Pain perception of older adults in nursing home and home care settings: evidence from China

Pilot testing implementation of the pain management clinical practice guideline in nursing homes

Pain is a common symptom for older adults living with dementia in nursing homes. Unfortunately, there are many challenges to pain assessment, diagnosis and management for these individuals. The purpose of this study was to pilot test the implementation of the newly published Pain Management Clinical Practice Guideline from AMDA: The Society of Post Acute and Long-Term Care using our theoretically based Pain-CPG-EIT approach. Implementation was provided by a research nurse facilitator and included four components: Component I: Establishing and working with a stakeholder team monthly; Component II: Education of the staff; Component III: Mentoring and motivating the staff; and Component IV: Ongoing monitoring of pain assessment, diagnosis and management for residents. Findings provide some preliminary support for the feasibility and effectiveness of our implementation approach.

Different impact on health outcomes of long-term care insurance between urban and rural older residents in China

Long-term care insurance (LTCI) is garnering attention internationally and is being considered a public policy in a growing number of countries. Previous research has focused on the effects of LTCI in developed countries, ignoring the health outcomes of developing countries, especially in rural regions. Therefore, this study investigates whether different impact on health outcomes is present in the effects of LTCI between urban and rural residents in China. We employed a quasi-experimental design with data from the China Health and Retirement Longitudinal Survey. The specific implementation time of each pilot city was sorted according to the LTCI policy texts, dividing these pilot cities into the treatment group and control group. Finally, difference-in-differences analyses were utilized to evaluate the health effects of LTCI between urban and rural residents, and the health effect in urban areas was further tested. The implementation of LTCI has effectively enhanced the self-rating health (SRH) of the entire group of residents; however, this effect may only be significant for the urban group. In particular, LTCI can increase the SRH of urban residents by 0.377 units compared to the urban residents without LTCI (P < 0.01). The result of the placebo effect test further verifies that LTCI could improve the health of residents to some extent. In China, LTCI may have triggered different impacts on health outcomes between urban and rural residents, and may not improve the SRH of rural residents and only prove efficacious for urban residents. Government and policy-makers should give more attention to the rural group as it needs long-term care the most.

Prevalence and Factors Associated with Pain in Nursing Home Residents: A Systematic Review of the Literature

OBJECTIVES

To describe the pain prevalence in nursing home (NH) residents and the factors associated with the experience of pain.

DESIGN

Systematic review of descriptive studies.

SETTING AND PARTICIPANTS

Three electronic databases were searched from 2010 to September 2020 in English. Descriptive studies that examined pain in NH residents, reported pain prevalence, and/or associated factors were included. Studies that focused exclusively on a specific disease or type of care such as cancer or hospice were excluded.

METHODS

Two reviewers independently screened, selected, extracted data, and assessed risk of bias from included studies; narrative synthesis was performed. The review was guided by the Biopsychosocial Model of Chronic Pain for Older Adults.

RESULTS

Twenty-six studies met our inclusion criteria. Overall, the prevalence of current pain ranged from 22.2% to 85.0%, the prevalence of persistent pain ranged from 19.5% to 58.5%, and the prevalence of chronic pain ranged from 55.9% to 58.1%. A variety of pain scales were used reporting higher pain prevalence for those using self-report measures (31.8% to 78.8%) or proxy measures (29.5% to 85.0%) compared with using chart review (22.2% to 29.3%) as the source of pain information. The studies reviewed provide support that certain diseases and clinical conditions are associated with pain. Impairment in activities of daily living (ADL) (12 studies), cognition (9 studies), depression (9 studies), and arthritis (9 studies) are the most widely studied factors, whereas depression, ADL impairment, arthritis, dementia, and cognitive impairment present the strongest association with pain.

CONCLUSION AND IMPLICATIONS

This review highlights the complexities of pain in NH residents and has implications for both clinical practice and future research. Understanding the factors that underlie the experience of pain, such as depression, is useful for clinicians evaluating pain and tailoring management therapies. In addition, the gaps in knowledge uncovered in this review are important areas for future research.

