Disparities in Pain Management Between Cognitively Intact and Cognitively Impaired Nursing Home Residents

School of Medicine, Division of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7030, USA. <>
Journal of Pain and Symptom Management (Impact Factor: 2.8). 04/2008; 35(4):388-96. DOI: 10.1016/j.jpainsymman.2008.01.001
Source: PubMed


This study tests the association between residents' cognitive impairment and nursing homes' pain management practices. We used chart abstraction to collect data on 551 adults in six North Carolina nursing homes. From the standard data collected in the Minimum Data Set, 24% of residents experienced pain in the preceding week. Reports of pain decreased as cognitive abilities declined: nurses completing the Minimum Data Set reported pain prevalence of 34%, 31%, 24%, and 10%, respectively, for residents with no, mild, moderate, and severe cognitive impairment (P<0.001), demonstrating a "dose-response"-type result. Eighty percent of cognitively intact residents received pain medications, compared to 56% of residents with severe impairment (P<0.001). Cognitively impaired residents had fewer orders for scheduled pain medications than did their less cognitively impaired peers. Yet the presence of diagnoses likely to cause pain did not vary based on residents' cognitive status. We conclude that pain is underrecognized in nursing home residents with cognitive impairment and that cognitively impaired residents often have orders for "as needed" analgesics when scheduled medications would be more appropriate.

