alc1-3_amdapain

8/12/2019 ALC1-3_AMDAPain

1/5

28 Assisted Living Consult May/June 2005

T his document focuses on themanagement of pain inALFs. It is based on theAmerican Medical Directors Associa-

tions (AMDA) clinical practice guide-

line, Pain Management in the Long

Term Care Setting. It recommends

processes that, if followed, will help

to ensure that pain among ALF resi-

dents is adequately recognized,

assessed, treated, and monitored. Ingeneral, guidance is directed to the

entire interdisciplinary care team.

Facility size, available resources,

existing policies and procedures, and

other factors may influence the pre-

cise manner in which a particular ALF

implements and uses these processes.

DefinitionPain is defined as an individualsunpleasant sensory or emotional

experience. Acute pain involvesabrupt onset or escalation. Chronicpain is persistent or recurrent. Painis a highly subjective, personalexperience for which there are noconsistent objective biologicalmarkers.

Despite the best efforts of practi-tioners and staff, pain is commonin the assisted living setting. How-ever, although disorders that cancause chronic pain are more com-

mon with increasing age, pain itselfis not a normal part of aging.

Approximately 45-80% of longterm care (LTC) residents are esti-mated to have chronic pain. Theprecise figures are unknown, aspain in the long term care setting issometimes under-recognized andunder-treated; and treatment forchronic non-cancer pain, especiallyamong those with non-terminal ill-

ness, is inconsistent.Nonetheless, pain in elderly

patients often can be reliably de-tected and effectively treated.Although the recognition and treat-ment of pain in ALFs present spe-cial challenges, a systematic effortcan result in positive outcomes.

Management of AcuteVersus Chronic Pain

Although the principles of painmanagement are similar for both

AMDA Clinical

Practice Guideline:Pain Managementin ALFs


2/5


3/5


Description of Pain in ALFsMost chronic pain in ALFs is relatedto arthritis and musculoskeletalproblems. Surveys have found thatnearly one in four residents in thelong term care setting has some

form of arthritis. Pain caused bynervous system damage or disease,including diabetic neuropathy andpostherpetic neuralgia, also is com-mon as is pain associated withosteoporosis.

Pain can cause or lead to otherconditions that can adversely affectresidents independence, level offunctioning, and quality of life.These include deconditioning, gaitdisturbances, falls, slow rehabilita-

tion, multiple medication use, cog-nitive impairment, malnutrition,depression, sleep disturbance,impaired mobility, and decreasedsocialization. At the same time,chronic pain in elderly people alsocontributes to increased health careutilization costs.

Pain in CognitivelyImpaired ResidentsPain frequently is undertreated in

cognitively impaired residents, partlybecause they are less able to expresstheir pain in words (eg, My handshurt.). However, contrary to a com-monly held belief, these residentsoften are capable of communicatingabout their pain in other ways. Forexample, one study tested the abilityof cognitively impaired residents in along term care facility to completescales that used words or pictures todescribe the severity of pain.1 The

authors found that more than 80% ofthe residents could complete at leastone of five scales.

Caregivers, family members, andothers should be encouraged tolook for signs that cognitively im-paired residents could be experi-encing pain. These include facialexpressions (grimacing, frowning),moaning, rubbing hands or otherbody parts, crying, and/or not eat-ing. It is important for all front-line

staff members to be educated aboutthese nondescript signs and symp-

toms of pain so that they are betterable to identify when a residentmay be in pain. At the same time,even when they cant say directlythat they are in pain, their wordsmay suggest discomfort nonethe-

less. Expressed memories about atime when they were hurt mayrelate to current pain they are feel-ing. For example, a resident mighttalk about a time when he fell outof a tree and broke his leg.

Managing PainIt is suggested that clinicians take astart low, go slow approach totreating pain in ALF residents, witha focus on taking the least invasive

route and reassessing frequently.Both nonpharmacologic and phar-macologic treatments have value intreating pain.

Nonpharmacological treatmentsinclude cognitive therapies, bio-feedback, and behavior therapy,as well as topical analgesics suchas counterirritants and capsaicincream. A number of complementarytherapies also may be helpful (seeTable 2).

