented clinical rationale, opioid doses > 60 mg morphine equivalents (MME)/day, more than one long-acting opioid concurrently, and a pro re nata (PRN) opioid on more than two occasions in the previous 7 days. Logistic regression was performed to investigate factors associated with residents who may benefit from analgesic review.

RESULTS

Of 381 (69.3%) residents charted regular acetaminophen, 176 (46.2%) were charted > 3000 mg/day. Of 165 (30%) residents charted regular opioids, only 2 (1.2%) had no prespecified potentially painful conditions in their medical record and 31 (18.8%) received > 60 MME/day. Of 153 (27.8%) residents charted long-acting opioids, 8 (5.2%) received more than one long-acting opioid concurrently. Of 212 (38.5%) residents charted PRN opioids, 10 (4.7%) received more than two administrations in the previous 7 days. Overall, 196 (35.6%) of 550 residents were identified as potentially benefiting from analgesic review. Females (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.20-2.91) and residents with prior fracture (OR 1.62, 95% CI 1.12-2.33) were more likely to be identified. Observed pain (OR 0.50, 95% CI 0.29-0.88) was associated with a lower likelihood of being identified compared with residents with no observed pain. Overall, 43 (7.8%) residents were identified based on opioid-related indicators.

CONCLUSIONS

Up to one in three residents may benefit from a review of their analgesic regimen, including 1 in 13 who may benefit from a specific review of their opioid regimen. Analgesic indicators represent a new approach to target analgesic stewardship interventions.

Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence

PURPOSE

The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality.

METHODS

Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable.

FINDINGS

The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain.

CONCLUSIONS

Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.

Development, evaluation, and implementation of an online pain assessment training program for staff in rural long-term care facilities: a case series approach

Background

Pain among long-term care (LTC) residents, and especially residents with dementia, is often underassessed and this underassessment has been attributed, in part, to gaps in front-line staff education. Furthermore, although evidence-based clinical guidelines for pain assessment in LTC are available, pain assessment protocols are often inconsistently implemented and, when they are implemented, it is usually within urban LTC facilities located in large metropolitan centers. Implementation science methodologies are needed so that changes in pain assessment practices can be integrated in rural facilities. Thus, our purpose was to evaluate an online pain assessment training program and implement a standardized pain assessment protocol in rural LTC environments.

Methods

During the baseline and implementation periods, we obtained facility-wide pain-related quality indicators from seven rural LTC homes. Prior to implementing the protocol, front-line staff completed the online training program. Front-line staff also completed a set of self-report questionnaires and semi-structured interviews prior to and following completion of the online training program.

Results

Results indicated that knowledge about pain assessment significantly increased following completion of the online training program. Implementation of the standardized protocol resulted in more frequent pain assessments on admission and on a weekly basis, although improvements in the timeliness of follow-up assessments for those identified as having moderate to severe pain were not as consistent. Directed content analysis of semi-structured interviews revealed that the online training program and standardized protocol were well-received despite a few barriers to effective implementation.

Conclusions

In conclusion, we demonstrated the feasibility of the remote delivery of an online training program and implementation of a standardized protocol to address the underassessment of pain in rural LTC facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03020-8.

Pharmacological Pain Treatment in 2012 and 2017 Among Older People with Major Neurocognitive Disorder

Background and Objective

Pain is highly prevalent among older people, and treatment is complicated because of comorbidities and polypharmacy. Among people with major neurocognitive disorder additional difficulties might arise. The aim of this study was to describe analgesic drug use in 2012 and 2017 and associated factors among older people with major neurocognitive disorder.

Methods

In this register-based study, the Swedish Dementia Registry and the Swedish Prescribed Drug Register were combined in order to obtain data regarding analgesic drug use among older people with major neurocognitive disorder. One or more filled prescriptions during the timeframe of 6 months (1 July–31 December 2012 and 1 July–31 December 2017) defined drug use during the respective period. A comparison between 2012 and 2017 was made, including a total of 56,101 people (20,889 and 35,212 respectively) with a mean age of 81.9 and 82.7 years, respectively.