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    • "Despite its prevalence, there is a substantial body of research that indicates that pain is under-recognised, under-assessed and under-treated in older adults, especially people living with dementia (Scherder and Bouma, 1997; Weiner and Hanlon, 2001; Scherder et al., 2009). Rates of analgesic administration have been found to be significantly lower for adults with dementia compared to without (Scherder and Bouma, 1997; Horgas and Tsai, 1998), even when diagnoses likely to cause pain did not vary based on residents' cognitive status (Reynolds et al., 2008). While it is true that pain assessment in the presence of dementia is complicated by diminished language, cognitive and communication skills (Horgas and Tsai, 1998; Fisher et al., 2006), pain has been found to go untreated in Copyright # 2015 John Wiley & Sons, Ltd. "
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    ABSTRACT: Objective: To develop a psychometrically sound tool for measuring the knowledge of nursing and care staff about the experience, assessment and management of pain in older people (including people with dementia) for use in the residential aged care setting. Methods: The Pain in Older Adults Knowledge Survey (POAKS) was developed and tested in two phases. Phase 1 involved developing an initial item pool with good content validity based on a review of the research literature and a modified Delphi technique involving national and international experts. A pool of 24 items was developed for testing. Initial testing of the psychometric properties of the POAKS with 30 university employees led to refinement and final wording of items. Phase 2 involved testing of the psychometric properties of the POAKS with 279 respondents, including first year (n = 176) and third year (n = 70) nursing students and staff in a residential aged care service (n = 33). Results: Results established the content validity and internal consistency of the POAKS and supported its use as an instrument to measure nursing staff knowledge about the experience, assessment and management of pain in older people. Conclusions: The POAKS will enable residential aged care facilities to measure the level of knowledge among nursing and care staff about pain in older people (including people with dementia). The measure provides a basis for the development and implementation of educational interventions to address knowledge gaps that may impact on the quality of care provided.
    International Journal of Geriatric Psychiatry 10/2015; DOI:10.1002/gps.4364 · 2.87 Impact Factor
    • "With the chronic progressive decline of cognition and loss of function that occur in dementia (Corbett et al., 2014), the expression of pain becomes more challenging (Corbett et al., 2014; Flo, Gulla, & Husebo, 2014; Shega et al., 2008). Consequently, as dementia progresses, these older adults tend to report fewer painful conditions (Burfield, Wan, Sole, & Cooper, 2012), even though they may suffer from the same painful diagnoses as cognitively intact older adults (Closs, Cash, Barr, & Briggs, 2005; Husebo et al., 2008; Reynolds, Hanson, DeVellis, Henderson, & Steinhauser, 2008). Burfield et al. (2012) found that 47.7% of cognitively intact older adults reported experiencing pain daily, while only 39.6% of those older adults with mild dementia, 29.4% of the moderately impaired, and 18.2% of older adults with severe dementia reported painful experiences despite similar painful diagnoses. "
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    ABSTRACT: Research supports using nonverbal pain behaviors to identify pain in persons with dementia. It is unknown whether variations exist among ethnic groups in the expression of nonverbal pain behaviors in this special population. The purpose of this descriptive study was to examine ethnic differences in the presentation and intensity of nonverbal pain behaviors among African American, Caucasian, and Hispanic older adults with dementia when screened for pain by certified nursing assistants. Six certified nursing assistants were trained to review and score 28 video recordings of subjects with dementia for nonverbal pain behaviors using the Non-Communicative Patient's Pain Assessment Instrument. Chi-square was used to examine differences among ethnic groups with regard to the display of nonverbal pain behaviors, and ANOVA was used to evaluate differences in the intensity of overall pain across ethnic groups. Of the 168 assessments, pain words (28%), pain noises (29.8%), and pain faces (28%) were observed most often as indicators of pain. Rubbing, bracing, and restlessness were rarely noted. Chi-square analysis revealed ethnic differences in the expression of pain words (χ(2) = 19.167, p < .001). No significant differences were noted across ethnic groups with regards to overall pain intensity. These findings are the first to examine ethnic differences in nonverbal pain behaviors for older adults with dementia. However, future work should examine assessment tendencies of providers in a larger, more diverse sample. Copyright © 2015 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
    Pain management nursing: official journal of the American Society of Pain Management Nurses 05/2015; 16(5). DOI:10.1016/j.pmn.2015.03.003 · 1.53 Impact Factor
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    • "Therefore, the authors wanted to compare pain reports for residents provided by the residents themselves , the care home staff and relatives. Analgesic drugs can often be under used or prescribed inappropriately , for example, 'when required' instead of regularly scheduled (Nygaard and Jarland, 2005; Reynolds et al., 2008). It has been reported that psychoactive drugs, which may be indicated in certain circumstances for the short-term management of behavioural and psychiatric symptoms associated with dementia, could mask behaviours that are indicative of pain (Cipher et al., 2006). "
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    ABSTRACT: Objectives This study aims to determine pain frequency amongst care home residents with dementia, to investigate variables associated with pain, to explore analgesic use among residents and to seek residents' relatives' views on provision of care and management of pain by the care home.Methods Structured face-to-face interviews were conducted with residents, nursing staff and relatives from nine dementia care homes in Northern Ireland, between May 2010 and March 2012. Demographic information was collected from participants, neuropsychiatric tests were used to assess residents' cognitive functioning, medication use was determined from care home records and residents' pain was assessed using a verbal descriptor scale. Relatives' views were sought on care provision and management of pain.ResultsForty-two residents, 16 nurses/care assistants and 35 relatives participated; the participation rate of residents was low (27.6%). Most residents were suffering moderate–severe dementia, and some residents (26.2%) were unable to provide a self-report of pain. A significantly higher proportion of relatives (57.1%) deemed residents to be experiencing pain at the time of the interview, compared with residents (23.8%, p = 0.005) and nurses/care assistants (42.9%, p = 0.035). Most residents (88.1%) were prescribed with analgesia; non-opioid analgesics were most commonly prescribed. High proportions of residents were prescribed with psychoactive medications. Antipsychotic drug use was associated with presence of pain (p = 0.046).Conclusions This study has reinforced the challenge of assessing and managing pain in this resident population and highlighted issues to be addressed by long-term care providers and clinicians. Participation of people with dementia, and their families, in healthcare research needs to be improved. Copyright © 2014 John Wiley & Sons, Ltd.
    International Journal of Geriatric Psychiatry 04/2014; 30(1). DOI:10.1002/gps.4111 · 2.87 Impact Factor
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