Differences in Staff-Assessed Pain Behaviors among Newly Admitted Nursing Home Residents by Level of Cognitive Impairment

A conceptual model for assessing the risk of unidentified pain

Untreated or undertreated pain is well established as a significant problem, but unidentified pain is a distinct construct that still needs to be clearly modeled or fully described. This paper aims to develop a conceptual model of unidentified pain in humans with the goal of future development of an unidentified pain risk tool. A multi-phase process was employed consisting sequentially of 1) brainstorming followed by consensus building, 2) peer-review and publication of an integrative theoretical review protocol for "unidentified pain," 3) conduct of the integrative review, and 4) a repeated brainstorming session to identify areas of risk for unidentified pain to produce a conceptual model. Brainstorming led to a consensus on "unidentified pain" as the concept of interest, followed by developing a review protocol. Twenty-four abstracts were reviewed after database searches, and four articles were included for full-text review. Three pain risk areas (hazards) were identified: cognition/communication problems, being alone or in the absence of a surrogate/proxy report, and the presence of known painful conditions or treatments and a conceptual model was developed. The hazards are posited to have the potential to both interact and be cumulative, increasing the risk for unidentified pain. There is currently no risk tool for assessing unidentified pain. The development of this conceptual model will be used for future development and psychometric testing of a tool to recognize the risk for unidentified pain in humans. PERSPECTIVE: This focus article describes the development a conceptual model for the concept of unidentified pain in humans. This pain may occur in individuals who experience one or more interactive and cumulative hazards: cognition/communication problems, being alone, absence of a surrogate/proxy report, or presence of known painful conditions or treatments.

Pain Prevalence and Pain Management in Nursing Home Residents With Cognitive Impairment. Results From Five Multicenter Cross-Sectional Surveys in Germany Between 2014 and 2018

BACKGROUND

Pain management depends on continuous pain assessment and a pain concept. In particular, pain assessment and treatment are major challenges for nursing home residents (NHR) with cognitive impairment (CI). Many caregivers often lack the knowledge to recognize and appropriately treat pain in this vulnerable group. Little is known about the proportion of NHR who are fundamentally dependent on external assessment for pain due to CI.

OBJECTIVE

The aim of the study was to determine pain prevalence and management among NHR with and without CI. A second objective was to determine the proportion of NHR who are dependent on external assessment for pain.

METHODS

Information on pain was collected from 3,437 NHR in multicenter cross-sectional surveys in 51 German nursing homes between 2014 and 2018. The presence of current pain in one-to-one interviews was determined as well as dependencies on third-party information, number of daily pain recordings, and administration of medication for pain. The analysis included a contingency table and log regression analyses.

RESULTS

Pain prevalence was 24.9% among NHR with severe CI and 40.4% among NHR without CI. Overall, 19.8% of all NHRs relied on a third-party assessment of pain. Significantly, NHR with severe CI were less likely to be classified as having pain (OR 0.51), to be assessed for pain several times a day (OR 0.53) or to receive pain medication (OR 0.55) compared with NHR without CI. No influence on pain management was shown for the type of pain assessment.

CONCLUSIONS

The study provides evidence of significant deficits in pain management among NHR with moderate and severe CI in nursing homes in Germany. NHR with moderate and severe CI are significantly less likely to be observed for pain or classified as pain sufferers and receive significantly less pain medication than NHR without CI. Intensive training of staff on pain management of NHR with severe CI is recommended.

Pain assessment tools in adults with communication disorders: systematic review and meta-analysis

BACKGROUND

Verbal communication is the "gold standard" for assessing pain. Consequently, individuals with communication disorders are particularly vulnerable to incomplete pain management. This review aims at identifying the current pain assessment instruments for adult patients with communication disorders.

METHODS

A systematic review with meta-analysis was conducted on PubMed, PEDRO, EBSCOhost, VHL and Cochrane databases from 2011 to 2023 using MeSH terms "pain assessment, "nonverbal communication" and "communication disorders" in conjunction with additional inclusion criteria: studies limited to humans, interventions involving adult patients, and empirical investigations.

RESULTS

Fifty articles were included in the review. Seven studies report sufficient data to perform the meta-analysis. Observational scales are the most common instruments to evaluate pain in individuals with communication disorders followed by physiological measures and facial recognition systems. While most pain assessments rely on observational scales, current evidence does not strongly endorse one scale over others for clinical practice. However, specific observational scales appear to be particularly suitable for identifying pain during certain potentially painful procedures, such as suctioning and mobilization, in these populations. Additionally, specific observational scales appear to be well-suited for certain conditions, such as mechanically ventilated patients.

CONCLUSIONS

While observational scales dominate pain assessment, no universal tool exists for adults with communication disorders. Specific scales exhibit promise for distinct populations, yet the diverse landscape of tools hampers a one-size-fits-all solution. Crucially, further high-quality research, offering quantitative data like reliability findings, is needed to identify optimal tools for various contexts. Clinicians should be informed to select tools judiciously, recognizing the nuanced appropriateness of each in diverse clinical situations.

