Florida’s Advocate for Long Term Care
Providers and the Elders They Serve

An Approach to Pain Management Howard Tuch, M.D.

Survey citations for pain management are on the rise. This article will help define the parameters of an effective approach in your facilities. Pain is defined as an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage. There are many ways in which a facility can develop and implement effective pain management strategies.

Goals for Pain Management

  1. Pain Prevention, prompt recognition and assessment of pain when present
  2. Improved well-being and quality of life for the resident for the resident in pain
  3. Maintaining highest level of functioning through effective pain treatment
  4. Establishing an optimum balance between pain relief on the one hand, and tolerable side effects and function on the other

Note that complete pain relief may not be the primary (or realistic) goal for many residents. The attempt to achieve complete relief may involve too much medication, intolerable side effects or limitation of activities. Elicit the resident�s goals and frequently ask about his/her satisfaction with their level of pain control.

Components of a Pain Management Policy

In this document, we outline the major parameters of an approach that can help address common pain management concerns in long-term care. The following areas are addressed:

  • Risk Assessment and Prevention Strategies
  • Observation, Assessment and Communication Strategies
  • Principles for Managing Pain
  • Development of Pain Care Plans
  • Quality Improvement Strategies
  1. Risk Assessment and Prevention Strategies

    Pain is extremely common and often under-recognized in nursing home residents. The most common causes of pain are due to musculoskeletal conditions (arthritis, fractures, and wounds) but cancers, vascular problems (cluadication, vascular insufficiency); nerve damage (peripheral neuropathy, trigeminal neuralgia) and many other conditions can cause significant pain problems. Chronic pain can take many forms, ranging from clear physical and verbal expressions of pain to social withdrawal, weight loss, agitation and depression. Severe chronic pain can even occur in the complete absence of any outward signs of discomfort. Also, older people may deny having "pain" but say that hey are "aching" or "stiff" or "sore". It is important to use many words or descriptors when asking about pain.

    All residents should be screened for pain upon admission in order to determine their risk for having unrecognized or unmanaged pain.

    1. During the admission assessment, the resident/family should be asked about a history of pain problems, history of stoicism or unwillingness to complain of pain, reactions to pain medication and the impact of pain on their life (on function, sleep, appetite, mood, mobility, rehabilitation efforts, socialization etc.?)
    2. For residents not complaining of pain, completion of the MDS assessment (J2a, b; J3) on admission, quarterly, annually and with significant changes will ensure ongoing pain screening. Screening for pain should involve questioning the resident and caregivers about discomfort, observing the resident during activities (especially during potentially painful procedures, dressing changes etc) and noting the use of and response to medications administered for pain.

      The MDS fields on pain are completed using the reported level of discomfort during the assessment period. (i.e. resident who reports mild pain in the last 7 days should be reported as having mild pain (J2b=1) even if they are being given strong pain medication for prior complaints of. severe pain (clinical documentation elsewhere in the record should support the use of the strong medication and the fact that pain is now being effectively managed)

    3. Pain prevention strategies should be initiated soon after admission. These may include:
    1. Ensuring a climate where residents can report pain and receive prompt attention i.e. ask often about pain, believe the resident when he/she complains of pain, even when residents are confused, pain complaints are usually reliable
    2. Train and educate family on goals of pain prevention and management, the importance of prompt reporting and dispelling myths (pain as normal aging, intolerable side effects, addiction etc)
    3. Position ( and re-position) for comfort and to prevent skin breakdown
    4. Promote joint mobility with exercise and range of motion
    5. Anticipate painful events (therapies, bathing, dressing change, blood draws, IV sites, ambulation clinic visits etc). Ensure adequate preparation and pre-treatment with appropriate medication if appropriate
    6. When pain is persistent administer medications round the clock rather than on a prn basis, use long acting preparations of medication and supplement with short acting preparations for breakthrough pain
  2. Observation, Assessment and Communication Strategies
     
    1. observation: Primary care givers are often the first to notice discomfort and pain in the resident. Observation of pain or discomfort should become part of the daily observation record as well as a routine part of vital signs.
      1. Modify existing 24-hour observation tools and vital sign sheets to include observations of pain or discomfort (observed both at rest or with basic care, wound care or mobility).
      2. Ensure that new observations of pain or discomfort are followed by skilled nursing review and further assessment if appropriate
    2. Assessment: Formal pain assessment should be completed when residents complain of pain or when observation indicates behavior consistent with pain or discomfort.
      1. A standardized pain assessment form should be utilized to ensure a comprehensive evaluation of pain complaints. Numerous forms are available from American Geriatrics Society, American Medical Directors Association and recommended for nursing home residents.
      2. At a minimum: pain frequency , pain intensity, pain site, and effects on resident (on activities, mood, sleep, appetite, mobility etc) should be addressed
      3. Perform a general physical exam, examine the site of pain and perform a focused neurological, musculoskeletal and vascular exam
        1. A pain intensity scale (numerical or word scale) should be used to follow a resident�s level of pain. Use the pain intensity scale that the resident can most easily use. Use the same pain scale to monitor ongoing pain or response to treatment.
        2. Residents unable to directly communicate about their pain or discomfort should be observed for signs of discomfort: facial expressions, guarding or bracing of affected area, changes in ambulation, mental status or mood changes, appetite, resistance to ADL care or hygiene. Observations should be made at rest and with some activity.
        3. Repeat formal assessments with indications of new pain problems, during significant clinical changes or when there is continued uncertainty as to the nature of the pain problem or its management.
    3. Communication: Prompt and accurate communication internally (resident/family to CNA / CNA to nurse/rehab to nursing) and externally (nurse to physician ) is essential to good pain management.