Results

The overall use of analgesic drugs increased significantly from 41.6% of individuals to 46.0% between the years 2012 and 2017. Users of opioid analgesics (15.2% vs 17.3%) and paracetamol (37.0% vs 42.3%) increased, while the users of non-steroidal anti-inflammatory drugs (4.9% vs 2.7%) declined between the two data collections. Multiple logistic regression analyses were performed for different drugs and drug classes, and it was found that the use of opioids and paracetamol was associated with older age and a longer time since diagnosis. In contrast, non-steroidal anti-inflammatory drugs were associated with younger age and a shorter time since diagnosis.

Conclusions

The results indicate that on a population level, pharmacological drug treatment has changed in line with guidelines between 2012 and 2017, with an increase in paracetamol and strong opioids and a decrease in non-steroidal anti-inflammatory drugs and tramadol. The relatively high prevalence of opioids warrants concern given the significant risk of adverse effects among older people with major neurocognitive disorder.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40266-021-00897-9.

Racial and Ethnic Disparities in the Treatment of Chronic Pain

OBJECTIVE

To summarize the current literature on disparities in the treatment of chronic pain.

METHODS

We focused on studies conducted in the United States and published from 2000 and onward. Studies of cross-sectional, longitudinal, and interventional designs were included.

RESULTS

A review of the current literature revealed that an adverse association between non-White race and treatment of chronic pain is well supported. Studies have also shown that racial differences exist in the long-term monitoring for opioid misuse among patients suffering from chronic pain. In addition, a patient's sociodemographic profile appears to influence the relationship between chronic pain and quality of life. Results from interventional studies were mixed.

CONCLUSIONS

Disparities exist within the treatment of chronic pain. Currently, it is unclear how to best combat these disparities. Further work is needed to understand why disparities exist and to identify points in patients' treatment when they are most vulnerable to unequal care. Such work will help guide the development and implementation of effective interventions.

Pain Incidence, Treatment, and Associated Symptoms in Hospitalized Persons with Dementia

BACKGROUND

Moderate to severe pain has been frequently reported in hospitalized older adults. Pain in hospitalized persons with dementia within the context of other common symptoms, functional decline, delirium, and behavioral and psychological symptoms of dementia (BPSD), has received little attention.

AIMS

Describe the incidence of pain, the pharmacologic management of pain, and the association of pain with physical function, delirium, and BPSD in hospitalized persons with dementia.

DESIGN

Descriptive, cross-sectional study.

SETTING

Six medical units in three hospitals.

PARTICIPANTS

Baseline data from 299 hospitalized persons with dementia enrolled in the Family-centered Function-focused Care (Fam-FFC) cluster randomized trial.

METHODS

Descriptive analyses of pain used the Pain Assessment in Advanced Dementia (PAINAD) scale and the use of medication for pain management. Linear regression analyses tested relationships between pain and:1) physical function (Barthel Index), 2) delirium severity (Confusion Assessment Method Severity Short Form) and 3) BPSD severity (Neuropsychiatric Inventory- Questionnaire).

RESULTS

The majority of the sample was female (61.9%), non-Hispanic (98%), and Black (53.2%), with a mean age of 81.58 (SD=8.54).Of the 299 patients, 166 (56%) received pain medication. Of the 108 individuals who demonstrated pain, 40% (n=43) did not receive pain medication. When controlling for age, gender, cognition, and comorbidities, pain was significantly associated with function, delirium severity, and BPSD severity.

CONCLUSIONS

Results suggest that pain may be undertreated in hospitalized persons with dementia, and should be considered upon admission to optimize function, decrease delirium, and prevent or decrease BPSD.

Management of Chronic Pain in Nursing Homes: Navigating Challenges to Improve Person-Centered Care

