Pain Management in the Nursing Home

Pain is reported to be twice as prevalent in the elderly as in younger individuals. In the nursing home, its prevalence has been reported as high as 85%. According to the American Geriatrics Society (AGS) Panel on Chronic Pain in Older Persons (1998), chronic pain in the long-term care setting is generally under-recognized and under-treated. Pain comes from a variety of acute (ex. hip fracture) and chronic medical conditions (ex. arthritis).

What are some barriers to pain management in the nursing home setting?

• Staff may not have knowledge of, or be skilled in, assessing pain or at using valid tools available to screen for pain.
• Staff not recognizing that pain is whatever the person says it is, existing whenever they say it does.
• Nursing home administration not giving priority to the recognition, assessment and treatment of pain. High turnover of staff, poorly functioning care teams, lack of organizational commitment to pain management, physician reluctance to use opioids, and fear of regulatory scrutiny are also barriers to pain management.

What are some nonverbal signs of pain?

Nonverbal signs of pain may include behavior changes, pained facial expressions, rigid body posture, moaning, grimacing, guarded positioning, withdrawing to touch, restlessness, irregular respirations, dilated pupils, sweating, favoring one extremity, irritability, withdrawal (emotional), fatigue, and loss of appetite.

What are some myths regarding pain in the elderly?

• Pain is expected with old age.
• Pain perception decreases with age.
• Pain is a punishment for past actions.
• Pain means death is near.
• Pain always indicates the presence of a serious illness.
• Acknowledging pain will lead to a loss of independence.
• The elderly, especially the cognitively impaired, have a higher tolerance for pain.
• The elderly and those with mental impairment cannot accurately report pain.
• Residents in nursing homes say they are in pain to get attention from staff.
• Elderly residents are likely to become addicted to pain medication.

How is pain assessed?

Multiple factors must be assessed to gain a true picture of an elder’s pain. Such factors include location, onset, progression, causes, quality, duration, intensity, severity, and alleviating factors. Elders may use words such as aching, throbbing, burning, numbness, squeezing, pressure, cramping, or tightness to describe pain instead of the word "pain."

How is pain treated in the nursing home?

Treatment of pain involves medicine and non-medicine therapies. Goals of treatment are to decrease pain, increase function, and improve quality of life.

Different types of medicines help with different types of pain. Pain medication can be given by mouth, rectally, through an injection, a patch on the skin, or various intravenous forms. Non-medicine interventions for pain include heat, cold, distraction, exercise, aromatherapy, massage, music, relaxation, and providing for basic care needs such as toileting.

How often should pain be assessed in the nursing home?

Pain assessment should occur at the time of admission, at quarterly intervals, with each change of condition, and at any time pain is reported. Medication effectiveness should also be assessed after requested pain medication is received.

How should I expect my loved one's pain to be managed in the nursing home?

• Staff must educate patients about the importance of reporting when pain occurs and before it increases, about interventions for pain, about side effects of pain medication, and that side effects should be reported to the nursing staff.
• Staff should assist the resident and other staff to overcome barriers to pain management.
• Administration should ensure staff are appropriately educated about pain management.
• If the resident has pain for 50% of the day, routine pain medication should be used. Too often only prn (as needed) pain mediation is ordered and not administered, leaving residents in pain.
• Patients who report pain prior to wound dressing changes and therapy should receive additional pain medication prior to such procedures.
• When a pain assessment shows evidence of pain, a care plan should be developed that addresses pain assessment, pain goals, interventions and education provided to the resident by the nursing staff. The care plan should be updated with every change in treatment or intervention.
• The physician should be notified if a resident's pain interventions are ineffective or if there are side effects from the medications.
• PRN medications must be documented on the medication administration record stating the reason for administration and follow up on effectiveness.

Questions you can ask the nursing home about how it manages pain:

• What signs and symptoms suggest to the nursing home that a resident may be in pain, and how often do they monitor for pain?
• How does the nursing home identify causes of pain, and how does it determine whether the cause can or cannot be corrected?
• Other than ordering pain medications, what treatments are used to relieve pain?
• What does the nursing home do if a patient refuses medication treatment for pain?

Resources

American Medical Directors Association. Chronic Pain Management in the Long Term Care Setting Clinical Practice Guideline. Columbia, MA: AMDA 1999.

American Geriatrics Society, Clinical Practice Guidelines. The Management of Chronic Pain in Older Persons: AGS Panel on Chronic Pain in Older Persons. JAGS 1998; 46: 635-651.