Prevalence of falls, incontinence, malnutrition, pain, pressure injury and restraints in home care: A narrative review

Global demographic changes and the strategy of 'ageing in place' will increase the importance of home care in the future. To deliver safe and high-quality care, clinical data on nursing-sensitive indicators and transparency are needed. A comprehensive narrative review of the literature was conducted to describe the prevalence and incidence of nursing-sensitive indicators, namely, falls, incontinence, malnutrition, pain, pressure injury and restraints in home care. A literature search was carried out in May 2021 in PubMed and CINAHL, and 28 studies were included. Data were extracted using two extraction tables designed for this review. Prevalence and incidence rates varied widely and internationally within each indicator. The prevalence range for falls was 4.8%-48%; urinary incontinence, 33.7%-62.5%; malnutrition, 20%-57.6%; pain, 6.5%-68.5%; pressure injury, 16%-17.4% and physical restraints, 5%-24.7%. Due to various measurements and different instruments, the rates are not comparable. The use of standardised measurement and risk assessment tools to assess nursing-sensitive indicators in home care is needed to implement suitable interventions and to prevent these indicators.

Depressive rumination and life satisfaction among institution-dwelling Chinese older adults: the roles of perceived burdensomeness and social support from individuals within the institution

Objectives: We examined how institution-dwelling older adults' depressive rumination was associated with their life satisfaction by taking perceived burdensomeness as a mediator and social support from individuals within the institution (SSII) as a moderator.Method: A total of 194 older adults from 24 institutions in four provinces of China completed a questionnaire survey.Results: Depressive rumination was negatively associated with life satisfaction, and perceived burdensomeness mediated this association. Moreover, SSII moderated the indirect association between depressive rumination and life satisfaction through perceived burdensomeness. Specifically, depressive rumination had a negative effect on life satisfaction through perceived burdensomeness only for older adults with less SSII.Conclusion: Our study indicated that depressive rumination could damage older adults' life satisfaction by increasing their perceived burdensomeness. Fortunately, older adults' perception of social support from individuals within the institution could attenuate this negative effect. This study has implications for designing intervention programs to improve the institution-dwelling older adults' life satisfaction.

Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis

OBJECTIVES

Pain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents.

DESIGN

A Cochrane-style systematic review and meta-analysis using PRISMA guidelines.

SETTING AND PARTICIPANTS

Randomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60 years receiving interventions to reduce chronic pain.

METHODS

Six databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0.

RESULTS

We included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD -0.80; 95% CI -1.47 to -0.12; P = .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD -0.70; 95% CI -0.95 to -0.45; P < .001), combined interventions (SMD -0.37; 95% CI -0.60 to -0.13; P = .002), and education interventions (SMD -0.31; 95% CI -0.48 to -0.15; P < .001).

CONCLUSIONS AND IMPLICATIONS

Our findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.

Chronic Pain in the Elderly: Mechanisms and Perspectives

Chronic pain affects a large part of the population causing functional disability, being often associated with coexisting psychological disorders, such as depression and anxiety, besides cognitive deficits, and sleep disturbance. The world elderly population has been growing over the last decades and the negative consequences of chronic pain for these individuals represent a current clinical challenge. The main painful complaints in the elderly are related to neurodegenerative and musculoskeletal conditions, peripheral vascular diseases, arthritis, and osteoarthritis, contributing toward poorly life quality, social isolation, impaired physical activity, and dependence to carry out daily activities. Organ dysfunction and other existing diseases can significantly affect the perception and responses to chronic pain in this group. It has been proposed that elderly people have an altered pain experience, with changes in pain processing mechanisms, which might be associated with the degeneration of circuits that modulate the descending inhibitory pathways of pain. Aging has also been linked to an increase in the pain threshold, a decline of painful sensations, and a decrease in pain tolerance. Still, elderly patients with chronic pain show an increased risk for dementia and cognitive impairment. The present review article is aimed to provide the state-of-art of pre-clinical and clinical research about chronic pain in elderly, emphasizing the altered mechanisms, comorbidities, challenges, and potential therapeutic alternatives.

