Vital Sign #5
Pain assessment & management in LTC requires a thorough, team-oriented care plan
by Kathleen K. Frampton, RN, MPH
Pain is not only an unpleasant sensory experience--it's also an emotional experience. As such, all pain involves processing by the highest levels of the central nervous system, including brain function. Pain is a common symptom. The presence of persistent pain among adults in the United States has been estimated to range from 2% to 40% of the general population, from 45% to 80% among nursing home residents, and up to 75% among patients with advanced cancer.
Despite the significant scientific and medical advances during the latter half of the 20th century, pain remains a significant problem for our health-care system. Worldwide, all types of pain are inadequately treated, whether acute or chronic or related to malignant or non-malignant conditions.
Aida Won, MD, medical director, Hammond Pointe Rehabilitation and Skilled Nursing Facility, Boston, reflected on this. "Studies in the nursing home population have demonstrated that moderate to severe pain often persists for a least six months to a year, and that analgesic use is sub-optimal," she said. "And, to make matters worse, about a quarter of patients experiencing daily pain are not receiving any analgesics."
The most common reason for unrelieved pain in U.S. hospitals is staff failure to routinely assess and relieve pain. For this reason the Joint Commission for Accreditation of Healthcare Organizations has designated pain as the "fifth vital sign" and has incorporated the assessment of pain into its practice standards.
Greater Awareness Needed
There remains a great need for improved training in pain management at all levels of professional medical education. It is widely felt that as long as education in this area remains substandard, the practice of pain management will continue to be substandard. Fewer than 7% of physicians who enter practice in the United States have had any formal education in the assessment of pain, and 52% of surveyed physicians rated their pain management training as poor.
"Providers need to be educated that, while the incidence of pain does increase in the elderly population, pain itself is not normative for older people," explained Wendy Stein, MD, CMD, medical director of long-term care services, San Diego Hospice and Palliative Care, and assistant professor of geriatrics at the University of California at San Diego. "The same principle holds true for such conditions as dementia and incontinence."
Consumer education is also part of the solution for greater awareness. Many patients under-report pain and some may fear addiction, side effects, intolerance, and toxicity of effective pain medication. Sadly, older people may feel that pain is inevitable and don't want to be bothersome and complain to staff. In cases where the patient is hesitant or unable to provide reliable information, it is critical to involve the family and other caregivers in the collection of this information.
How Pain Works
Pathophysiological categories of pain have been delineated in the American Geriatrics Society Guideline for Management of Persistent Pain in Older Adults. Nociceptive pain is experienced when pain receptors are stimulated during injury or trauma. Neuropathic pain arises due to injury or disease of the peripheral or central nervous system. Diabetic neuropathic pain and post-stroke pain are common examples of this type.
Mixed or unspecified pain refers to pain whose exact origin in unknown or uncertain. Psychogenic pain refers to pain sustained by psychological factors. There is evidence that psychiatric disorders and pain have a strong relationship because pain is associated with anxiety and depressive disorders. The number of pain sites or "diffuseness of pain" and the extent to which pain interferes in daily life are the characteristics that most strongly predict depression. Also, several neurochemicals seem to be involved in the overlapping phenomenon of coexisting depression and pain. Serotonin (or 5-HT) and norepinephrine have emerged as the two neurotransmitters that appear to be involved in both.
Evelyn Hutt, MD, director, Research to Improve Veterans Quality of Life and Care in Long-term Care, Denver Veteran's Administration Medical Center, Denver, feels that quality of life is of paramount importance in the nursing home setting.
"It is pretty clear that pain is an important detractor in achieving this goal," she said. "Sadly, we often do not provide comfort and treat our elders effectively in assessing and managing their pain."
Among nursing home residents, the major sources of pain included low back pain (40%), arthritis of appendicular joints (24%), previous fracture sites (14%), and neuropathies (11%). Additionally, a large portion (59%) of residents has multiple pain complaints.
The Challenge of Pain Assessment in the Elderly
The guiding principle in pain assessment is simple and straightforward: The patient is the most important source of information about their pain. Therefore, you must regularly ask them about their pain and assess it systematically.