A medication schedule is advisedfor pharmacologic treatments. Sever-

al non-steroidal anti-inflammatorydrugs (NSAIDs) are considered inap-propriate for elderly individuals.These include indomethacin, me-clofenamate, piroxicam, and tol-metin. Also considered inappropriate

for this population are the opioidsmeperidine, propoxyphene, penta-zocine, and nalbuphine, as well asphenylbutazone, trimethyl benza-mide, flurazepam, amitriptyline,long-acting benzodiazepines, musclerelaxants, and anticholinergics.

For mild to moderate pain, con-sider a trial with acetaminophen.However, it is important to note thatcaution is necessary in administer-ing acetaminophen to patients who

also are taking warfarin or whohave liver disease or alcohol abuseproblems. Studies have shown thatpatients often say they get greaterrelief from NSAIDs over aceta-minophens; and a combination ofacetaminophen and tramadol pro-vides greater pain relief than eitheralone and results in quicker painrelief than tramadol by itself. Thiscombination also has the benefit ofreduced adverse drug reactions.

Oral immediate-release opioiddosing calls for a dose every four

Table 2.Complementary Therapies for Pain Management

ALF should consider offering complementary therapies for pain management, including:

Physicial Therapies Exercise

Physical and occupational therapy Positioning (eg, braces, splints, wedges) Cutaneous stimulation (eg, superficial heat or cold, massage therapy, pressure,

vibration)

Neurostimulation (eg, acupuncture, transcutaneous electrical nerve stimulation) Chiropractic treatments Magnet therapy

Nonphysical Therapies Cognitive/behavioral therapy Psychological counseling

Spiritual counseling Peer support groups Alternative medicine (eg, herbal therapy, naturopathic and homeopathic remedies)

Aromatherapy Music, art, drama therapy Biofeedback Meditation, other relaxation techniques

Hypnosis


4/5

May/June 2005 Assisted Living Consult 31

hours, adjusted daily. Dosage canbe adjusted 25% to 50% for mild ormoderate pain and 50% to 100%for severe or uncontrolled pain.This adjustment can be made morequickly for severe, uncontrolled

pain. For extended-release oralopioid dosing, dosage is product-specific, but typically administeredevery 8, 12, or 24 hours. It is im-portant that residents and caregiversknow that these tablets should notbe crushed or chewed.

Common adverse effects of opi-oids may include constipation, drymouth, nausea or vomiting, seda-tion, and sweating. It is important toprescribe anticonstipation medica-

tions, such as stool softeners, whenprescribing opioids. Nurses accept-ing or receiving orders for opioidsshould ask the practitioner for anti-constipation medications if nonehave been ordered. The ALF alsoshould have bowel regimen careplans in place for those residentswho are on opioids.

The WHO Pain Ladder is usefulin selecting drug therapies to treatpain (see Figure 1). It is essential to

follow this ladder, even in caseswhere hospice is being instituted. Itis inappropriate to go from an as-needed (PRN) non-opioid medica-tion to an opioid pain patch. Evenin cases where hospice care is war-ranted, an appropriate dose of mor-phine that controls the residentspain must be established prior togoing to an opioid patch.

Guiding Principles

In ALFs, the comfort and well-beingof the individual resident shouldalways be paramount. This princi-ple is the foundation for effectivepain management. Individualizedcare planning ensures that painmanagement is tailored to each res-idents needs, circumstances, condi-tions, and risk factors. Members ofthe interdisciplinary care team havea responsibility to advocate for resi-dent comfort and to find clinically

appropriate, cost-effective ways ofachieving it.

Facility PreparednessAs previously noted, many factorsmake pain assessment and manage-ment in the assisted living settingchallenging. A facility commitmentto resident comfort is essential toovercoming these barriers. Man-

agers should develop and imple-ment policies and procedures orguidelines that facilitate the recog-nition, assessment, treatment, andmonitoring of pain.

CommunicationAppropriate staff should communi-cate information about a residentspain routinely and in a timely fash-ion to those who will act on thesereports. Facilities should consider

encouraging all members of theinterdisciplinary care team to use a

common vocabulary to describepain and a standard array of painassessment tools. It is important tohave ongoing and consistent stafftraining regarding the use of thesetools to ensure that they are beingused properly.

