Geriatric Nursing and Pain Management
Whats is Pain
Pain is a very common experience among older adults. The prevalence
of pain in older adults ranges from 50% to 86% (Horgas, Elliott, &
Marsiske, 2009). Across all care settings and most specialty areas, nurses will
interact with older adults (Herr, 2010).
By the year 2030, it is projected that
one in five US residents will be older than 65 years of age (Rosenthal &
Kavic, 2004), and those older than age 85 represent the fastest growing segment
of the population.
In 2000, adults older than the age of 65 accounted for half
of all hospital inpatient days (Rosenthal & Kavic, 2004). Furthermore,
approximately 50% of admissions to the intensive care unit (ICU) are adults
older than the age of 65 (McNicoll et al., 2003; Pisani, McNicoll, &
Inouye, 2003).
Thus, care of older adults is no longer restricted to nurses
working in long-term care. Nurses in the acute care setting also need to be knowledgeable
about the most effective strategies for assessing and managing pain in this
population (Herr, 2010).
Pain as Health Care Issue
There are many causes of pain in older adults. Acute pain is
typically associated with surgery, fractures, or trauma (Herr, Bjoro,
Steffensmeier, & Rakel, 2006).
Persistent pain (ic.. pain that continues
for more than 3-6 months) is most frequently associated with musculoskeletal
conditions such as osteoarthritis (The American Geriatrics Society [AGS] Panel
on the Pharmacological Management of Persistent Pain in Older Persons, 2009).
In 2000, it was estimated that almost 9 million surgeries were performed on
older adults, including 1.25 million musculoskeletal surgeries (Herr, Titler,
& Schilling, 2004).
In addition, cancer is associated with significant pain
for one third of patients with active disease and for two thirds of those with
advanced disease (Reiner & Lacasse, 2006). In the acute care setting, older
adults are therefore likely to have acute pain superimposed on persistent pain.
Pain in Geriatric Nursing Care
Pain has major implications for older adults’ health, functioning,
and quality of life (Wells, Pasero, & McCaffery, 2008). Pain is associated
with depression, social withdrawal, sleep disturbances, impaired mobility,
decreased activity engagement, and increased health care use (AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons, 2009).
Other
geriatric conditions that can be exacerbated by pain include falls, cognitive
decline, deconditioning, malnutrition, gate disturbances, and slow
rehabilitation (AGS Panel on the Pharmacological Management of Persistent Pain
in Older Persons, 2009).
In the hospital setting, older adults suffering from
acute pain have been reported to be at increased risk for thromboembolism,
hospital-acquired pneumonia, and functional decline (Wells et al., 2008).
Unrelieved acute pain has also been implicated in the development of subsequent
persistent pain (Desbiens, Mueller-Rizner, Connors, Hamel, & Wenger, 1997;
Desbiens, Wu, et al., 1997). Unrelieved pain, thus, has important implications
for physical, functional, and mental health among older adults.
Over the past decade, a substantial number of clinical and
empirical efforts have been undertaken to improve the assessment and management
of pain in older adults.
For instance, in 2001, the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) addressed pain assessment and
management as part of the survey and accreditation process.
The Joint
Commission (2001) asserted that patients have the right to appropriate
assessment and management of pain and declared pain as the fifth vital sign.
This mandate exposed some of the challenges associated with assessing and
managing pain in older adults in general, and in persons with dementia in
particular.
This, in part, spurred clinical and research activity to develop
measures for assessing pain in older adults, particularly those with cognitive
impairment.
These behavioral measures have been reviewed in several published
reports (Herr, Bjoro, & Decker, 2006; Herr, Bursch, Ersek, Miller, &
Swafford, 2010), including a comprehensive chapter focusing specifically on
pain assessment tools in the classic reference by Pasero and McCaffery (2011).
In addition, there have been multiple clinical guidelines by leading scientific
and clinical organizations including the AGS (AGS Panel on the Pharmacological
Management of Persistent Pain in Older Persons, 2009; Hadjistavropoulos et al.,
2007).
The American Pain Society (Hadjistavropoulos et al., 2007), and the
American Society for Pain Management Nursing (Herr, Coyne, et al., 2006). Links
to these resources are included at the end of this chapter.