According to Steve Levenson, MD, CMD, Caring editorial board chair, the patient often doesn't do a good job of describing pain unless someone asks them specific questions. In other words, they may be indistinct in the terms they use to describe pain.
"The patient should be listened to, but the nurse or practitioner must verify," said Dr. Levenson. "It is often not wise to take what a patient says at face value without adequate verification. Also, how the questions are asked makes a difference."
As an example, many nurses simply ask, "Are you still having pain?" They then report to the physician that the patient still says they're in pain instead of giving the physician a comparison of current to previous pain. Upon hearing that the patient still has pain, the physician raises the analgesic dose or switches to narcotics--even if more restrained adjustments or maintaining the current dose would suffice.
Dr. Levenson says other problems include inadequately describing the patient's whole situation (i.e., information about factors that might be causing or influencing the patient's pain, such as medication side effects or co-morbid conditions) and physician's failure to ask enough questions or to listen to all relevant information about a patient's condition before prescribing analgesics.
"In other words, it isn't just about describing pain," he said. "It's about describing and reporting on the whole patient--who also happens to be having pain. It's also about thinking more about the causes of pain because most analgesics are symptomatic--not cause-specific--interventions."
When you as a provider assume that patients are unreliable sources of information about their own condition, then you may rely on your own best guess and derive a false conclusion. It works the other way around, too. If you take the patient's word without adequately verifying it, you can be led down the wrong path.
"A recent study by Chu demonstrated that 87% of patients who are only oriented times one can answer simple pain questions reliably," said Dr. Won. "Surprisingly, even 52% of residents oriented times zero can answer simple pain questions reliably. It depends on how you ask the question. They should be very simple yes-no, response-type questions such as 'Do you have pain now?' or 'Do you have pain every day?' or 'Does pain keep you from sleeping at night?' and the like."
The initial pain evaluation involves assessing both the intensity and character of the experience. JCAHO recommends exploring the following to obtain specifics about the nature of your patient's pain:
- Onset and temporal pattern;
- Aggravating and relieving factors;
- Previous treatment;
- Effect; and
The PQRST mnemonic (Provocation/Palliative factors, Quality, Region, Severity, and Temporal features) is also used as a good reminder of the domains we must cover in a comprehensive assessment. All of these pain descriptors need to be put in the context of the patient's physical and social function in such areas as activities of daily living, sleep, exercise, appetite, energy, and mood.
Today many pain assessment tools and scales exist for use in the clinical setting. Generally, a facility should identify and use one scale for consistency in terminology and interpretation among the staff.
"Many of these scales were developed for research purposes and they may not always yield acceptable results in practice," cautioned Dr. Stein. "They usually need to be modified for the patient population and your facility."
Below, a review of several standardized instruments for use with patients who are cognitively intact and verbal, as well as for severely cognitively impaired patients who may not be able to communicate.
Cognitively intact patients: The scales most commonly used for cognitively intact patients and for those who can verbalize or indicate their choice of descriptors:
- Visual Analogue Scale;
- Verbal Numeric Rating Scale;
- Face Pain Scale;
- Verbal Descriptor Scale; and
- Revised Verbal Descriptor Scale (with some additional verbal descriptors and a visual pain thermometer).
A recent study conducted by Keela Herr, PhD, RN, professor and chair, Adult and Gerontological Nursing Area of Study, the University of Iowa, Iowa City, concluded that elderly patients were most familiar with the Verbal Numeric Scale and that all were sensitive to changes in pain intensity. This study concluded that the Face Pain Scale correlated less well with measurement of pain intensity.
"The word pain is often not the term used by our current cohort of older patients," remarked Dr. Stein. "You need to use a term they can relate to such as 'ache,' 'hurt,' or 'discomfort.' In practice I simply ask patients to tell me how intensely they are feeling their pain--none, some, or severe? I get the information that I need with this simple scale."
Cognitively impaired patients: If patients are unable to answer questions about pain, staff must then look for behaviors that suggest the presence of pain. Many patients with dementia are unable to clearly or consistently verbalize their pain symptoms.