It is useful to have a systematicapproach to care that includes seek-ing the input of individuals such asfacility assistants and family mem-

bers who are familiar with the resi-dent and can describe his or hersymptoms. Other ideas that can helpensure adequate pain recognitionand management in ALFs include: Designating a staff member to

ensure that all residents in thefacility are properly assessed forpain and that all residents whohave pain receive treatment

Including documentation ofongoing pain assessment and

treatment in every residentsmedical record

Ensure that the facilitys process-es for assessing residents, reportingcritical information, and obtainingtimely and appropriate responsesfrom physicians are functioningoptimally and that any problemsrelated to these processes areaddressed.

Importance of Staff EducationHealth care professionals at all

Figure 1. WHO Pain Ladder

Opioid for Moderate to Severe Pain

Nonopioid Adjuvant

3Opioid for Mild to Moderate Pain Nonopioid Adjuvant

Nonopioid Adjuvant

2

1

Increa

singPain

Pain can cause

or lead to other

conditions that can

adversely affect

independence and

quality of life.


5/5


levels need ongoing education about pain manage-ment. Training and orientation programs for employeesand affiliated professionals in ALFs should include edu-cation about all aspects of pain assessment and treat-ment. Nursing assistants and other direct caregivingstaff should receive training and mentoring in pain

recognition. When they help identify pain in a resident,they should receive proper recognition and praise.A pain management education program is important

and should: Address misconceptions and myths about pain that

hinder its recognition and treatment Help staff to recognize and overcome misconceptions

and biases that may affect their response to residentscomplaints of pain or behaviors suggestive of pain

Train direct caregiving staff in the proper use ofpain assessment tools

Educate staff and practitioners about the effective

operation of the facilitys overall care deliveryprocess, which includes timely, appropriate painassessment and management

Educate staff, practitioners, residents, and families oradvocates about the benefits of various treatments forpain and the risks and limitations of pain medications

Educate staff and practitioners about the benefits ofinterventions that may indirectly influence pain (eg,the benefits of exercise in improving strength andmobility and of activities in helping address anxietyand depression that may lead to an exaggeratedpain response)

Promote an aggressive, coordinated approach topain management throughout the facility

Staff DeploymentSome evidence suggests staffing policies that enable care-givers to remain with the same residents for extendedtime periods improve pain detection. In one study, nurs-es who had developed relationships with cognitivelyimpaired residents could tell when one of them was inpain by observing subtle changes in the individualsbehavior or demeanor.2 These results suggest that consis-tent staffing that enables familiarity with a residents base-

line characteristics facilitates the recognition of importantcondition changes, including the onset of or an increasein pain. For various reasons, however, facilities may findit difficult to accomplish the desirable goal of consistentstaffing. Nonetheless, this should be a goal wheneverpossible.

Most ALF residents have predisposing factors for thedevelopment of chronic, non-cancer pain. For this rea-son, a high index of suspicion for the presence of painis warranted. Every resident shouldbe regularly and systematically assessed for pain. Theassessment process should be conducted at least:

On admission to the ALF facility At regularly scheduled reviews

At any time that there is a change in condition At any time it is suspected that a resident is in pain

ConclusionBy implementing the steps described in this guideline,health care providers can meet the expectations of resi-

dents, their families, advocates, and policy makers foradequate, compassionate pain management. Simultane-ously, to serve their residents most effectively and tohelp each resident achieve the highest practicable levelof well being, ALFs should review andas neededrevise its operating procedures to incorporate newinformation about pain recognition, assessment, treat-ment, and monitoring. Tools such as the complete clin-ical practice guideline on pain management developedby AMDA can make these processes more thoroughand effectively. ALC

References

1. Parke B. Realizing the presence of pain in cognitively impairedolder adults: gerontological nurses ways of knowing. J Gerontol Nurs1998;24:21-28.

2. Stein WM, Ferrell BA. Pain in the nursing home. Clin Geriatr Med1996;12(3):601-613.

For more information about AMDA and its products,

see the organizations Web site at www.amda.com.

Our workflowspeaks in volumes.If you need a high-volume pharmacy

management system with built-in

tools for improving efficiency, you

need PrimeCare. Call QS/1 todayat 1-800-231-7776.

2005, J M SMITH CORPORATION. QS/1 and PrimeCare are registered trademarksof the J M Smith Corporation.

1-800-231-7776www.qs1.com

alc1-3_amdapain

Documents