Nonpharmacological interventions for persistent, noncancer pain in elders residing in long-term care facilities: An integrative review of the literature

Non-pharmacological management of neuropathic pain in older adults: a systematic review

INTRODUCTION

Neuropathic pain encompasses multiple diagnoses with detrimental impacts on quality of life and overall health. In older adults, pharmacological management is limited by adverse effects and drug interactions, while surgical management involves perioperative risk. Prior reviews addressing non-pharmacological interventions for neuropathic pain have not focused on this demographic. Therefore, this systematic review synthesizes the evidence regarding the effectiveness of non-pharmacological interventions in reducing neuropathic pain severity in older adults.

METHODS

PubMed, CINAHL, Web of Science, and PsycInfo were searched using key terms, with inclusion criteria of age ≥ 65, neuropathic pain, non-pharmacological intervention, pain severity measurement, English language, peer-reviewed, and either randomized controlled trial (RCT) or quasi-experimental design. In total, 2759 records were identified, with an additional 28 records identified by review of reference lists. After removal of duplicates, 2288 records were screened by title and abstract, 404 full-text articles were assessed, and 19 articles were critically reviewed and synthesized.

RESULTS

Of the 14 RCTs and 5 quasi-experimental studies included in the review, the most common intervention was electric and/or magnetic therapy, followed by acupuncture, mindfulness meditation, exercise, and light therapy. Several studies revealed both statistical and clinical significance, but conclusions were limited by small sample sizes and methodological shortcomings. The interventions were generally safe and acceptable.

CONCLUSIONS

Results should be interpreted with consideration of clinical vs statistical significance, mediators of pain severity, and individual variations in effectiveness. Further research should address multimodal and novel interventions, newer models of care, and technology-based interventions.

Helpful social support for chronic pain in long-term care residents: "With a little help I manage on my own"

AIMS AND OBJECTIVES

To understand older adults' experiences of receiving formal pain-related social support and to identify which caregivers' responses are perceived as (un)helpful to chronic pain adjustment.

BACKGROUND

Chronic pain is highly prevalent in long-term care residents, negatively impacting their psychological, physical and social functioning. However, research has lacked to address the extent to which residents' experiences with staff responses, to their pain, may influence chronic pain outcomes.

DESIGN

Qualitative study.

METHODS

Twenty-nine older adults (7 men, 22 women, Mage  = 87.7) were interviewed online through semi-structured interviews, and a thematic analysis was conducted. COREQ guidelines were followed.

RESULTS

Two main themes emerged: (1) support during a pain crisis aiming at its relief and (2) support with daily activities because of pain to overcome pain interference. Findings indicate pain-related support is helpful when residents feel their psychological and functional autonomy is protected, and the interactions convey connection and intimacy. Furthermore, residents actively try to shape the support to be received. Also, gender roles and expectations seem to influence pain-related supportive interactions.

CONCLUSION

Pain-related social support may contribute to the maintenance of older adults' health status and autonomy, ensuring a fulfilling and healthy aging process despite chronic pain.

RELEVANCE TO CLINICAL PRACTICE

Findings can inform effective pain-related care practices in long-term care, regarding (1) how residents can shape the support they need; (2) which kind of support should be provided, and (3) how caregivers and organizations should provide pain-related support.

PATIENT OR PUBLIC CONTRIBUTION

Older adults who participated in the study were recruited from 3 long-term care facilities in Lisbon, in which they resided for longer than 3 months, had persistent/intermittent pain for more than 3 months; were able to maintain a conversation, recollect real episodes, and to fully provide informed consent to participate.

A Descriptive Study of Treatment of Pain in Acute Care for Patients Living With Dementia

BACKGROUND

During the hospital stay pain is very common among patients living with dementia.

METHODS

Descriptive data was obtained from chart review and included age, gender, race, comorbidities and admitting diagnosis.

AIMS

The purpose of this study was to describe pain among patients living with dementia, the use of pharmacologic and nonpharmacologic treatment, and to compare treatments among those with and without pain.

DESIGN

This was a descriptive study using baseline data from the first 233 participants from the study "Testing the Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT)".

PARTICIPANTS/SUBJECTS

The mean age of participants was 83 (SD=5) and the majority was female (65%) and White (67%) with evidence of dementia (based on a mean Saint Louis University Mental Status Test = 7.23, SD=5.85).

RESULTS

Overall 98 (42%) participants had pain and 135 (58%) no pain. Only 14 (6%) participants received no nonpharmacologic or pharmacologic interventions for pain and five of these individuals had pain. The most frequently used pharmacologic intervention among all participants was acetaminophen (n = 121, 52%), then tramadol (n = 19, 8%). Comfort measures and general nonpharmacologic approaches were the most frequently used non-pharmacologic approaches, then physical activity and therapeutic communication. From admission to discharge, there was a trend towards a decrease in pain. There was more use of opioids, physical activity, and therapeutic communication in the no pain group versus the pain group.

CONCLUSIONS

The majority of hospitalized medical patients living with dementia were treated for pain, but an ongoing focus is needed to assure optimal pain management for all patients.

Non-pharmacological interventions for pain in people with dementia: A systematic review

CONTEXT

Pain commonly occurs in people living with dementia but is often undertreated. Non-pharmacological interventions are a safer first-line option for pain management, but evidence-based interventions for people living with dementia have not been established. An increasing number of studies have examined the effect of non-pharmacological interventions in pain management. However, the evidence that specifically focuses on people living with dementia has not been systematically reviewed.

OBJECTIVES

This review aimed to systematically synthesize current evidence on non-pharmacological interventions to manage pain in people living with dementia.

