Resources: Pain Management in Nursing Homes

News/Important Information

Related to Pain Management in Nursing Homes

The Centers for Medicare and Medicaid Services has issued the revised survey guidance for F309 Quality of Care, which includes a new section for review of residents who have pain symptoms, are being treated for pain, or have the potential for pain symptoms due to their conditions or treatments.

• Effective as of April 10, 2009

• Copy available online

• Requires recognition of pain or potential for pain, comprehensive assessment of pain, identification of and treatment of underlying cause of pain if possible, development of plan of care that incorporates resident/family preferences and is consistent with current standards of practice, consideration of non-pharmacologic as well as pharmacologic strategies for pain management, and assessment of effectiveness of pain management strategies and modifications in plan of care as necessary. 

A pain toolbox has been developed by Katherine Jones, Regina Fink, Evelyn Hutt and other team members through a research project funded by the Agency for Healthcare Research and Quality (AHRQ) that contains items useful for nursing homes in their efforts to improve pain assessment and management. The toolbox includes laminated assessment cards, workbooks for nurses, nursing assistants and staff educators, and videos and CD-ROMS for staff education and resident/family education about pain and its management. The toolboxes are available from Kinkos/FedEx in Denver, Colorado. Download the order form.

American Geriatrics Society (AGS) Updates Clinical Practice Guideline “Pharmacologic Management of Persistent Pain in Older Persons”

• This newly updates guideline (released in August, 2009) focuses specifically on pharmacological management of persistent pain in older persons.

• Major changes have been made in the recommendations for use of non-opioids in the management of mild to moderate pain.

• The major change is that nonselective NSAIDS and COX-2 selective inhibitors should be considered rarely, and with extreme caution, in highly selected individuals (high quality evidence, strong recommendation). Absolute and relative contraindications are identified. Older persons taking nonselective NSAIDS or COX-2 selective inhibitors with aspirin should receive a proton pump inhibitor or Misoprostal for GI protection.

• Reference: AGS Panel on Pharmacological Management of Persistent Pain in Older Persons. 2009. Pharmacological Management of Persistent Pain in Older Persons. Journal of the American Geriatrics Society, 57(8):1331-1346.

• Further information is available.

The American Medical Directors Association (AMDA) has recently (2009) updated its clinical practice guideline for managing pain in the long-term care setting. The revised guideline includes:

• an acute pain component

• expanded section on recognizing pain in the cognitively impaired

• an expanded section on pain management in palliative care

• an updated pharmacological information

• an expanded section on alternative therapies

• strategies for measuring pain in residents who do not ask for pain medication or residents whose pain is most likely controlled but still report being in pain

• Ordering information can be found online.

Tools and Instruments 

• The NOPPAIN (Non-Communicative Patient’s Pain Assessment Instrument) is a publicly available one page tool for assessing pain in residents with cognitive impairment. It is meant to be completed by the nursing assistant. It is available in English and Spanish.
  

• Pain management in the AGED “Pearl  Card” 
  

• WILDA Pain Assessment Card:

• Contains structured pain assessment on one side (words, intensity, location, duration and frequency, aggravating and alleviating factors) and pain intensity scales on the reverse side

• Available in English and Spanish as single item from University of Colorado Pain Toolbox

AHRQ Nursing Home Pain Study Publications 

• Jones KR, Fink R, Pepper G, Hutt E, Clark L, Vojir, Scott J, & Mellis K. (2004). Improving Nursing Home Staff Knowledge and Attitudes About Pain.  The Gerontologist, 44(4):469-478.

• Clark L, Jones K, & Pennington K.  (2004). Pain Assessment Practices with Nursing Home Residents.  Western Journal of Nursing Research. 26(7):733-750.

• Jones, K, Fink, R, Hutt, E, Vojir, C, Pepper, G, Clark, L, Scott, J, Martinez, R, Vincent, D, & Mellis, K.  (2004). Translation Research in Long-Term Care: Improving Pain Management in Nursing Homes. Worldviews on Evidence-Based Nursing. 1(S1): S13-S20.

• Jones, K., Fink, R., Clark, L., Hutt, E., Vojir, C., & Mellis, K. (2005). Nursing Home Resident Barriers to Pain Management: Why Nursing Home Residents May Not Seek Pain Medication. Journal of American Medical Directors Association, 6(1):10-17.

• Jones, KR., Fink, R, Hutt, E, Vojir, C, Pepper, G, Scott-Cowiezell, J, & Mellis, BK. (2005). Measuring Pain Intensity in Nursing Home Residents. Journal of Pain & Symptom Management, 30(6):519-527.

• Jones, KR. (2006). Effective Pain Management: Lessons From a Nursing Home Study. Journal for Healthcare Quality, 28(1):41-47.

