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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    • "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; 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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    • "The discrepancy between the prescribed and actual doses widens as cognition decreases [2]. Residents with dementia are prescribed and administered significantly fewer pain medications and in smaller doses than those without dementia [3,4]. Evidence shows that the provision of inadequate pain treatment for residents with dementia is partly due to inadequate pain assessment and documentation [5]. "
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    ABSTRACT: Systematic use of observational pain tools has been advocated as a means to improve pain management for care home residents with dementia. Pain experts suggest that any observational tool should be used as part of a comprehensive pain management protocol, which should include score interpretation and verification with appropriately suggested treatments. The Observational Pain Management Protocol (Protocol) was therefore developed. This study aims to investigate the extent to which the implementation of this Protocol can improve pain management in care home residents with dementia.Methods/design: In this two-group, single-blinded, cluster-randomized controlled trial, 122 care home residents with dementia and pain-related diagnoses will be recruited from eight care homes (that is 15 to 16 residents from each care home). Invitations will be sent to all local care homes who meet the home selection criteria. The eight care homes will be randomly selected from all care homes that agree to join this trial. They will then be randomized to either the control or experimental conditions. Participants from each care home will be placed into their home's corresponding group to avoid 'contamination' effects across participants. Each intervention cycle will take 16 weeks (that is, baseline assessment and care home staff training for 4 weeks and Protocol implementation for 12 weeks). The Protocol will guide the pain management of the participants in the experimental care homes. Meanwhile, the control care homes will continue their usual pain management strategies. Intervention effects will be measured weekly during the protocol implementation period and compared with the baseline measurements, as well as between the experimental and control conditions. Although similar pain protocols have been suggested previously, the recommendations were based on experts' opinions rather than evaluation of research studies. The feasibility and effectiveness of this kind of pain management protocol, tailored to older people with dementia, remains unknown. The findings of this trial will offer strong evidence that better strategies for pain management should be used in the care home daily routine.Trial registration: The Chinese University of Hong Kong, Centre for Clinical Trials: CUHK-CCT00367.
    Trials 03/2014; 15(1):78. DOI:10.1186/1745-6215-15-78 · 1.73 Impact Factor
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