METHODS

A comprehensive search of the literature was conducted in PubMed, CINAHL, Scopus, and Web of Science databases. Studies were included if they were 1) peer-reviewed original quantitative research, 2) tested the effect of non-pharmacological interventions on pain in people with dementia, and 3) English language. Studies were excluded if they 1) included both pharmacological and non-pharmacological interventions and did not report separate results for the non-pharmacological interventions; 2) enrolled participants with and without dementia and did not have separate results reported for individuals with dementia; 3) tested dietary supplements as the intervention; and 4) were not original research, such as reviews, editorials, commentaries, or case studies. Title, abstract, and full text were screened. Quality assessment was conducted using the Cochrane Risk of Bias tool and Johns Hopkins Level of Evidence. Pain assessment tools, participant characteristics, study designs, intervention condition, and results were extracted. Results were synthesized through grouping the type of the interventions and weighting evidence based on quality and design of the studies.

RESULTS

A total of 11 articles and 12 interventions were identified. A total of 486 participants were included. Interventions that have shown a positive impact on pain include ear acupressure, music therapy, reflexology, tailored pain intervention, painting and singing, personal assistive robot, cognitive-behavioral therapy, play activity, and person-centered environment program. Nevertheless, a majority of the interventions were only evaluated once. Moreover, most studies had similar sample characteristics and setting.

CONCLUSION

Overall, the quality of included studies were mostly low to mixed quality and most participants only had mild to moderate baseline pain, which limits detection of the intervention's effect. Hence, these findings need to be duplicated in studies with a greater sample size, a more diverse population (race, gender, and settings), and a more rigorous design to validate the results.

[Pain and dementia: what to consider?]

Pain history should be adapted to their cognitive abilities of people with dementia who can still communicate. With increasing limitations of communication skills, history of a third party and standardized observation instruments increase in importance. Non-drug therapies are hardly investigated for pain therapy in people with dementia. The few data on drug pain therapy prove the effectiveness and good tolerability of paracetamol even in people with dementia. Opioids and coanalgetics have hardly been studied in this group although frequently used. Anticholinergic side effects are especially important in people with dementia.

Pain assessment and management in care homes: understanding the context through a scoping review

Background

Internationally, 2–5% of people live in residential or nursing homes, many with multi-morbidities, including severe cognitive impairment. Pain is frequently considered an expected part of old age and morbidity, and may often be either under-reported by care home residents, or go unrecognized by care staff. We conducted a systematic scoping review to explore the complexity of pain recognition, assessment and treatment for residents living in care homes, and to understand the contexts that might influence its management.

Methods

Scoping review using the methodological framework of Levac and colleagues. Articles were included if they examined pain assessment and/or management, for care or nursing home residents. We searched Medline, CINAHL, ASSIA, PsycINFO, EMBASE, Cochrane Library, and Google Scholar; reference lists were also screened, and website searches carried out of key organisations. Conversations with 16 local care home managers were included to gain an understanding of their perspective.

Results

Inclusion criteria were met by 109 studies. Three overarching themes were identified: Staff factors and beliefs - in relation to pain assessment and management (e.g. experience, qualifications) and beliefs and perceptions relating to pain. Pain assessment – including use of pain assessment tools and assessment/management for residents with cognitive impairment. Interventions - including efficacy/effects (pharmaceutical/non pharmaceutical), and pain training interventions and their outcomes.

Overall findings from the review indicated a lack of training and staff confidence in relation to pain assessment and management. This was particularly the case for residents with dementia.

Conclusions

Further training and detailed guidelines for the appropriate assessment and treatment of pain are required by care home staff. Professionals external to the care home environment need to be aware of the issues facing care homes staff and residents in order to target their input in the most appropriate way.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02333-4.

Chronic non-cancer pain management by nurses in specialist pain clinics

BACKGROUND

Chronic non-cancer pain (CNCP) is one of the major causes of disability globally, and patients who suffer from it are a complex population, which makes it difficult to provide effective care. Specialist pain clinics and nursing professionals in them are the main care providers, but there is little research conducted in this field.

AIM

To explore the attitudes and knowledge of nurses working in specialist pain clinics regarding care of CNCP patients.

METHODS

Qualitative phenomenological approach. Sixteen semi-structured interviews were conducted in 2017 with nurses who worked in specialist pain clinics in six hospitals in southern Spain.

RESULTS

Data analysis led to the formation of two categories, 'being trained and improving knowledge in CNCP' and 'the challenge of caring for patients with CNCP', and five subcategories.

CONCLUSION

The need for care in CNCP is not covered by nurses in all the areas it requires. Lack of time, staffing issues, and specific training in this area makes it difficult to provide care. However, some areas for improvement are proposed, such as psychological interventions, group workshops, continuous training, and multidisciplinary teams.

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.

Pain in dementia

The ageing revolution is changing the composition of our society with more people becoming very old with higher risks for developing both pain and dementia. Pain is normally signaled by verbal communication, which becomes more and more deteriorated in people with dementia. Thus, these individuals unnecessarily suffer from manageable but unrecognized pain. Pain assessment in patients with dementia is a challenging endeavor, with scientific advancements quickly developing. Pain assessment tools and protocols (mainly observational scales) have been incorporated into national and international guidelines of pain assessment in aged individuals. To effectively assess pain, interdisciplinary collaboration (nurses, physicians, psychologists, computer scientists, and engineers) is essential. Pain management in this vulnerable population is also preferably done in an interdisciplinary setting. Nonpharmacological management programs have been predominantly tested in younger populations without dementia. However, many of them are relatively safe, have proven their efficacy, and therefore deserve a first place in pain management programs. Paracetamol is a relatively safe and effective first-choice analgesic. There are many safety issues regarding nonsteroidal anti-inflammatory drugs, opioids, and adjuvant analgesics in dementia patients. It is therefore recommended to monitor both pain and potential side effects regularly. More research is necessary to provide better guidance for pain management in dementia.