Despite the Joint
Commission mandate and the dissemination of clinical guidelines aimed at
improving pain management, there is persistent evidence that pain remains
ineffectively assessed and poorly managed in older adults across care settings
(Herr, 2010; Herr et al., 2004; Horgas et al. ., 2009; Morrison, Magaziner,
McLaughlin, et al., 2003: Titler et al., 2009).
The purpose of this chapter is
to provide the best evidence on the assessment and treatment of pain in older
adults, especially those with cognitive impairment. It is hoped that the
information here can be used to establish, implement, and evaluate protocols in
the acute care setting that will improve pain management for older adults.
Pain
Pain is defined as a complex, multidimensional subjective
experience with sensory, cognitive, and emotional dimensions (AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons, 2009; Melzack
& Casey, 1968). For clinical practice, Margo McCaffery’s classic definition
of pain is perhaps the most relevant.
She states Pain is whatever the
experiencing person says it is, existing whenever he says it does (McCaffery,
1968). This definition serves as a reminder that pain is highly subjective and
that patients’ self-report and description of pain is paramount in the pain
assessment process.
This definition, however, also highlights the difficulty
inherent in pain assessment. There is no objective measure of pain; the
sensation and experience of pain are completely subjective. As such, there is a
tendency for clinicians to doubt patients’ reports of pain.
Pasero and
McCaffery (2011) provided a comprehensive chapter on biases, misconceptions,
and misunderstandings that hampered clinicians’ assessment and treatment of
patients who reported pain. These issues apply to patients across the life
span, and led the authors to conclude the following:
A veritable mountain of literature published during the past three
decades attests to the undertreatment of pain. Much of this literature is
consistent with the hypothesis that human beings, including health care
providers in all societies, have strong tendencies or motivations to deny or
discount pain, especially severe pain, and to avoid relieving the pain.
Certainly we should struggle to identify and correct personal tendencies that
lean to inadequate pain management, but this may not be a battle that can be
won.
Perhaps it is best to assume that there are far too many biases to
overcome and that the best strategy is to establish policies and procedures
that protect patients and ourselves from being victims of these influences.
Among older adults, there is persistent evidence that pain is under
detected and poorly managed among older adults (Herr, 2010; Horgas et al.,
2009; Horgas & Tsai, 1998; Smith, 2005). There are a number of factors that
contribute to this situation, including individual based, caregiver-based, and
organizational-based factors.
Individual-based factors that may impair pain
assessment include the following:
(a) belief that pain is a normal part of
aging
(b) concern of being labeled a hypochondriac or complainer
(c) fear of
the meaning of pain in relation to disease progression or prognosis
(d) fear
of narcotic addiction and analgesics
(e) worry about health care costs
(f) a belief that pain is not important to health care providers (AGS Panel on
Persistent Pain in Older Persons, 2002 ; Gordon et al., 2002).
In addition,
cognitive impairment is an important factor in reducing older adults’ ability
to report pain (Horgas et al., 2009; Smith, 2005).
Pain detection and management are also influenced by provider-based
factors. Health care providers have been found to share the mistaken belief
that pain is a part of the normal aging process and to avoid using opioids due
to fear about potential addiction and adverse side effects (Pasero &
McCaffery, 2011).
Similarly, cognitive status influences providers’ assessment
and treatment of pain. Several studies have documented that cognitively
impaired older adults were prescribed and administered significantly less
analgesic medication than were cognitively intact older adults (Horgas &
Tsai, 1998; Morrison. Magaziner, Gilbert, et al., 2003).
This finding may
reflect cognitively impaired adults’ inability to recall and report the
presence of pain to their health care providers. It may also reflect
caregivers’ inability to detect pain, especially among frail older adults.
Health care providers should face the challenge of pain assessment by first
systematically examining their own biases, beliefs, and behaviors about pain,
and eliciting and understanding the challenges and beliefs their patients bring
to the situation as well (Pasero & McCaffery, 2011).
Self Reported Pain
There is no objective biological marker or laboratory test for the
presence of pain. Thus, the patients’ self-report is considered the gold
standard for pain assessment (AGS Panel on Persistent Pain in Older Persons,
2002, AGS Panel on the Pharmacological Management of Persistent Pain in Older
Persons, 2009).
The first principle of pain assessment is to ask about the
presence of pain in regular and frequent intervals (Pasero & McCaffery,
2011). It is important to allow older adults sufficient time to process the
questions and formulate answers, especially when working with cognitively
impaired older adults.
