Want to know more

PAIN
Nursing Standard of Practice Protocol: Pain Management in Older Adults

Ann L. Horgas, RN PhD FGSA FAAN, Saunjoo L. Yoon, PhD, RN

Evidence-Based Content - Updated January 2008

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Standard

All older adults will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the elder to maintain the highest level of functioning possible.

Pain is a common experience for many older adults, and is associated with a number of chronic (e.g., osteoarthritis) and acute (e.g., cancer, surgery) conditions.

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Overview

Pain a common, subjective experience for many older adults, is associated with a number of chronic (e.g., osteoarthritis) and acute (e.g., cancer, surgery) conditions. Despite its prevalence, evidence suggests that pain is often poorly assessed and poorly managed, especially in older adults. Cognitive impairment due to dementia and/or delirium represents a particular challenge to pain management because older adults with these conditions may be unable to verbalize their pain. Nurses, an integral part of the interdisciplinary care team, need to understand myths associated with pain management, including addiction and belief that pain is a normal result of aging, to provide optimal care and to educate patients and families about managing pain.

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Background

A. Definitions

1. Pain is defined as "an unpleasant sensory and emotional experience" 1, 2 and also as "whatever the experiencing person says it is, existing whenever he says it does." 3, 4 These definitions highlight the multidimensional and highly subjective nature of pain. Pain is usually characterized according to the duration of pain (e.g., acute versus persistent) and the cause of pain (e.g., nociceptive versus neuropathic). These definitions have implications for pain management strategies.

2. Acute pain defines pain that results from injury, surgery, or tissue damage. It is usually associated with autonomic activity, such as tachycardia and diaphoresis. Acute pain is usually time-limited and subsides with healing.

3. Persistent pain defines pain that persists for a prolonged period (usually more than 3 to 6 months). 1, 5 Persistent pain may or may not be associated with a diagnosable disease process and autonomic activity is usually absent. Persistent pain is often associated with functional loss, mood and behavior changes, and reduced quality of life.

4. Nociceptive pain refers to pain caused by stimulation of specific peripheral or visceral pain receptors. This type of pain results from disease processes (e.g., osteoarthritis), soft-tissue injuries (e.g., falls), and medical treatment (e.g., surgery, venipuncture, and other procedures). It is usually localized and responsive to treatment.

5. Neuropathic pain refers to pain caused by damage to the peripheral or central nervous system. This type of pain is associated with diabetic neuropathies, post-herpetic and trigeminal neuralgias, stroke, and chemotherapy treatment for cancer. It is usually more diffuse and less responsive to analgesic medications.

B. Epidemiology

1. Approximately 50% of community-dwelling older adults have pain.

2. Approximately 85% of nursing home residents experience pain.

C. Etiology

1. More than 80% of older adults have chronic medical conditions that are typically associated with pain, such as osteoarthritis and peripheral vascular disease.

2. Older adults often have multiple medical conditions, both chronic and/or acute, and may suffer from multiple types and sources of pain.

• Significance

3. Pain has major implications for older adults’ health, functioning, and quality of life. If unrelieved, pain is associated with the following:

• depression
• sleep disturbances
• withdrawal and decreased socialization
• functional loss and increased dependency
• exacerbation of cognitive impairment
• increased health care utilization and costs

4. Nurses have a key role in pain management. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain in late life to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary health care teams.

5. The Joint Commission on Accreditation of Healthcare Organizations.6 now requires regular and systematic assessment of pain in all hospitalized patients. Because older adults constitute a significant portion of the patient population in many acute care settings, nurses need to have the knowledge and skill to address specific pain needs of older adults.

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Assessment Parameters

A. Assumptions

1. The majority of hospitalized older patients suffer from both acute and persistent pain.

2. Older adults with cognitive impairment experience pain but are often unable to verbalize it. 7

3. Both patients and health care providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that (a) influence the pain management process, and (b) must be acknowledged before optimal pain relief can be achieved. 1

4. Pain assessment must be regular, systematic, and documented to accurately evaluate treatment effectiveness. 1

5. Self-report is the gold standard for pain assessment. 1

B. Strategies for Pain Assessment

1. Review medical history, physical exam, and laboratory and diagnostic tests to understand sequence of events contributing to pain. 1

2. Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors. 1

3. Review medications, including current and previously used prescription drugs, over-the-counter drugs, and home remedies. Determine which pain control methods have previously been effective for the patient. Assess patient's attitudes and beliefs about use of analgesics, adjuvant drugs, and nonpharmacological treatments. 1

4. Use a standardized tool to assess self-reported pain. Choose from published measurement tools and recall that older adults may have difficulty using 10-point visual analog scales. Vertical verbal descriptor scales or faces scales may be more useful with older adults. 8

5. Assess pain regularly and frequently but at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness.

6. Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient's usual patterns. 8

7. Gather information from family members about the patient's pain experiences. Ask about the patient's verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.

