http://careinaging.duke.edu/longterm care presenter: gwendolyn buhr, md long-term care chronic pain...

http://careinaging.duke.edu/longtermcare

Presenter:Gwendolyn Buhr, MD

long-term care

Chronic Pain in the Nursing Chronic Pain in the Nursing Home ResidentHome Resident

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Chronic Pain in the Nursing Chronic Pain in the Nursing Home ResidentHome Resident

Key PrinciplesKey Principles

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Pain Prevalence in the Nursing Pain Prevalence in the Nursing HomeHome Overall 45% to 80%Overall 45% to 80% Nationwide, 14.7% of all nursing home Nationwide, 14.7% of all nursing home

residents were in persistent pain residents were in persistent pain In north Carolina in 1999, 40% of In north Carolina in 1999, 40% of

nursing home residents who were in pain nursing home residents who were in pain at the first MDS assessment were still in at the first MDS assessment were still in pain at the next assessment 60 to 180 pain at the next assessment 60 to 180 days laterdays later


Pain Management in the Pain Management in the Nursing HomeNursing Home Data gathered from 1,492 nursing Data gathered from 1,492 nursing

facilities in 5 states facilities in 5 states Of 13,625 residents >65 years with cancerOf 13,625 residents >65 years with cancer

– 24% - 38% reported daily pain24% - 38% reported daily pain– 16% received non-opioid medications, 16% received non-opioid medications,

adjuvants or bothadjuvants or both– 26% received strong opioids (morphine)26% received strong opioids (morphine)– 26% did not receive any analgesic agent26% did not receive any analgesic agent


Legal Consequences of Poorly Legal Consequences of Poorly Managed PainManaged Pain 1990: North Carolina, $15 million1990: North Carolina, $15 million

– Settled on appeal for undisclosed amountSettled on appeal for undisclosed amount– Nursing home failed to treat cancer painNursing home failed to treat cancer pain– Nurses did not give prescribed medicationsNurses did not give prescribed medications

1997: Virginia, $200 thousand1997: Virginia, $200 thousand– Hospital failed to treat cancer painHospital failed to treat cancer pain

2001: California, $1.5 million2001: California, $1.5 million– Hospital settled (undisclosed)Hospital settled (undisclosed)


Morbidity of Poorly Managed Morbidity of Poorly Managed PainPain Sleep disturbanceSleep disturbance MalnutritionMalnutrition Decline in social and recreational Decline in social and recreational

activitiesactivities Physical function decline: fallsPhysical function decline: falls Depression, anxiety, impaired cognitionDepression, anxiety, impaired cognition Decreased quality of lifeDecreased quality of life Increased health care utilization/costsIncreased health care utilization/costs


Pain and DementiaPain and Dementia

No evidence that pain transmission is No evidence that pain transmission is impaired in dementiaimpaired in dementia

Controversy about central nervous system Controversy about central nervous system changes that influence interpretation of changes that influence interpretation of pain transmissionpain transmission

ASSUME PAIN PREVALENCE AND ASSUME PAIN PREVALENCE AND SEVERITY SAME AS IN SEVERITY SAME AS IN

COGNITIVELY INTACT ELDERSCOGNITIVELY INTACT ELDERS


Pain and DementiaPain and Dementia

Decreased verbal pain report Decreased verbal pain report Decreased analgesic useDecreased analgesic use Significant untreated painSignificant untreated pain Complaints of pain are reliableComplaints of pain are reliable

– 83% able to quantify their pain with a scale 83% able to quantify their pain with a scale

Noncommunicative dementia patientsNoncommunicative dementia patients– Pain identified much less frequentlyPain identified much less frequently


AMDA Clinical Practice AMDA Clinical Practice GuidelineGuideline Pain assessmentPain assessment

– On admissionOn admission– At each quarterly reviewAt each quarterly review– At any time that change in patient’s At any time that change in patient’s

condition prompts a new MDScondition prompts a new MDS– Any time that pain is suspectedAny time that pain is suspected


Pain in the Cognitively Pain in the Cognitively ImpairedImpaired Do not assume that assessment is Do not assume that assessment is

impossibleimpossible Ask simple yes/no questions Ask simple yes/no questions

– Are you uncomfortable? Do you feel pain? Are you uncomfortable? Do you feel pain? Hurt? Aching?Hurt? Aching?