It is also important to explore different words that patients
may use synonymously with pain, such as discomfort or aching.
Pain intensity can be measured in various ways. Some commonly used
tools include the numerical rating scale, the verbal descriptor scale, and the
faces scale (Herr, 2002a). The numerical rating scale (NRS) is widely used in
hospital settings. Patients are asked to rate the intensity of their pain on a
0-10 scale.
The NRS requires the ability to discriminate differences in pain
intensity and may be difficult for some older adults to complete. The verbal
descriptor scale, however, has been specifically recommended for use with older
adults (Herr, 2002a).
This tool measures pain intensity by asking participants
to select a word that best describes their present pain (eg, no pain to worst
pain imaginable). This measure has been found to be a reliable and valid
measure of pain intensity and is reported to be the easiest to complete and the
most preferred by older adults (Hen, Bjoro, & Decker, 2006).
Pictures of
faces are also used to measure pain intensity, especially among cognitively
impaired older adults. The Faces Pain Scale (FPS), initially developed to
assess pain intensity in children, consists of seven facial depictions, ranging
from the least pain to the most pain possible (Herr, Bjoro, & Decker,
2006).
Among adults, the FPS is considered more appropriate than other
pictorial scales because the cartoon faces are not age-, gender-, or
race-specific.
However, the FPS has relatively low reliability and validity
when used among older adults with cognitive impairment and is not recommended
for use in this population (Herr, Bjoro, & Decker, 2006). See the Resources
section for information on accessing these measurement tools.
Pain Indicators
Dementia compromises older adults’ ability to self-report pain. In
patients with dementia, and other patients who cannot provide self-report,
other assessment approaches must be used to identify the presence of pain. A
hierarchical pain assessment approach is recommended that includes four steps:
1. attempt to obtain a self-report of pain
2. search for an underlying cause of pain, such as surgery or a
procedure
3. observe for pain behaviors
4. seek input from family and caregivers (Herr, Coyne, et al.,
2006; Wells et al., 2008).
If any of these steps are positive, the nurse should
assume that pain is present and a trial of analgesics can be initiated. Pain
behaviors should be observed before and after the analgesic trial in order to
evaluate if the analgesic was effective or if a stronger dose is needed.
Observational techniques for pain assessment focus on behavioral or
nonverbal indicators of pain (Hadjistavropoulos et al., 2007; Herr, Coyne, et
al., 2006; Horgas et al., 2009).
Behaviors such as guarded movement, bracing,
rubbing the affected area, grimacing, painful noises or words, and restlessness
are often considered pain behaviors (Horgas & Elliott, 2004; Horgas et al.,
2009).
In the acute care setting, vital signs are often considered
physiological indicators of pain. It is important to note, however, that
elevated vital signs are not considered a reliable indicator of pain, although
they can be indicative of the need for pain assessment (Herr, Coyne, et al.,
2006; Pasero & McCaffery, 2011).
A number of observational measures have been developed over the
past decade. These behavioral tools are typically either pain behavior scales
(scored by identifying the number and intensity of behaviors) or pain
checklists (identifying the number and types of behaviors that individuals
display, without intensity ratings:Wells et al., 2008).
Although there is no
perfect behavioral measure of pain, three specific tools have been recommended
for use in patients who cannot self-report (Pasero & McCaffery, 2011).
These are the Checklist of Nonverbal Pain Indicators (CNPI; Feldt, 2000), the
Pain Assessment in Advanced Dementia (PAINAD) scale (Warden. Hurley, &
Volicer, 2003), and the Pain Assessment Checklist for Seniors with Severe
Dementia (PACSLAC; Fuchs-Lacelle & Hadjistavropoulos, 2004).
A
comprehensive review of these measures, as well as other similar tools, is
available on the City of Hope website (see Resources section).In addition, the
Hartford Institute for Geriatric Nursing provides online resources for pain
assessment in older adults with dementia that include information on the PAINAD
tool, and an instructional video on how to use it (see Resources section for
link).
Several caveats about observational tools must be noted:
(a) the
presence of these behaviors is suggestive of pain but is not always a reliable
indicator of pain
(b) the presence of pain behaviors does not provide
information about the intensity of pain ( Pasero & McCaffery, 2011; Wells
et al., 2008).