Despite the dynamic demands in the nursing home (NH), a definitive approach to managing chronic pain in older adults has yet to be established. Due to concerns for potential adverse pharmacologic effects, balancing appropriate pain management is a challenge among NH residents. The challenges encompass but are not limited to medical complexities, functional disabilities, and physical frailty. Barriers to the successful implementation of a comprehensive chronic pain management at the NH may include ambiguous directions on specific therapeutic interventions, insufficient guidance on treatment duration, and limited available treatment options. The Centers for Medicare and Medicaid Services' reporting requirement of adequate pain control among NH residents coupled with widely variable clinician-prescribing habits highlights the difficulties in overcoming the preceding challenges and barriers. The Coronavirus Disease 2019 (COVID-19) pandemic has further complicated pain management due to its negative consequences on well-being of residents of NHs. Associated symptoms of psychosocial stress, anxiety and depression, and chronic pain symptoms can exacerbate during the COVID-19 pandemic, leading to increased requirement for pain medications including but not limited to opioids. Pain is a multidimensional symptom and requires a strategic multimodal approach for its management. Nonpharmacologic modalities are underutilized in the NH setting and are the preferred first steps for mild pain, and nonopioid pharmacological agents can be added as a second step for a synergistic effect for moderate to severe pain. Opioids should be used as a last resort. Short-acting opioids are preferred over extended-release/long-acting opioids for chronic pain. Clinicians are encouraged to engage residents in proactive strategies in managing their pain, and to set realistic expectations toward improving their quality of life, as complete elimination of pain is not feasible in most cases. This review article provides the interdisciplinary team with a contemporary perspective of the multitude of changes and challenges influencing the prescribing as well as deprescribing of various pain medications.

Wearable Devices: Current Status and Opportunities in Pain Assessment and Management

INTRODUCTION

We investigated the possibilities and opportunities for using wearable devices that measure physical activity and physiometric signals in conjunction with ecological momentary assessment (EMA) data to improve the assessment and treatment of pain.

METHODS

We considered studies with cross-sectional and longitudinal designs as well as interventional or observational studies correlating pain scores with measures derived from wearable devices. A search was also performed on studies that investigated physical activity and physiometric signals among patients with pain.

RESULTS

Few studies have assessed the possibility of incorporating wearable devices as objective tools for contextualizing pain and physical function in free-living environments. Of the studies that have been conducted, most focus solely on physical activity and functional outcomes as measured by a wearable accelerometer. Several studies report promising correlations between pain scores and signals derived from wearable devices, objectively measured physical activity, and physical function. In addition, there is a known association between physiologic signals that can be measured by wearable devices and pain, though studies using wearable devices to measure these signals and associate them with pain in free-living environments are limited.

CONCLUSION

There exists a great opportunity to study the complex interplay between physiometric signals, physical function, and pain in a real-time fashion in free-living environments. The literature supports the hypothesis that wearable devices can be used to develop reproducible biosignals that correlate with pain. The combination of wearable devices and EMA will likely lead to the development of clinically meaningful endpoints that will transform how we understand and treat pain patients.

Prevalence of Therapeutic use of Opioids in Chronic non-Cancer Pain Patients and Associated Factors: A Systematic Review and Meta-Analysis

Objectives: To determine the prevalence and factors associated with the use of opioids among patients with chronic non-cancer pain (CNCP).

Methods: A systematic review and meta-analysis. Comprehensive literature searches in Medline-PubMed, Embase and SCOPUS databases. Original studies published between 2009 and 2019 with a cross-sectional design were included. The quality of the studies was assessed with Critical Appraisal Checklist for Studies Reporting Prevalence Data from the Joanna Briggs Institute. Protocol registered in the International Prospective Register of Systematic Reviews with reference number: CRD42019137990.

Results: Out of the 1,310 potential studies found, 25 studies fulfilled the inclusion criteria. Most of the studies were of high quality. High levels of heterogeneity were found in the studies included. In the general population, the prevalence of long-term opioid use was 2.3% (95% CI: 1.5–3.6%), the prevalence of short-term opioid use was 8.1% (95% CI: 5.6–11.6%), and among people with chronic low back pain it was 5.8% (95% CI: 0.5–45.5%). The prevalence of opioid use among patients from the health records or medical surveys was 41% (95% CI: 23.3–61.3%). Finally, in patients with musculoskeletal pain, the prevalence was 20.5% (95% CI: 12.9–30.9%) and in patients with fibromyalgia, 24.5% (95% CI: 22.9–26.2%). A higher prevalence of opioid use was observed among men, younger people, patients receiving prescriptions of different types of drugs, smokers and patients without insurance or with noncommercial insurance. In addition, non-white and Asian patients were less likely to receive opioids than non-Hispanic white patients.

Conclusions: The prevalence of opioid use among patients with CNCP was higher in subjects with short or occasional use compared to those with long-term use. Men, younger people, more chronic pain conditions, and patients without insurance or with noncommercial insurance were most related to opioid use. However, non-white and Asian patients, and those treated by a physician trained in complementary medicine were less likely to use opioids.