• Hutt, E., Pepper, GA, Vojir, C, Fink, R., &  Jones, K.  (2006). Assessing the Appropriateness of Pain Medication Prescribing Practices in Nursing Homes.  Journal of American Geriatrics Society, 54:231-239.

• Clark L, Fink R, Pennington K, Jones K. (2006). Nurses’ Reflections on Pain Management in a Nursing Home Setting. Pain Management Nursing, 7(2):71-77.

• Jones K, Vojir C, Hutt E, Fink R. (2007). Determining Mild, Moderate, and Severe Pain Equivalency Across Pain Intensity Tools. Journal of Rehabilitation Research and Development, 44(2):305-314.

• Hutt E, Buffum M, Fink R, Jones R, Pepper G. (2007).  Optimizing Pain Management in Long-Term Care Residents. Geriatrics & Aging, 10(8):523-527.

Other Publications

Herman AD, Johnson TM, Ritchie CS, Parmelee PA. 2009. Pain management interventions in the nursing home: A structured review of the literature. Journal of the American Gerontological Society, 57(7):258-267.

Twenty-one articles were reviewed. The overall quality of the research was judged to be uneven. Process endpoints were often used as surrogates for resident endpoints. The authors state that actor, decision support, treatment and system modifications need to be addressed to accomplish quality pain management in nursing homes.

Jablonski A, Ersek M. 2009. Nursing home staff adherence to evidence-based pain management practices. J Gerontological Nursing, 35(7):28-31.

This study documents continuing gaps between actual practices and current best practices as documented in evidence-based pain guidelines. Results revealed: limited assessment of persistent pain, inadequate pain relief in spite of improved prescribing practices, and limited use of non-pharmacologic pain management practices.

Macea DD, Gajos K, Daglia C, Tregni F. 2010. Efficacy of web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. Journal of Pain, July 20, 2010 (Epub ahead of print).

The objective was to quantify the efficacy of web-based cognitive behavioral interventions for treatment of patients with chronic pain. The findings suggest that web-based interventions for chronic pain result in small pain reductions in intervention groups compared with waiting list control groups.

Mayyas F, Fayers P, Kaasa S, Dale O. 2010. A systematic review of oxymorphone in the management of chronic pain. Journal of Pain & Symptom Management, 39(2):296-308.

The objective was to assess the effectiveness of oxymorphone as an analgesic in chronic pain. Results were reported as follows: Limited evidence suggests that oxymorphone is effective for pain control in patients with cancer; oxymorphone is superior to placebo; no evidence that efficacy of oxymorphone differs from other opioids; no significant difference between oxymorphone and oxycodone at equipotent doses.

Moore RA, Eccleston C, Derry S, et al. for the ACTINPAIN Writing Group of the IASP Special Interest Group on Systematic Reviews in Pain Relief and the Cochrane Pain, Palliative and Supportive Care Systematic Review Group Editors. “Evidence” in chronic pain – establishing best practice in the reporting of systematic reviews. 2010. Pain, 150:386-389.

This article discusses common misconceptions in evidence synthesis and reviews of trials, including quality (randomization, blinding, incompletes), validity, sample size, core outcome reporting, and comparability.

Papaleontiou M, Henderson CR, Turner BJ, et al. 2010. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. JAGS, 58(7):1353-1369.

This review summarized the evidence on efficacy, safety and abuse/misuse potential of opioids as treatment for chronic non-cancer pain in older adults. Adults 65 and older were as likely as those younger than 65 to benefit from treatment; common adverse events (constipation, nausea, dizziness) prompted discontinuation in 25% of the cases; abuse and misuse were negatively associated with older age; short-term use is associated with reduction in pain intensity and better physical functioning, but also poorer mental functioning. Long-term outcomes remain to be determined.

Van Herk R, van Dijk M, Biemold N, Tibboel D, Baar FP, de Wit R. 2009. Assessment of pain: Can caregivers or relatives rate pain in nursing home residents? J Clinical Nursing, 18(17):2478-85.

This study showed that proxy report of relatives and caregivers in presence and intensity of pain is unreliable, especially for cognitively impaired persons. The authors recommend use of a standard pain observation scale, education of caregivers about assessment and treatment of chronic pain, and more use of non-pharmacologic interventions.

Additional Clinical Practice Guidelines Related to Pain

• Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: ICSI, 2008 July.

• Registered Nurse Association of Ontario (RNAO). Assessment and management of pain. Toronto (ON): RNAO, 2002 November; supplement 2007 February.

• University of Iowa Geriatric Nursing Intervention Research Center. Persistent pain management. 2005 August.

• University of Iowa Geriatric Nursing Intervention Research Center. Acute pain management. 1997; 2006 revision

• International Association for the Study of Pain. Pharmacologic management of neuropathic pain: evidence-based recommendations. IASP, 2003, 2007 revision.

• Hartford Institute for Geriatric Nursing. Pain management. In: Evidence-based geriatric Nursing Protocols. 2003; 2008 revision.