As such, pain behavior tools are one part of a comprehensive
pain assessment.In summary, pain assessment is a clinical procedure that can be
hampered by many factors. Systematic and thorough assessment, however, is a
critical first step in appropriately managing pain in older adults.
Assessment
issues are summarized in the recommended pain management protocol. The use of a
standardized pain assessment tool is important in measuring pain.
It enables
health care providers to document their assessment, measure change in pain,
evaluate treatment effectiveness, and communicate to other health care
providers, the patient, and the family.
Comprehensive pain assessment includes
measures of self-reported pain and pain behaviors. Information from family and
caregivers should also be obtained, although these data should be considered
supplemental rather than definitive (Horgas & Dunn, 2001).
Interventions And Care Strategies
Managing pain in older adults can be a challenging process. The
main goal is to maximize function and quality of life by minimizing pain
whenever possible (Herr, 2010; Wells et al., 2008).
Optimal pain treatment uses
a multimodal approach, tailored to the patient, that combines pharmacological
and nonpharmacological strategies (Wells et al., 2008). Pharmacological
interventions are an integral component of pain management in older adults
(Pasero & McCaffery, 2011).
Important considerations regarding the use of
pharmacological pain management must be taken into account. given the
physiological changes that occur with aging.
It should be emphasized that
pharmaceutical pain management is often more imperative in older adults with
dementia because their ability to participate in nonpharmacological pain
management strategies may be limited by their cognitive capacity (Buffum, Hutt,
Chang, Craine, & Snow, 2007). .
When choosing pain strategies, consideration should be given to
severity of pain because moderate and severe pain often require different
modalities in order to provide adequate pain relief.
Additionally, cognitive
impairments are often confused by visual and hearing impairments in older
adults. Therefore, to optimize pain relief while minimizing the potential for
poor outcomes, careful consideration should be given to an individual’s ability
to adhere to treatment (Pergolizzi et al., 2008).
Several excellent pain management guidelines and protocols have
been developed for use in the management of pain in older adults. For instance,
the AGS has recently updated their clinical practice guidelines for managing
persistent pain in older adults (AGS Panel on the Pharmacological Management of
Persistent Pain in Older Persons, 2009).
The consensus statement by the World
Health Organization (WHO) on the use of Step III opioids for chronic, severe
pain in older adults provides detailed guidelines pertaining to the assessment
of pain and use of opioids for cancer and non-cancer-related pain (Pergolizzi
et al., 2008).
In addition, there are other published guidelines for the
assessment and management of pain in specific diseases, such as osteoarthritis
(American Pain Society, 2002; American Pain Society Quality of Care Committee,
1995).
Pasero and McCaffery (2011) also provide one of the most comprehensive
guides for pain management, including a recently updated edition that addresses
pain management in older adults. See Resources section of Protocol 14.1 for
more information on accessing these resources.
Pharmacological Pain Treatment
Pain treatment with medications involves decision making based on
multiple considerations. Ideally, it is a mutual process among health care
providers, patients, and caregivers, with the goal of optimizing quality of
life and functioning (Wells et al., 2008).
An effective pain management
strategy includes a careful discussion of risks versus benefits, frequent
reviews of drug regimens used by older adults, and the establishment of clear
goals of therapy with the patient. It is often a process of trial and error
that aims to balance medication effectiveness with management of side effects.
Guiding principles for optimal pain management in older adults
include the following components (Buffum et al., 2007; Gordon et al., 2005).
First, the treatment of pain should be initiated immediately upon the detection
of pain.
Secondly, regularly scheduled (rather than “as-needed”) dosing of pain
medications should be employed.
Additionally, multiple modalities for the
evaluation of pain control should be used, including verbal, behavioral, and
functional responses to pain medication. Pain medication should be titrated
according to these responses, and a pain medication regimen should be chosen
based on what is known about each individual patient.
This includes the
severity of cognitive impairment and how this affects the patient’s ability to
express pain, interaction of pain medications with other medications, and
knowledge of pain medication side effects, such as constipation.
For individuals with cancer-related pain, the WHO provides a
three-step analgesic ladder that has been widely used as a guide for treating
pain in this population. Choices are made from three drug categories based on
pain severity: the nonopioids, opioids, and adjuvant agents.