Factors influencing trends in opioid prescribing for older people: a scoping review

Aim:

The review aimed to identify factors influencing opioid prescribing as regular pain-management medication for older people.

Background:

Chronic pain occurs in 45%–85% of older people, but appears to be under-recognised and under-treated. However, strong opiate prescribing is more prevalent in older people, increasing at the fastest rate in this age group.

Methods:

This review included all study types, published 1990–2017, which focused on opioid prescribing for pain management among older adults. Arksey and O’Malley’s framework was used to scope the literature. PubMed, EBSCO Host, the UK Drug Database, and Google Scholar were searched. Data extraction, carried out by two researchers, included factors explaining opioid prescribing patterns and prescribing trends.

Findings:

A total of 613 papers were identified and 53 were included in the final review consisting of 35 research papers, 10 opinion pieces and 8 grey literature sources. Factors associated with prescribing patterns were categorised according to whether they were patient-related, prescriber-driven, or system-driven. Patient factors included age, gender, race, and cognition; prescriber factors included attitudes towards opioids and judgements about ‘normal’ pain; and policy/system factors related to the changing policy landscape over the last three decades, particularly in the USA.

Conclusions:

A large number of context-dependent factors appeared to influence opioid prescribing for chronic pain management in older adults, but the findings were inconsistent. There is a gap in the literature relating to the UK healthcare system; the prescriber and the patient perspective; and within the context of multi-morbidity and treatment burden.

Opioid prescribing on discharge to skilled nursing facilities

PURPOSE

Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs.

METHODS

This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay.

RESULTS

Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF.

CONCLUSION

Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.

Patterns of Opioid Prescribing among Medicare Advantage Beneficiaries with Pain and Cardiopulmonary Conditions

Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p < 0.001) and both conditions (17%; p < 0.001) but higher than patients with neither condition (13.1%; p < 0.001). There was no difference in time to initiation of opioids at follow-up among patients with cardiopulmonary conditions only, relative to cancer only (adjusted hazard ratio 1.03; 95% confidence interval 0.88-1.21). Conclusions: Opioid use is lower among patients with pain and cardiopulmonary conditions relative to patients with cancer. Findings emphasize the importance of pain assessment and management for patients with cardiopulmonary conditions.

Prescription analgesia and adjuvant use by pain severity at admission among nursing home residents with non-malignant pain

OBJECTIVE

We estimated the use of prescribed analgesics and adjuvants among nursing home residents without cancer who reported pain at their admission assessment, in relation to resident-reported pain severity.

METHODS

Medicare Part D claims were used to define 3 classes of analgesics and 7 classes of potential adjuvants on the 21st day after nursing home admission (or the day of discharge for residents discharged before that date) among 180,780 residents with complete information admitted between January 1, 2011 and December 9, 2016, with no cancer diagnosis.

RESULTS

Of these residents, 27.9% reported mild pain, 46.6% moderate pain, and 25.6% reported severe pain. The prevalence of residents in pain without Part D claims for prescribed analgesic and/or adjuvant medications was 47.3% among those reporting mild pain, 35.7% among those with moderate pain, and 24.8% among those in severe pain. Among residents reporting severe pain, 33% of those ≥ 85 years of age and 35% of those moderately cognitively impaired received no prescription analgesics/adjuvants. Use of all classes of prescribed analgesics and adjuvants increased with resident-reported pain severity, and the concomitant use of medications from multiple classes was common.

CONCLUSION

Among nursing home residents with recognized pain, opportunities to improve the pharmacologic management of pain, especially among older residents, and those living with cognitive impairments exist.

Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents

OBJECTIVE

Current information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents.

DESIGN

Repeated measures cross-sectional study.

SETTING

Long-term care nursing homes.

PARTICIPANTS

Using 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927).

MEASUREMENTS

Dementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression.

RESULTS

Overall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.

CONCLUSIONS AND IMPLICATIONS

Use of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.

Special High-Risk Populations in Dentistry: The Adolescent Patient, the Elderly Patient, and the Woman of Childbearing Age

Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.