8. When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume pain is unrelieved and treat accordingly. 9

C. Assessment Tools

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Nursing Care Strategies

A. Prevention of Pain

1. Assess pain regularly and frequently to facilitate appropriate treatment. 1

2. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. 1

3. Educate patients, families, and other clinicians to use analgesic medications prophylactically prior to and after painful procedures. 1

4. Educate patients and families about pain medications and their side effects; adverse effects; and issues of addiction, dependence, and tolerance. 1

5. Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate. 1

6. Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and heat/cold. 1

B. Treatment Guidelines

1. Pharmacologic 1

a. Older adults are at increased risk for adverse drug reactions.

b. Monitor medications closely to avoid over- or under-medication.

c. Administer pain drugs on a regular basis to maintain therapeutic levels; avoid PRN drugs.

d. Document treatment plan to maintain consistency across shifts and with other care providers.

e. Use equianalgesic dosing and the WHO three-step ladder to obtain optimal pain relief with fewer side effects. 10

2. Nonpharmacologic 1

a. Investigate older patients' attitudes and beliefs about, preference for, and experience with nonpharmacological pain-treatment strategies.

b. Tailor nonpharmacologic techniques to the individual.

c. Cognitive-behavioral strategies focus on changing the person's perception of pain (e.g., relaxation therapy, education, and distraction) and may not be appropriate for cognitively impaired persons.

d. Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain (e.g., heat, cold, TENS units) and are generally safe and effective.

3. Combination approaches that include both pharmacological and nonpharmacological pain treatments are often the most effective.

C. Follow-up Assessment

1. Monitor treatment effects within 1 hour of administration and at least every 4 hours.

2. Evaluate patient for pain relief and side effects of treatment.

3. Document patient's response to treatment effects.

4. Document treatment regimen in patient care plan to facilitate consistent implementation.

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Expected Outcomes

A. Patient:

1. Will be either pain free or pain will be at a level that the patient judges as acceptable.

2. Maintains highest level of self care, functional ability, and activity level possible.

3. Experiences no iatrogenic complications, such as falls, GI upset/bleeding, or altered cognitive status.

B. Nurse:

1. Will demonstrate evidence of ongoing and comprehensive pain assessment.

2. Will document evidence of prompt and effective pain management interventions.

3. Will document systematic evaluation of treatment effectiveness.

4. Will demonstrate knowledge of pain management in older patients, including assessment strategies, pain medications, nonpharmacological interventions, and patient and family education.

C. Institution

1. Facilities and institutions will provide evidence of documentation of pain assessment, intervention, and evaluation of treatment effectiveness.

2. Facilities and institutions will provide evidence of referral to specialists for specific therapies (e.g., psychiatry, psychology, biofeedback, physical therapy, or pain treatment centers).

3. Facilities and institutions will provide evidence of pain management resources for staff (e.g., care-planning and pain management references, pain management consultants).

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Treatment Guidelines

A. Pain

1. The Hartford Institute for Geriatric Nursing: Try This Series: Assessing Pain in Older Adults http://www.hartfordign.org/resources/education/tryThis.html

2. American Geriatric Society Guideline on the Management of Persistent Pain http://www.americangeriatrics.org/education/manage_pers_pain.shtml

3. Herr, K., Steffensmeier, J., Rakel, B. (2006). University of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core; Iowa City, IA.

4. American Association of Pain Management Nurses (ASPMN): Geriatric Pain Assessment: Self-Directed Learning https://www.commercecorner.com/aspmn/productlist1.aspx

5. American Pain Society: Pain Guidelines and Online Resource Centers http://www.ampainsoc.org/links/clinician1.htm

6. International Association for the Study of Pain: Curriculum on Pain for Schools of Nursing; Pain in Older Persons Book http://www.iasp-pain.org/

B. Pain in Persons with Dementia and Long Term Care

1. American Medical Directors Association (AMDA): Clinical Practice Guideline: Pain Management in the Long Term Care Setting http://www.amda.com/tools/cpg/chronicpain.cfm

2. City of Hope: State-of-the-Art Review of Tools for Assessing Pain in Nonverbal Older Adults http://www.cityofhope.org/prc/elderly.asp

3. American Association of Pain Management Nurses (ASPMN): Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. http://www.aacn.org/AACN/practice.nsf/vwdoc/PainAssmt

C. Measurement Tools

1. See City of Hope Web site listed previously for comprehensive review of tools for persons with dementia

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Horgas, A. L. & Yoon, S. L. (2008). Pain management. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-based geriatric nursing protocols for best practice (3rd ed.) (pp. 199-222). New York: Springer Publishing Company, Inc.

References

1. American Geriatrics Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50, S205–S224. Evidence Level VI: Expert Opinion.

2. Melzack, R., & Casey, K. L. (1968). Sensory, motivational, and central control determinants of pain: A new conceptual model. In D. R. Kenshalo (Ed.), The skin senses (pp. 423–443). Springfield, IL: Charles C. Thomas Press.

3. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man–environment interaction. Los Angeles: UCLA Students Store.

4. McCaffery, M., & Pasero, C. (1999). Pain: Clinical manual (2nd ed.). St. Louis, MO: Mosby.

5. Harkins, S. W. (2002). What is unique about the older adult's pain experience? In D. K. Weiner, K. Herr, & T. E. Rudy (Eds.), Persistent pain in older adults: An interdisciplinary guide for treatment (pp. 4–17). New York: Springer Publishing Company.

6. Joint Commission on the Accreditation of Healthcare Organization (2001). Accreditation manual for hospitals.Oakbrook Terrace, IL: JCAHO.

7. Smith, M. (2005). Pain assessment in nonverbal older adults with advanced dementia. Perspectives in psychiatric care, 41, 99–113. Evidence Level I: Systematic Review.

8. Taylor, L., J., Harris, J., Epps, C. D., & Herr, K. (2005). Psychometric evaluation of selected pain-intensity scales for use with cognitively impaired and cognitively intact older adults. Rehabilitation Nursing, 30, 55–61. Evidence Level V: Care Report/Narrative Literature Review.

9. Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., et al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44–52. Evidence Level VI: Expert Opinion.

10. World Health Organization (WHO) (1996). Cancer pain relief and palliative care (technical report series) (2nd ed). World Health Organization: Geneva, Switzerland.

Last updated - January 2008

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