Use a scale if possibleUse a scale if possible– Clear explanation, give time to grasp taskClear explanation, give time to grasp task

Ask about present painAsk about present pain


Pain in DementiaPain in Dementia

Learn a given patient’s baseline activities Learn a given patient’s baseline activities and behaviorand behavior

Document changesDocument changes Could this be due to pain?Could this be due to pain? ScreamingScreaming Difficult behaviorsDifficult behaviors Attempt an analgesic trial Attempt an analgesic trial


WHO 3-step LadderWHO 3-step Ladder

Opioid “around the

clock”± adjuvants

Non-narcotic“around the


StrongOpioid

“around theclock”

± adjuvants

1 Mild1 Mild

2 Moderate2 Moderate

3 Severe3 Severe


Step Approach to Pain Step Approach to Pain ManagementManagement



1 Mild1 Mild

Non-opioidsNon-opioids•Acetaminophen•NSAIDS

•Ibuprofen•naproxen

•COX-2





1 Mild1 Mild

AdjuvantsAdjuvants•Calcitonin•Corticosteroids•Anticonvulsants•Topical agents•Antidepressants


Different Types of Pain Different Types of Pain Require Different TreatmentsRequire Different Treatments Somatic — localized tissue destructionSomatic — localized tissue destruction

– Arthritis, bone pain, pain after surgery, Arthritis, bone pain, pain after surgery, traumatrauma

Visceral — stretching internal organsVisceral — stretching internal organs– Bowel obstruction, angina, urinary Bowel obstruction, angina, urinary

retention, constipationretention, constipation

Neuropathic — injury to nervesNeuropathic — injury to nerves– Diabetic foot pain, shingles, pinched nervesDiabetic foot pain, shingles, pinched nerves



Opioid “around the




StrongOpioid

“around theclock”

± adjuvants

1 Mild1 Mild

2 Moderate2 Moderate

3 Severe3 Severe

OpioidsOpioids•Tramadol•Tylenol #3•Tylenol #4•Vicodin•Percocet

Strong OpioidsStrong Opioids•Morphine•Dilaudid•MSContin•OxyContin•Transdermal fentanyl


Medications Not Recommended Medications Not Recommended in the Nursing Homein the Nursing Home NSAIDs: indomethacin (Indocin), NSAIDs: indomethacin (Indocin),

piroxicam (Feldene), tolmetin (Tolectin), piroxicam (Feldene), tolmetin (Tolectin), meclofenamatemeclofenamate

Opioids: butorphanol (Stadol), Opioids: butorphanol (Stadol), propoxyphene (Darvoset), meperidine propoxyphene (Darvoset), meperidine (Demerol), nalbuphine (Nubain), (Demerol), nalbuphine (Nubain), pentazocine (Talwin)pentazocine (Talwin)


Current Status of Treating Current Status of Treating Pain in the Nursing HomePain in the Nursing HomeCharacteristics of residents receiving at least one Characteristics of residents receiving at least one

analgesic (n=2,065)analgesic (n=2,065) Pain type: chronic 77%, acute 20%Pain type: chronic 77%, acute 20% 40.6% had no pain assessment40.6% had no pain assessment Most residents received no nonpharmacologic Most residents received no nonpharmacologic

treatment: 69.4%treatment: 69.4% Most analgesics prescribed PRN: 63.2%Most analgesics prescribed PRN: 63.2% Propoxyphene was the most commonly Propoxyphene was the most commonly

prescribed opioid: 55.8%prescribed opioid: 55.8%

http://careinaging.duke.edu/longterm care presenter: gwendolyn buhr, md long-term care chronic pain...

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