The role of geriatric palliative care in hospitalized older adults

Take-Away Points:1. Geriatric palliative care requires integrating the disciplines of hospital medicine and palliative care in pursuit of delivering comprehensive, whole-person care to aging patients with serious illnesses.2. Older adults have unique palliative care needs compared to the general population, different prevalence and intensity of symptoms, more frequent neuropsychiatric challenges, increased social needs, distinct spiritual, religious, and cultural considerations, and complex medicolegal and ethical issues.3. Hospital-based palliative care interdisciplinary teams can take many forms and provide high-quality, goal-concordant care to older adults and their families.

Opioid Prescribing in the Elderly: A Systematic Review

Objective: To characterize the literature describing the therapeutic use of opioids in the elderly. Data Sources: Two electronic databases, EMBASE and MEDLINE, were searched from years 1990 to September 5, 2018. Relevant reference lists were reviewed. Searches were restricted to English language. Study Selection and Data Extraction: Two reviewers independently screened 827 citations to identify observational studies, population-based cohort studies, retrospective analyses, and control trials looking at the management of persistent pain in patients aged ≥65 years and/or frail patients. Data Synthesis: Thirty-nine articles were included in the systematic review. More specifically, 17 observational studies, 7 population-based cohort studies, 10 retrospective analyses, and 4 controlled trials. The most common etiology of persistent pain was musculoskeletal (50%), and the most often adverse effects reported were central nervous system related (41%) and falls/fractures (39%). Relevance to Patient Care and Clinical Practice: As there is a lack of strong evidence-based recommendations for opioid use in the elderly, this review aims to evaluate opioid use in the elderly and compare their efficacy and safety among this population. Conclusions: Overall, central nervous system adverse effects were most commonly seen in the elderly. However, higher quality evidence is required to further appreciate the dose-related effects on efficacy and safety of opioids in the elderly.

Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment

OBJECTIVES

To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity.

DESIGN

Prospective individual data were collected over 1 to 3 days for each participant.

SETTING

Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey.

PARTICIPANTS

Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years).

MEASUREMENTS

A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep).

RESULTS

Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week.

CONCLUSION

Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

Effect of an Educational and Organizational Intervention on Pain in Nursing Home Residents: A Nonrandomized Controlled Trial

OBJECTIVES

To determine whether an intervention based on education and professional support to nursing home (NH) staff would decrease the number of residents with a pain complaint, and to determine whether the intervention would improve pain management.

DESIGN

Nonrandomized controlled trial. NHs were nonrandomly allocated either to a strong intervention group consisting in audit, feedback, and collaborative work on quality indicators with a hospital geriatrician, or to a light intervention group (LIG) consisting in audit and feedback only.

SETTING

One hundred fifty-nine NHs located in France.

PARTICIPANTS

A subgroup of 3722 residents.

MEASURES

Information on pain complaint and pain-related covariates at the resident-related and at the NH level were recorded by NH staff at baseline and 18 months later. These covariates were included in a mixed-effects logistic regression on resident's pain complaint. Pain management was compared between intervention groups by chi-square tests.

RESULTS

A greater reduction of residents with a pain complaint after the strong intervention (odds ratio 0.69, 95% confidence interval 0.53, 0.90) and a better pain management (47.6% gold standard, vs 30.6% in the LIG, P < .001) than controls.

CONCLUSION/IMPLICATIONS

Combining educational and organizational measures, evaluating pain as a patient-reported outcome and as a process endpoint, and implementing a broad-spectrum intervention were original approaches to improve quality of care in NHs. Our results support nonspecific, collaborative, educational, and organizational interventions in NHs to decrease residents' pain complaint and improve pain management.

Opioid Use in Long-Term Care: Guidelines and Policy Recommendations

Older adults living in long-term care (LTC) settings experience a higher incidence of chronic pain than those living in the community and are prescribed opioids at approximately twice the rate. Opioids are effective in managing pain in LTC residents, who are often not candidates for nonopioid pharmacological or nonpharmacological therapies. The recent Centers for Disease Control and Prevention guideline for opioid stewardship recommends conservative opioid prescribing and discourages long-term opioid use for chronic pain management, raising concern that pain may not be adequately treated for LTC residents. The Society for Post-Acute and Long-Term Care Medicine recently published a policy statement that addresses responsible opioid stewardship in LTC. The current article describes clinical guidelines and standards that can guide LTC nurses in assessing, treating, and monitoring opioid use so that residents have diminished pain without significant adverse events. [Journal of Gerontological Nursing, 45(9), 5-10.].