"The Pain Assessment in Advanced Dementia Scale--known as the PAINAD Scale--was developed by our team at the E.N. Rogers Memorial VA Hospital in Bedford, Massachusetts, for individuals with advanced dementia," explained Ladislav Volicer, MD, PhD, professor of pharmacology and psychiatry at Boston University School of Medicine. "It was developed specifically for all levels of nursing staff to use since they are closest to the patient and can observe them carefully and often. We specifically developed it so that it would be easily used to measure pain--truly--as the fifth vital sign."
The PAINAD Scale is a hybrid tool (click here to view). It has features of the Flagg Scale (used for newborns and children) and features of the Discomfort Scale of Dementia of the Alzheimer Type (DSDAT) Scale (developed for advanced Alzheimer patients).
The domains rated and scored using PAINAD are breathing, negative vocalization, facial expression, body language, and consolability. Specific behaviors in each domain are assigned a score of 0, 1, or 2 based on their relationship to pain. Behaviors include labored breathing, calling out or moaning, crying, facial grimacing, rigidity, clenched fists, striking out, and inability to console or reassure.
A score of four or more requires an intervention, whereas lower scores require careful monitoring. However, once again, these are nonspecific symptoms that could represent other important conditions such as delirium and adverse drug reactions. It should not automatically be assumed that nonspecific symptoms represent pain until other relevant causes are considered, based on adequate evaluation.
Another tool, the Assessment of Discomfort in Dementia (ADD) Protocol, was developed by Christine Kovach, PhD, RN, associate professor, University of Wisconsin, Milwaukee. "The best framework for managing pain in the cognitively impaired because it is not just a scale--it is a total approach," suggested Dr. Stein.
|The ADD Protocol
Step 1: Look for the physical source of discomfort, such as infection, illness, or a chronic condition. If the source is identified, nurses should work with health-care providers to diagnose and treat the problem.
Step 2: Review the patient's history for potentially painful conditions resulting from old fractures, bowel problems, arthritis, or previous illnesses.
Step 3: If the history and physical assessment don't reveal potential causes for pain, nurses should move on to the third step--attempting to comfort the patient without medication. This approach might include providing massage therapy, using music or therapeutic communication, talking to the patient in a calm manner, or holding the patient's hand.
Step 4: If the first three steps don't help, move ahead to administer a prescribed pain reliever, such as acetaminophen. Nurses should then observe the patient to see if the pain reliever has a positive effect on the patient's behavior. The use of pain relievers as part of the assessment sets the ADD protocol apart.
Step 5: If the pain reliever doesn't improve behavior, nurses should consult with health-care providers about administering a psychotropic medication.
The ADD Protocol is a systematic tool used by nurses to make a differential assessment and treatment plan for both physical pain and affective discomfort experienced by people with dementia (see box at right). A nursing assistant notes any change in a demented patient's usual behavior pattern and responds by providing basic comfort measures, such as giving food or fluid, changing clothes or incontinence products, and repositioning.
If these interventions don't ameliorate the discomfort behaviors, the nursing assistant reports this immediately to the nurse, who then conducts a physical assessment to look for physical causes of discomfort (e.g., infection, inflammation, acute illness, and so on).
"This is fine, but, unfortunately, is rarely done," said Dr. Levenson. "Skipping these steps can, indeed, prove detrimental to patient care. So it's important to follow this approach thoroughly before tossing analgesics at the patient."
The first step in the protocol requires that the nurse or health-care practitioner conduct a physical assessment to look for physical causes of discomfort (i.e., infection, inflammation, acute illness). The next step involves reviewing the patient's medical history for potentially painful conditions. This is followed by the nurse performing an "affective needs assessment" by reviewing the patient's physical environment for extraneous and noxious stimuli (i.e., room temperature, glare, noise, uncomfortable clothing, and so on).
If the non-pharmacological comfort interventions don't work, the nurse administers a non-opioid PRN analgesic. If the trial analgesic is unsuccessful, the nurse consults with a physician to reconsider the diagnosis and treatment. "Our staff has implemented a modified version of the ADD Protocol in our facility with much success," reported Jane Winston, MD, medical director at Royal Oaks Lifecare Community, Sun City West, Ariz. "The positive clinical outcomes we have measured as a result of this approach include a decrease in use of psychotropic drugs and PRN pain medication, with a simultaneous increase in the ordering of routine pain medication for our dementia patients."
