Journal of the American Medical Directors Association
Original studiesNursing home resident barriers to effective pain management: Why nursing home residents may not seek pain medication
Section snippets
Methods
We conducted a multifaceted educational and behavioral intervention study to improve nursing home pain practices. A detailed description of the study can be found in the article by Jones et al.22 The setting was 12 rural and urban nursing homes in Colorado, with six selected by the investigators to be intervention sites and six serving as control sites. A 20% random sample of each nursing home’s residents, with over-sampling of Hispanic residents, was interviewed quarterly over the course of
Results
About 10% of the residents approached by the RA declined to participate, due to consent form issues, being too busy, or lack of interest. Some residents were very willing to talk with the RA but were unwilling to sign the consent form. These residents were not included in the study. Slightly more legal guardians refused to allow their relatives to participate than residents themselves. One legal guardian retracted her permission once she received the consent form in the mail. The subject’s data
Discussion
Pain management is a complex problem in nursing homes. More than one-half of residents experience acute pain, persistent pain, or both, of varying etiologies (neuropathic, somatic, and/or visceral) and intensity. Analgesic selection and dosing schedule must consider the intensity and type of pain, other medications the resident may be receiving, and physiologic changes that influence the metabolism and excretion of certain drugs. Physiologic considerations, however, are often overshadowed by
Conclusion
Our categorization of resident barriers is similar to, yet different from, previous categorization schemes. Although we noted concerns about addiction, tolerance, dependence, and side effects, we believe that these reasons all fall under a more general category of concerns about medication. Fatalism or passive reactions to pain did not occur very frequently in this sample of nursing home residents, but “being a good patient” was certainly apparent in the categories reflecting staff concerns and
Acknowledgments
The authors acknowledge the contributions of Jill Scott, Ginny Pepper, Ruby Martinez, Evelyn Casiano, and Lori Jarrell to the nursing home pain project.
References (40)
- et al.
What do nurses know and believe about patients with pain?
J Pain Symptom Manage
(1995) Pain in cognitively impaired older persons
Clin Geriatr Med
(1996)- et al.
Utilizing pain assessment scales increases the frequency of diagnosing pain among elderly nursing home residents
J Pain Symptom Manage
(2001) - et al.
Patient-related barriers to pain managementThe Barriers Questionnaire II (BQ-II)
Pain
(2002) - et al.
Patient-related barriers to management of cancer pain
Pain
(1993) The checklist of nonverbal pain indicators
Pain Manag Nurs
(2000)- et al.
Race, ethnicity, and pain
Pain
(2001) - et al.
Development and preliminary validation of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)
Pain Manag Nurs
(2004) - et al.
Use of the assessment of discomfort in dementia protocol
Appl Nurs Res
(2001) - et al.
Pain Assessment for the Demented Elderly (PADE)Reliability and validity of a new measure
J Am Med Dir Assoc
(2003)
Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale
J Am Med Dir Assoc
Pain in the Nursing Home
J Am Geriatr Soc
Pain Management in Elderly People
J Am Geriatr Soc
Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology
JAMA
Organization of hospital-based acute pain management programs
South Med J
A drug use evaluation of selected opioid and nonopioid analgesics in the nursing facility setting
J Am Geriatr Soc
Persistent pain in nursing home residents
JAMA
Pain in older adults
Annals of Long-Term Care
Elder BeliefsBlocks to pain management
Journal of Gerontological Nursing
The problems of pain and its detection among geriatric nursing home residents
J Am Geriatr Soc
Cited by (32)
Barriers to Optimal Pain Management in Aged Care Facilities: An Australian Qualitative Study
2018, Pain Management NursingPain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial
2016, Journal of the American Medical Directors AssociationEvidence-based practice for pain identification in cognitively impaired nursing home residents
2014, Nursing Clinics of North AmericaCitation Excerpt :Of those who had care plans addressing pain, only 35% had nondrug interventions, and only 10% identified the pain scale tool to use to ensure assessment consistency. Challenges to successfully evaluating and managing pain may include communication difficulties due to illness, language and/or cultural barriers, stoicism about pain, and cognitive impairment.8–10 The results of the baseline data led the Core Team to analyze the demographic profile of residents as well as staff ethnic composition (Fig. 4).
Chronic Pain: The Help-Seeking Behavior, Attitudes, and Beliefs of Older Adults Living in the Community
2011, Pain Management NursingCitation Excerpt :Population-based cross-sectional surveys exploring the factors associated with help-seeking for chronic low back pain (Mortimer & Ahlberg, 2003) and knee pain (Bedson et al., 2007; Mitchell et al., 2006) have revealed that pain intensity and disability are also salient clinical factors influencing help-seeking. There is growing evidence to suggest that stoic attitudes, i.e., attitudes demonstrating courage in the face of pain, are associated with the underreporting of pain in older adults living in nursing homes (Jones, Fink, Clark, Hutt, Vojir, & Melis, 2005; Weiner & Rudy, 2002). One qualitative study examined the attitudes of residents in a long-term care setting toward chronic pain.
Pain prevalence and characteristics in three Dutch residential homes
2008, European Journal of PainCitation Excerpt :Those who take already numerous pills are reluctant to ingest any more (Weiner, 2002; Feldt, 2004; Jones et al., 2005), in spite of the pain and the way this interferes with daily activities. Some feel that by giving up their homes and moving into a residential home they have already lost much of their independency and, although they are not satisfied with the treatment, pain control is seen as the last part of independency (Jones et al., 2005). The fact that so many elderly are convinced that pain is a part of old age (Yates et al., 1995) and therefore unavoidable, may explain their satisfaction with the received pain treatment in this study.
The Application of Evidence-Based Principles of Care in Older Persons (Issue 4): Pain Management
2007, Journal of the American Medical Directors AssociationCitation Excerpt :Many elderly are stoic, are slow to respond to pain assessment, and may have subtle cognitive defects, further disguising their condition or ability to communicate pain.2 Multiple barriers to effective pain management are present in the nursing home setting.2,7,8 The purpose of a recent nursing home pain study was to determine the extent to which residents in pain declined to request pain medication from the staff, and the reasons provided by the residents to explain this behavior.
Supported by Grant U18-HS11093 from the Agency for Healthcare Research and Quality.