TRIAL REGISTRATION

This systematic review is registered in PROSPERO (International prospective register of systematic reviews) with the ID: CRD42022323655 .

The association between cognitive ability and opioid prescribing in vulnerable older adults with chronic pain in ambulatory care: a secondary data analysis using the Medical Expenditure Panel Survey

BACKGROUND

Vulnerable older adults living with Alzheimer's disease or Alzheimer's disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care.

METHODS

We used the Medical Expenditure Panel Survey (MEPS), years 2002-2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses).

RESULTS

Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31-1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04-1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34-1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23-1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07-1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75-1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups.

CONCLUSIONS

The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.

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.

Nursing-sensitive quality indicators for quality improvement in Norwegian nursing homes - a modified Delphi study

BACKGROUND

Use of nursing-sensitive quality indicators (QIs) is one way to monitor the quality of care in nursing homes (NHs). The aim of this study was to develop a consensus list of nursing-sensitive QIs for Norwegian NHs.

METHODS

A narrative literature review followed by a non-in-person, two-round, six-step modified Delphi survey was conducted. A five-member project group was established to draw up a list of nursing-sensitive QIs from a preliminary list of 24 QIs selected from Minimum Data Set (2.0) (MDS) and the international Resident Assessment Instrument for Long-Term Care Facilities (interRAI LTCF). We included scientific experts (researchers), clinical experts (healthcare professionals in NHs), and experts of experience (next-of-kin of NH residents). The experts rated nursing-sensitive QIs in two rounds on a seven-point Likert scale. Consensus was based on median value and level of dispersion. Analyses were conducted for four groups: 1) all experts, 2) scientific experts, 3) clinical experts, and 4) experts of experience.

RESULTS

The project group drew up a list of 20 nursing-sensitive QIs. Nineteen QIs were selected from MDS/interRAI LTCF and one ('systematic medication review') from the Norwegian quality assessment system IPLOS ('Statistics linked to individual needs of care'). In the first and second Delphi round, 44 experts (13 researchers, 17 healthcare professionals, 14 next-of-kin) and 28 experts (8 researchers, 10 healthcare professionals, 10 next-of-kin) participated, respectively. The final consensus list consisted of 16 nursing-sensitive QIs, which were ranked in this order by the 'all expert group': 1) systematic medication review, 2) pressure ulcers, 3) behavioral symptoms, 4) pain, 5) dehydration, 6) oral/dental health problems, 7) urinary tract infection, 8) fecal impaction, 9) depression, 10) use of aids that inhibit freedom of movement, 11) participation in activities of interest, 12) participation in social activities, 13) decline in activities of daily living, 14) weight loss, 15) falls, and 16) hearing loss without the use of hearing aids.

CONCLUSIONS

Multidisciplinary experts were able to reach consensus on 16 nursing-sensitive QIs. The results from this study can be used to implement QIs in Norwegian NHs, which can improve the quality of care.

The use of analgesics and associated factors among nursing home residents

Aim: This study examined the use of analgesics and associated factors among nursing home residents (NHRs). Materials & methods: A descriptive correlational design and a convenience sample of 209 NHRs receiving analgesics was used in this study. Results: Higher use of analgesics was noted among NHRs without cognitive impairment (p < 0.001), those with higher anticholinergic burden scores (p = 0.002) and those with a higher average number of oral pills taken daily (p = 0.045). Conclusion: These findings contribute to a better understanding of the prevalence and associated factors of analgesic use, which will inform the development and application of evidence-based pain practice and guidelines in nursing homes in Jordan and beyond.

Pain Behaviors and Pharmacological Pain Management Among Newly Admitted Nursing Home Residents

BACKGROUND

Clinicians may place more weight on vocal complaints of pain than the other pain behaviors when making decisions about pain management.

OBJECTIVES

We examined the association between documented pain behaviors and pharmacological pain management among nursing home residents.

METHODS

We included 447,684 residents unable to self-report pain, with staff-documented pain behaviors (vocal, nonverbal, facial expressions, protective behaviors) and pharmacological pain management documented on the 2010-2016 Minimum Data Set 3.0. The outcome was no pharmacological pain medications, as needed only (pro re nata [PRN]), as scheduled only, or as scheduled with PRN medications. We estimated adjusted odds ratios and 95% confidence intervals from multinomial logistic models.

RESULTS

Relative to residents with vocal complaints only, those with one pain behavior documented (i.e., nonverbal, facial, or protective behavior) were more likely to lack pain medication versus scheduled and PRN medications. Residents with multiple pain behaviors documented were least likely to have no treatment relative to scheduled with PRN medications, PRN only, or scheduled only pain medication regimens.

DISCUSSION

The type and number of pain behaviors observed are associated with pharmacological pain management regimen. Improving staff recognition of pain among residents unable to self-report is warranted in nursing homes.

Multiple imputation to quantify misclassification in observational studies of the cognitively impaired: an application for pain assessment in nursing home residents

Background

Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment.

Methods

Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain.

Results

The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting.

Conclusions

In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01327-5.