Opioid, antipsychotic and hypnotic use in end of life in long-term care facilities in six European countries: results of PACE

Background

Opioids, antipsychotics and hypnotics are recommended for comfort care in dying. We studied their prescription during the last 3 days in residents deceased in the long-term care facility (LTCF).

Methods

In a retrospective, cross-sectional survey in Belgium, England, Finland, Italy, the Netherlands and Poland, LTCFs, selected by proportional stratified random sampling, reported all deaths over the previous 3 months. The nurse most involved in the residents’ care reviewed the chart for opioid, antipsychotic and hypnotic prescription, cause of death and comorbidities. Multivariable logistic regression was performed to adjust for resident characteristics.

Results

Response rate was 81.6%. We included 1079 deceased residents in 322 LCTFs. Opioid prescription ranged from 18.5% (95% CI: 13.0–25.8) of residents in Poland to 77.9% (95% CI: 69.5–84.5) in the Netherlands, antipsychotic prescription from 4.8% (95% CI: 2.4–9.1) in Finland to 22.4% (95% CI: 14.7–32.4) in Italy, hypnotic prescription from 7.8% (95% CI: 4.6–12.8) in Finland to 47.9% (95% CI: 38.5–57.3) in the Netherlands. Differences in opioid, antipsychotic and hypnotic prescription between countries remained significant (P < 0.001) when controlling for age, gender, length of stay, cognitive status, cause of death in multilevel, multivariable analyses. Dying from cancer showed higher odds for receiving opioids (OR 3.51; P < 0.001) and hypnotics (OR 2.10; P = 0.010).

Conclusions

Opioid, antipsychotic and hypnotic prescription in the dying phase differed significantly between six European countries. Further research should determine the appropriateness of their prescription and refine guidelines especially for LTCF residents dying of non-cancer diseases.

Time trends in opioid prescribing among Ontario long-term care residents: a repeated cross-sectional study

BACKGROUND

Opioids are an important pain therapy, but their use may be associated with adverse events in frail and cognitively impaired long-term care residents. The objective of this study was to investigate trends in opioid prescribing among Ontario long-term care residents over time, given the paucity of data for this setting.

METHODS

We used linked clinical and health administrative databases to conduct a population-based, repeated cross-sectional study of opioid use among Ontario long-term care residents between Apr. 1, 2009, and Mar. 31, 2017. We identified prevalent opioid use by drug type, dosage and coprescription with benzodiazepines, and within certain vulnerable subgroups. We used log-binomial regression to quantify the percent change between 2009/10 and 2016/17.

RESULTS

Among an average of 76 147 long-term care residents per year, the prevalence of opioid use increased from 15.8% in 2009/10 to 19.6% in 2016/17 (p < 0.001). Over the study period, the use of hydromorphone increased by 233.2%, whereas the use of all other opioid agents decreased. The use of high-dose opioids (> 90 mg of morphine equivalents) and the coprescription of opioids with benzodiazepines decreased significantly, by 17.7% (p < 0.001) and 23.8% (p < 0.001), respectively. Increases in opioid prevalence were more notable among frail residents (37.6% v. 18.8% among nonfrail residents, p < 0.001) and those with dementia (38.6% v. 21.6% among those without dementia, p < 0.001).

INTERPRETATION

Within Ontario long-term care, trends suggest a shift toward increased use of hydromorphone but reduced prevalence of use of other opioid agents and potentially inappropriate opioid prescribing. Further investigation is needed on the impact of these trends on resident outcomes.

Pain Assessment, Management, and Impact Among Older Adults in Assisted Living

OBJECTIVES

The purpose of this study was to describe the incidence, pharmacologic management, and impact of pain on function, agitation, and resistiveness to care among assisted living residents.

DESIGN

This was a descriptive study.

DATA SOURCES

Baseline data from 260 residents in the second cohort of the study Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle.

REVIEW/ANALYSIS METHODS

Descriptive analyses for the Pain Assessment in Advanced Dementia (PAINAD), Visual Descriptor Scale (VDS), and use of medication for pain management and hypothesis testing using linear regression analyses were performed.