Determine Pain Etiology & Treatment
Successful pain management occurs when the underlying cause of pain is identified and addressed. "It is not unusual for nursing home patients to have two or three distinct sources and types of pain," said Kerry Cranmer, MD, CMD, Geriatric Medical Services, Oklahoma City. "These pain locations need to be carefully cataloged in the medical record. In order to develop an appropriate treatment plan, the physician must perform a comprehensive physical exam, along with a pain intervention history, functional, and psychological assessment."
Because most pain in older patients is of neurological or musculoskeletal origin, specifically focusing on these areas in your workup remains paramount. "Obtain consults as necessary for both diagnostic or other treatment options [including] podiatry, neurology, rheumatology, physiatry, and pain management specialists," urged Dr. Won.
Still, while consultant may eventually play a role in the patient's pain care plan, Dr. Levenson urges first getting an adequate assessment from the patient's nurses and primary care physician before calling in consultants. "In the nursing home, consultants are often called too quickly and they are often an inadequate substitute for effective primary care nursing and medical assessment and care," he said.
It's acceptable to treat the pain concurrently with the diagnostic workup, and it's certainly appropriate to aggressively treat pain in patients with terminal and end-stage conditions. "You must always treat the pain--it is only ethical to do so, regardless of the etiology or prognosis," emphatically stated Deidra Woods, MD, CMD, medical director, Hospice of Naples, Fla. However, the initial management may need to be modified as the cause(s) of pain are identified and depending on the progression of other medical conditions that may affect pain.
AMDA's Pain Management in the Long-term Care Setting Clinical Practice Guideline sets the goals for pain treatment as improving function, mood, and sleep. This guideline also supports the use of the World Health Organization's Pain Ladder for approaches to analgesia in both cancer and non-cancer pain. The WHO Ladder supports prompt oral administration of drugs in the following order: non-opioids, then as necessary mild opioids (with a non-opioid and an adjuvant if needed), then strong opioids (with a non-opioid and an adjuvant if needed) until the patient is free of pain.
As you consider using the WHO Ladder or other scales to assess and subsequently treat pain, do so cautiously. "It is not enough just to climb the pain ladder without assessing and investigating the causes and identifying whether the treatment is on the right course," explained Dr. Levenson. "As an example, I saw a physician give a patient a fentanyl patch for tendinitis of the shoulder. He kept raising the dose and adding other drugs, but the correct interventions that worked for the patient were local ice, ultrasound, and NSAIDs."
To maintain freedom from pain (and when an adequate assessment has demonstrated that appropriate measures are being taken and that any analgesics are the right ones for the identified or suspected condition), drugs should be given "by the clock," that is every three to six hours, rather than "on demand." Adjuvant agents are defined as drugs that don't contain acetaminophen and those not classified as non-steroidal anti-inflammatory or opioid agents.
In reality, adjuvant medications are considered first-line treatment for neuropathic pain. The most useful adjuvant agents for this category of pain are antiepileptics such as gabapentin, carbamazepine, lomotrigine, and (in selected patients) baclofen, mexiletine, and clonidine. However, it is critical to first conduct a sufficient assessment to identify that the pain truly is neuropathic. Sometimes, patients have "burning" or "stabbing" pain that is not neuropathic and should not be treated with these medications.
Balancing medication side effects and treating pain requires the safe, wise use of all classes of medications. Narcotics, for example, may produce many significant side effects including nausea, anorexia, lethargy, confusion, delirium, severe intestinal ileus, and urinary retention. When added to the regimen of individuals who are also receiving other psychoactive medications and drugs that affect vascular tone and central nervous system function, the aggregate may precipitate functional decline and even death.
"With our older patients, we must avoid drugs that have high rates of bleeding, such as indomethacin, or significant central nervous system side effects, such as Demerol," noted Dr. Won. "Starting with low doses will minimize problems with side effects. In frail elders, this means that the dose of NSAIDs or COX-2 inhibitors should be one-half to one-third the usual dose, and the starting dose for opioids should be 2.5 mg morphine equivalents."