      Prior to discussion with the physician about new or worsening pain in the resident:

      1. Review medical diagnoses and active medical conditions
      2. Review effectiveness of prior treatments or medications
      3. Review pain assessment form, note frequency, type, location and intensity of pain.
      4. Note the consequences of the pain on behavior, function, appetite, mood, rehabilitation outcomes, resistance to care etc)
      5. Review current medications (number of prn doses given over the last few days, effectiveness or side effects of medication given)
      6. Note resident goals for pain control and their level of satisfaction (or lack of) with their current level of pain control
  3. Develop Pain Care Plan
     
    1. Define the pain problem, its diagnosis�s or functional consequences i.e. pain due to severe arthritis in knee, limiting restorative ambulation, mobility and adequate range of motion
    2. Set reasonable goals and time frame for resolution of the pain problem i.e. diminish pain such that resident can more fully participate in ambulation and achieve greater independence and safety in transfers over next 3-4 weeks
    3. Design resident specific interventions involving both pharmacologic and non-pharmacologic means) i.e. will pre-treat with prn medication 1 hour prior to therapy or dressing change , use cold pack for inflamed knee prn
    4. Monitor outcomes and modify care plan as necessary
  4. Principles of Pain management: pain management is best achieved through an interdisciplinary approach involving nursing, physical and occupational therapies, recreation therapy, social services, and physician.
    1. Non-pharmacologic approaches to pain control are often helpful by themselves or in combination with medication. Techniques of distraction, relaxation exercise, physical modalities (heat, cold, and massage), music therapy and aromatherapy may be helpful. Strengthening through physical therapy or psychological support can also be useful.
    2. To the extent possible, the resident should be in control over as much as the pain management approaches as desired.
    3. Use of analgesic medication is the mainstay of pain management. The following are some general principles that apply:
    1. Choose the single best medication based on the intensity, type of pain and prior treatment and medical history of the resident
    2. Use the lowest effective dose of the medication
    3. Administer the medication through the least invasive route (usually oral)
    4. Adopt the best regimen (prn vs. standing order) based on the frequency and predictability of pain
    5. When using standing orders of pain medication or long-acting medication, supplement with short acting preparations for breakthrough control
    6. Increase the dose of the medication for insufficient pain control (generally can increase by 25-50% in the presence of pain while observing for side effects))
    7. Prevent and treat side effects. Common side effects are restlessness, delirium, nausea, headache, somnolence and constipation. Note that most side effects are temporary and resident should be reassured that they will diminish after several days of treatment. All residents should receive stimulant laxative therapy while on strong pain medication unless contraindicated; as constipation is unlikely to diminish with continue use of opiates.
    8. Use a step-wise approach to drug therapy:
      1. Mild to moderate pain: Step 1 agents like acetaminophen or non-steroidal anti-inflammatory agents
      2. Moderate pain: Step2 agents like combination Preparations of hydrocodone, codeine, or low dose oxycodone .or morphine)
      3. Moderate to severe pain: Step 3 agents like morphine or oxyxodone or hydromorphone codone titrated to relieve pain
    9. Use adjuvant medication to supplement above agents or for treatment of neuropathic pain (antidepressants, anticonvulsants, steroids, non-steroidal agents)
    10. Frequently re-evaluate the response to treatment and any side effects noted. , If prn medications are being given on a daily basis, consider the need to use long acting preparations, the need to increase doses of the standing order or to re-assess the approaches chosen
  5. Quality Improvement Strategies
     
    1. Develop a mission statement declaring the right of the resident to have his/her pain assessed and treated and the commitment of the facility to manage pain.
    2. Perform an audit of pain and its management in your facility to determine the extent of the problem and source of barriers to effective pain management
    3. In-service all new staff on the facility pain management policy and commitment Periodically in-service all staff on principles of pain management and facility policy.
    4. Educate residents and families about pain treatment, side effects, dispelling myths and reinforcing the need to report symptoms and develop shared goals
    5. Incorporate pain management into monthly quality improvement meetings: monitor for consistent assessments, use of pain intensity scales, CNA observation entries, care plan development, communication with physicians, appropriate use of medications titrated to achieve comfort and resident goals, interdisciplinary approaches used and modifications of interventions based on resident response.
    6. Monitor the pain quality measure on the Medicare.gov website for short term and long term residents,

Bibliography

  1. Chronic Pain Management in the Long-Term Care Setting, Clinical Practice Guideline, American Medical Directors Association, 1999
  2. American Geriatrics Society Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. J Am Geriatr Soc. 1998; 46:635-651
  3. American Pain Society: Principles of Analgesic Use in the Treatment of Acute pain and Cancer Pain, 4th edition Skokie, Ill: American Pain Society; 1999
  4. Medicare.gov: Nursinghomecompare website