Evaluating the long-term care insurance policy from medical expenses and health security equity perspective: evidence from China

Background

Since the national long-term care (LTCI) policy pilot in 2016 of China, the LTCI policy has had significant impact on the residents in the pilot area.

Methods

From the perspective of medical expenses and health security equity, this study selects tracking survey data from the CHARLS database in 2013, 2015, and 2018 and empirically investigates the effect of LTCI policy pilot by using differences-in-differences method (DID). Moreover, this study measures the economic distribution and health equity of the treated and untreated groups using the concentration and Theil indices.

Results

The results showed that group heterogeneity of medical expenses and health level of elderly in the treatment group were narrowing. Moreover, the policy results showed that the LTCI policy pilot significantly affects the outpatient, hospital expenses, and length of stay of elders. Residence registration, income level, and basic medical insurance play a significant regulatory role. Additionally, LTCI policy pilot significantly improved the overall health of the elderly.

Conclusions

The measurement results of inequality show that the policy increases the income of low-income people, lowers the inequality level of outpatient and inpatient reimbursement, and reduces the concentration index of ADL disability and serious diseases. However, the inequality of serious diseases is becoming higher. Based on this, this paper provides several suggestions on optimizing the pilot policy of LTCI.

Differences in Pain Characteristics and Functional Associations between Nursing Home Residents and Community-Dwelling Older Adults: A Cross-Sectional Study

Background

Pain is one of the most critical issues in older adults, and the place of residence may play an important role in pain characteristics and related factors. However, it is an understudied subject. This study investigated differences in pain characteristics and functional associations between nursing home residents and community-dwelling older adults.

Methods

Older adult participants were recruited from nursing homes (n=73) and the community (n=73). Pain characteristics, including type, intensity, and number of pain sites, were evaluated. Other outcome measures were functional mobility, walking speed, functional independence, physical activity, anxiety, depression, and health-related quality of life.

Results

Nursing home residents experienced musculoskeletal pain more frequently and had a greater number of pain sites than community-dwelling older adults (p<0.05). Walking speed and mobility were significantly lower and anxiety and depression were significantly higher in nursing home residents (p<0.05). While higher pain intensity was significantly correlated with low scores on physical measures, low health-related quality of life, and higher depression and anxiety symptoms in both groups (p<0.05), the magnitudes of the correlations were much higher in nursing home residents. The number of pain sites was significantly correlated with low scores on physical measures, low health-related quality of life, and higher depression and anxiety symptoms mainly in nursing home residents (p<0.05).

Conclusion

Compared to community-dwelling older adults, nursing home residents experienced musculoskeletal pain more frequently and at more sites in the body. Higher pain intensity and number of pain sites were associated with worse clinical variables, mainly in nursing home residents. This study highlights the importance of regular pain assessment, especially in nursing home care settings.

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.

Pain management and cognitive function among older adults: an exploratory study of the China Health and Retirement Longitudinal Study

BACKGROUND

Chronic pain and cognitive decline are common age-related conditions affecting a large segment of older populations. Little is known about the pathway of cognitive functioning during the course of pain management in older adults.

AIMS

The study aimed to examine the association between chronic body pain management and cognitive function over time among Chinese older adults.

METHODS

A total of 792 respondents aged 60 and above from urban and rural households in 28 provinces, 150 counties/districts, and 450 communities were selected from the China Health and Retirement Longitudinal Study (2013-2015). Cognitive function was measured in three domains: episodic memory, mental status, and global cognitive function. Difference-in-differences approach and mixed-effects linear regression models were employed to assess the association between chronic body pain management and cognitive function over time.

RESULTS

Scores of mental status were found to decline slower by 0.49 unit (SE = 0.22, p < 0.05) in respondents who received pain management using analgesics, complementary and alternative medicine, or both from 2013 to 2015 after controlling for basic demographic and health confounders.

CONCLUSION

Chronic pain management was associated with slower decline in domain-specific cognitive function, mental status over time. Findings of the study may contribute to understanding the mechanism of change in diverse cognitive abilities attributable to pain symptoms. More research is needed to elucidate the mediating effect of pain on cognitive decline, which could lead to testing of the impact of pain management on cognitive function among older population in both clinical and community settings.