RESULTS

The majority of the sample was female (71%) and white (96%) with a mean age of 87 (standard deviation = 7). Fifty-two out of the 260 residents (20%) reported pain based on either the PAINAD or the VDS. Out of the total 260 residents, 75 (29%) received pain medication. Twenty-two out of the 52 individuals (42%) reporting pain were not getting pain medication. Controlling for age, gender, and cognition, the PAINAD was significantly associated with agitation, function, and resistiveness to care and the VDS was only associated with function.

CONCLUSIONS

The incidence of pain was low among participants based on the PAINAD or the VDS. Pain measured by the PAINAD was significantly associated with function, agitation, and resistiveness to care.

Cognitive status and use of analgesics and anxiolytics in residents of nursing homes in the Czech Republic

Background

The treatment of pain and treatment of anxiety are two of the most complex issues in nursing homes worldwide, mainly because of the large numbers of people with cognitive impairment who reside in this environment.

Aim

The aim of this study was to investigate the administration of analgesics and anxiolytics to people living in nursing homes, taking into account cognitive status.

Methods

For this cross-sectional study, we used data from 404 residents who lived in nine randomly selected nursing homes in the Czech Republic and participated in the Czech-Austrian Long-Term Care Research Project called DEMDATA. Information about medication administration was obtained from medical records. Cognitive impairment was evaluated by the Mini-Mental State Examination, and pain was measured by the Pain Assessment in Advanced Dementia. To measure anxiety, we used the Behavioral Pathology in Alzheimer’s Disease Rating Scale in residents with severe-to-moderate dementia and also the standardized questionnaire EuroQol in other residents.

Results

In all, 68% (95% CI 62–74) of residents with pain did not receive any analgesic medication and 31% (95% CI 25–38) of residents were administered some analgesics and continued to report pain. The lowest reported occurrence of pain, as well as the lowest prevalence of analgesic administration, was in residents with moderate-to-severe dementia. We found that an alarming percentage of residents in the nursing homes were not treated sufficiently.

Conclusion

This study indicates that treatment effects should be better monitored.

Pain and Pain Medication among Older People with Intellectual Disabilities in Comparison with the General Population

Little is known about pain and pain treatment among people with intellectual disabilities (IDs). We aimed to describe pain and pain medications among older people with ID compared to the general population. Data on diagnoses and prescriptions were collected from national registers for the period between 2006 and 2012 for 7936 people with an ID and a referent cohort from the general population. IDs were associated with a decreased risk of being diagnosed with headaches, musculoskeletal pain, and pain related to the circulatory and respiratory systems, but they were associated with increased risk of being diagnosed with pain related to the urinary system. Among men, IDs were associated with an increased risk of being diagnosed with visceral pain. People with IDs were more likely to be prescribed paracetamol and fentanyl regardless of the type of pain but were less likely to be prescribed COX(1+2) and COX2 inhibitors and weak opioids. Healthcare staff and caregivers must be made aware of signs of pain among people with IDs who may not be able to communicate it themselves. Further research is needed to investigate whether people with IDs are prescribed paracetamol rather than other pain drugs due to physicians trying to avoid polypharmacy or if there are other reasons not to prescribe a greater range of pain treatments.

Long-acting opioid initiation in US nursing homes

PURPOSE

To estimate the proportion of residents newly initiating long-acting opioids in comparison to residents initiating short-acting opioids and examine variation in long-acting opioid initiation by region and resident characteristics.

METHODS

This cross-sectional study included 182 735 long-stay nursing home residents in 13 881 US nursing homes who were Medicare beneficiaries during 2011 to 2013 and initiated a short-acting or long-acting opioid (excluding residents <50 years old, those with cancer, or receiving hospice care). Medicare Part D prescription claims were used to identify residents as newly initiating short-acting or long-acting opioids, defined as having a prescription claim for an opioid with no prior opioid prescriptions in the preceding 60 days. We estimated the overall proportion of initiators prescribed long-acting opioids. Regional variation was examined by mapping results by state and hospital referral regions. Logistic models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Two percent of opioid initiators were prescribed long-acting opioids. State variation in long-acting opioid initiation ranged from 0.6% to 7.5% (5th-95th percentiles: 0.6-6.4%). Resident characteristics associated with increased long-acting opioid initiation included severe physical limitations (vs none/mild limitations; aOR: 2.13, 95% CI: 1.92-2.37) and pain (staff-assessed vs no pain; aOR: 1.59 95% CI: 1.40-1.80), whereas being non-White was inversely associated (non-Hispanic black vs non-Hispanic white; aOR: 0.70, 95% CI: 0.62-0.79).