Combinations of
drugs are used because two or more drugs can treat different underlying pain
mechanisms, different types of pain, and allow for smaller doses of each
analgesic to be used, thus minimizing side effects.
In 2008, the WHO
established guidelines for the use of Step III opioids (buprenorphine,
fentanyl, hydromorphone, methadone, morphine, and oxycodone) in older adults
with cancer and noncancer pain (Pergolizzi et al., 2008).
Their criteria for
the selection of analgesics in older adults with cancer are based on the type
of pain, efficacy of the medication, side-effect profile, potential for abuse,
and interactions with other medications (Pergolizzi et al., 2008).
These
guidelines make it clear that Step III opioids are the gold standard of
treatment for cancer pain and are also efficacious in non cancer diseases. The
authors point out, however, a dearth of specific studies investigating the use
of these drugs in older adults.
Special Considerations for Administering Analgesics
When considering the addition of pain medication to an older, and
potentially frail person’s medication regimen, several issues must be
evaluated. Confounding factors for medication side effects include
comorbidities, the use of multiple medications, and drug-to-drug interactions
(Klotz, 2009).
Normal physiological changes that occur with aging, superimposed
on comorbidities, place older adults at higher risk for side effects. Specific
age-related changes influence the pharmacodynamics (mechanisms of drug action
in the body) and pharmacokinetics (processes of drug absorption, distribution,
metabolism, and elimination in the body; Klotz, 2009).
Specific side effects to
consider when prescribing and/or administering pain medications to the older
adult include risks for sedation, mental status changes and cognition, balance,
and gastrointestinal side effects including bleeding and constipation (Buffum
et al., 2007).
Recommendations for beginning pain medication treatment include
starting at low doses and gradually titrating upward, while monitoring and
managing side effects. The adage “start low and go slow” is often used.
Titrate
doses upward to desired effect using short-acting medications first, and
consider using longer duration medications for long-lasting pain, once drug
tolerability has been established. For most older adults, choose a drug with a
short half-life and the fewest side effects if possible (Pasero &
McCaffery, 2011; Wells et al., 2008).
Multiple drug routes are available for administration of pain
medications. As long as patients are able to swallow safely, the oral route is
the first choice because it is the least invasive and very effective.
The onset
of action is within 30 minutes to 2 hours. For more immediate pain relief,
intravenous administration is recommended, particularly in the immediate
postoperative period. Intramuscular injections should be avoided in older
adults because of the potential for tissue injury and unpredictable absorption,
and because they produce pain.
Overall, adopting a preventive approach to pain
management, whenever possible, is recommended. By treating pain before it
occurs, less medication is required than to relieve it (Wells et al., 2008).
Examples of pain prevention are around-the-clock dosing and dosing prior to a
painful treatment or event.
Types of Analgesic Medications
The AGS has recently published updated guidelines for pain
management in older adults (AGS Panel on the Pharmacological Management of
Persistent Pain in Older Persons, 2009). Information on accessing these
guidelines is included in the Resources section at the end of this chapter.
The
guidelines provide comprehensive information about managing persistent pain,
but the recommendations apply to acute pain management as well. Thus, the
reader is referred to these guidelines for more comprehensive information.
Nonopioid Medications. Acetaminophen is considered the drug of
choice for mild-to-moderate pain in older adults (Herr, Bjoro, Steffensmeier,
et al., 2006). It is recommended that the total daily dose should not exceed 4
g per day (maximum 3 g/day in frail elders).
Because of the potential for
hepatic toxicity, the maximum dosage should be reduced by 50%-75% in adults
with impaired hepatic metabolism, renal disease, or a history of alcohol abuse
(Herr, Bjoro, Steffensmeier, et al., 2006).
Nonsteroidal anti-inflammatory drugs (NSAIDs), commonly used to
treat pain in the general population, are not recommended for use in persons
older than the age of 75 (Kuehn, 2009).
There are two types of NSAIDs:
nonselective (eg, ibuprofen, naproxen) and cyclooxygenase (COX)-2 selective
inhibitors. Several of the COX-2 drugs have been removed from the market
because of serious, life-threatening cardiovascular side effects, and those
that remain available should be used with caution and only within the
recommended dosages (AGS Panel on the Pharmacological Management of Persistent
Pain in Older Persons, 2009).