Nonetheless, some patients are very susceptible and experience persistent drug side effects. Dr. Levenson recalled a patient who was put on a large dose of amitriptyline for depression. The patient then developed intestinal ileus and was put on narcotics to treat the pain that resulted from the intestinal ileus. "This patient's intestinal ileus was caused by the amitriptyline," he explained. "The narcotics made the problem much worse."
While acute pain is generally considered a medical emergency and should be treated as such, the AMDA pain CPG cautions that there may be times when treatment can mask the cause of a patient's pain and make it harder to identify.
"Fibromyalgia is a common cause of pain in millions of people, but it is almost never recognized, understood, mentioned, or managed properly in long-term care," reported Dr. Levenson. "It is an example of the narrow vision and sometimes excessive obsession with treatment that can result in people being put on potent drugs that may not be needed and that cause side effects unnecessarily.
"Again, it is about the whole patient who is also having pain--not about just the pain," he reiterated. "Like all symptoms, pain cannot be addressed in isolation--although it often is."
An Integrated Approach to Pain Management
Think of a pain medication regime as just one component of your patient's overall pain management plan. Because functional disability remains a significant problem for older adults who reside in long-term care facilities and 95% of them have a limitation in at least one activity of daily living, both the AMDA and AGS pain management guidelines recommend a trial of supervised physical rehabilitation therapy or leisure exercise.
Such programs may improve range of motion, reverse specific muscle weakness and other impairments associated with persistent pain, and improve physical functioning. This is particularly true in such chronic conditions as osteoporosis, osteoarthritis, or fibromyalgia.
Additional benefits of exercise include improved sleep, decreased depressive symptoms, decreased hospitalization, and reduced mortality. "Use topical agents such as capsaicin, heat, or ice, or medicate the resident before exercise in order to minimize discomfort during the activity," recommended Dr. Stein. "I have also used Velcro joint supports for patients with knee pain to reduce discomfort when getting out of a wheelchair."
In keeping with the philosophy that pain management should be multi-modal and comprehensive, Dr. Won stressed, "We should not forget to consider alternatives such as nerve blocks, intra-articular or spinal injections, radiation therapy, or hormonal treatments as effective ways of treating pain without the use of systemic drugs."
As the field of pain management becomes more formalized and mature, it naturally expands into complementary and alternative medicine (CAM) approaches to pain treatment. During the past decade, CAM approaches have increased in popularity with an estimated 35% of adults using some form of massage therapy to relieve back pain.
Research studies on the efficacy of massage for pain support a possible biological explanation that massage increases the synthesis of endogenous opioids that inhibit pain by activating the descending pain inhibitory system.
Further research is needed to support the effectiveness of massage therapy in long-term care. An estimated 14% of visits to acupuncturists are for back pain, but the data for its effectiveness remain unclear. Dr. Stein supports affiliations among hospice programs and nursing homes with schools of massage and acupuncture.
"By providing practicum settings for these students' clinical rotations, you are supporting the student's training and simultaneously providing comfort at the end of life to many residents," she said.
In the past, providers worried about possible liability for the over-prescription of habit-forming narcotics. With the development of pain management guidelines and educational programs there has been a turnaround of events.
While some states have passed laws protecting doctors from claims of overprescription, long-term care practitioners must be aware of increased scrutiny from litigious parties. The best defense remains to embrace the pervasive theme in the field of pain management, the biggest detractor to overall quality of life: Do all that is possible to alleviate suffering. However, a thoughtful and sufficiently detailed approach--not a haphazard or superficial one--is the key both to doing good and to not doing harm while trying to do good.
Contributing Writer Kathleen Frampton wrote the geriatric mental health special report in the April issue.
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LTC Team in Action
What is the biggest challenge you face in treating pain in the long-term care setting?
Assessing pain in the non-communicative patient...you really have to be a detective and keep looking for cues to determine the presence of pain. It takes the entire team, which means that everyone has to be educated in pain management.
--Kerry Cranmer, MD, CMD, medical director, Geriatric Medical Services, Oklahoma City
Keeping up with educating staff in the principles of pain management in the face of the high staff turnover in long-term care. Also, educating patients and families in the notion that pain is not a normal part of aging and that much can be done--but they must be proactive.
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