CONCLUSION

United States nursing home residents predominantly initiate short-acting opioids in accordance with Center for Disease Control and Prevention guidelines. Documented variation by geographic and resident characteristics suggests that improvements are possible.

Prescription of potentially inappropriate medications among older people with intellectual disability: a register study

BACKGROUND

Older people have a greater disease burden and are more likely than younger to be prescribed medications. They are also more sensitive to adverse effects. With this in mind, a range of medications have been suggested inappropriate in this population. People with intellectual disability (ID) have a higher disease burden than the general population, putting them at even greater risk of prescription of such medications. The aim of this study was to describe prescription of potentially inappropriate medications among older people with ID in relation to prescriptions among their age peers in the general population.

METHODS

We established an administrative cohort of people with ID (ID cohort; n = 7936), using a Swedish national register. A referent cohort from the general population (gPop) was matched one-to-one by sex and year of birth. Data regarding prescription of potentially inappropriate medications were collected from the Swedish prescribed drug register for the years 2006-2012.

RESULTS

People with ID were more likely than the general population to be prescribed medications with anticholinergic effects, intermediate- or long-acting benzodiazepines, and antipsychotics at least once during the study period, and also had more number of years with prescription. Except for benzodiazepines, those in the ID cohort with at least one prescription had larger amounts prescribed than those in the gPop cohort. People in the ID cohort were less likely than the general population to be prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Among those with at least one prescription of NSAIDs, those in the ID cohort had prescriptions during fewer years and in lower amounts than those in the gPop cohort.

CONCLUSIONS

Although prescription of potentially inappropriate medications overall is more common among people with ID than in the general population, the opposite pattern is found for medications for pain management. This may be a result of pain being under-recognized and under-treated in this population. Thus, there is a need for training as well as increased knowledge and awareness among care and health care professionals regarding signs of adverse effects and the need of continuous evaluation of treatment in this vulnerable group.

Prevalence of Long-Term Opioid Use in Long-Stay Nursing Home Residents

BACKGROUND/OBJECTIVES

Overall and long-term opioid use among older adults have increased since 1999. Less is known about opioid use in older adults in nursing homes (NHs).

DESIGN

Cross-sectional.

SETTING

U.S. NHs (N = 13,522).

PARTICIPANTS

Long-stay NH resident Medicare beneficiaries with a Minimum Data Set 3.0 (MDS) assessment between April 1, 2012, and June 30, 2012, and 120 days of follow-up (N = 315,949).

MEASUREMENTS

We used Medicare Part D claims to measure length of opioid use in the 120 days from the index assessment (short-term: ≤30 days, medium-term: >30-89 days, long-term: ≥90 days), adjuvants (e.g., anticonvulsants), and other pain medications (e.g., corticosteroids). MDS assessments in the follow-up period were used to measure nonpharmacological pain management use. Modified Poisson models were used to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for age, gender, race and ethnicity, cognitive and physical impairment, and long-term opioid use.

RESULTS

Of all long-stay residents, 32.4% were prescribed any opioid, and 15.5% were prescribed opioids long-term. Opioid users (versus nonusers) were more commonly prescribed pain adjuvants (32.9% vs 14.9%), other pain medications (25.5% vs 11.0%), and nonpharmacological pain management (24.5% vs 9.3%). Long-term opioid use was higher in women (aPR = 1.21, 95% CI = 1.18-1.23) and lower in racial and ethnic minorities (non-Hispanic blacks vs whites: APR = 0.93, 95% CI = 0.90-0.94) and those with severe cognitive impairment (vs no or mild impairment, aPR = 0.82, 95% CI = 0.79-0.83).

CONCLUSION

One in seven NH residents was prescribed opioids long-term. Recent guidelines on opioid prescribing for pain recommend reducing long-term opioid use, but this is challenging in NHs because residents may not benefit from nonpharmacological and nonopioid interventions. Studies to address concerns about opioid safety and effectiveness (e.g., on pain and functional status) in NHs are needed.

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.