NSAIDs are associated with serious cardiovascular and
gastrointestinal side effects. and gastric damage is the most common side
effect. All adults older than the age of 65 are considered to be at moderate
risk for gastrointestinal side effects and should receive gastric protective
therapy with proton pump inhibitor (Kuehn, 2009).
Opioid Medications. Opioid drugs (eg, codeine and morphine) are
effective at treating moderate-to-severe pain from multiple causes. According
to the AGS (AGS Panel on the Pharmacological Management of Persistent Pain in
Older Persons, 2009), opioid analgesics can be used safely and effectively in
older adults if they are properly selected and monitored.
All providers caring
for older patients should prescribe opioids based on clearly defined
therapeutic goals. Prescribing should occur based on serial attempts to reach
these goals, with the lowest doses chosen based on efficacy and side effects.
Many older adults and health care providers are reluctant to use
opioids because of fears of addiction, side effects, and intolerance. Potential
side effects include nausea, pruritus, constipation, drowsiness, cognitive
effects, and respiratory depression.
The most serious side effect, respiratory
depression, is rare and can be mitigated by slow dose escalation and careful
monitoring for signs of sedation (AGS Panel on the Pharmacological Management
of Persistent Pain in Older Persons, 2009; Wells et al., 2008).
To prevent
constipation, preventive measures should be initiated when the opioid is
started (eg, stool softeners, adequate fluid intake, moderate activity; AGS Panel
on Persistent Pain in Older Persons, 2002).
conjunction with analgesics to relieve pain.
They are often administered with
nonopioids and opioids to achieve optimal pain control through additive
analgesic effects or to enhance response to analgesics, especially for
neuropathic pain (AGS Panel on Persistent Pain in Older Persons, 2002; Wells et
al., 2008).
Although tricyclic antidepressants (eg, nortriptyline, desipramine)
have shown dual effects on both pain and depression, they are inappropriate for
pain management in older adults because of high rates of serious
anticholinergic side effects (AGS Panel on the Pharmacological Management of
Persistent Pain in Older Persons, 2009; Fick et al., 2003).
With the advent of
antidepressants that exert serotonin reuptake inhibition, and mixed serotonin
and norepinephrine uptake inhibition.
Pain management with these types of
medications has become more common in older adults because they are effective
in the treatment of neuropathic pain and have a better side-effect profile (AGS
Panel on the Pharmacological Management of Persistent Pain in Older Persons,
2009).
Anticonvulsants (eg, gabapentin) may be used as adjuvant drugs for
neuropathic pain, such as trigeminal neuralgia and postherpetic neuralgia, and
they have fewer side effects than tricyclic antidepressants (AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons, 2009).
Local
anesthetics, such as lidocaine as a patch, gel, or cream, can be used as an
additional treatment for the pain of postherpetic neuralgia.
Equianalgesic refers to equivalent analgesia effects. Understanding
equianalgesic dosing (eg, dose conversion chart, conversion ratio) improves
prescribing practices for managing pain in older adults.
Equianalgesic dosing
charts provide lists of drugs and doses of commonly prescribed pain medications
that are approximately equal in providing pain relief and can provide practical
information for selecting appropriate starting doses when changing from one
drug to another or finding optimal drug combinations (AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons, 2009; Pasero
& McCaffery, 2011; Pasero, Portenoy, McCaffery, 1999).
Drugs to Avoid in Older Adults
Some medications should be generally avoided in older adults
because they are either ineffective for them or cause higher risk of having
side effects. Meperidine (Demerol), ketorolac (Toradol), and pentazocine
(Talwin) are considered inappropriate analgesic medications for older adults.
These
medications cause central nervous system side effects, including confusion or
hallucinations, and may not be effective enough when administered at the
commonly prescribed dose or may produce more side effects than positive
analgesic effect (Fick et al., 2003).
Additionally, sedatives, antihistamines,
and antiemetics should be used with caution because of long duration of action,
risk of failures, hypotension, anticholinergic effects, and sedating effects
(Gordon et al., 2005).
Non-Pharmacological Pain Treatment
Nondrug strategies are an important component of pain management.
Many older adults report using several nonpharmacological modalities to manage
pain (AGS Panel on Persistent Pain in Older Persons, 2002; Barry, Gill, Kerns,
& Reid. 2005; Herr, 2002b).
The most commonly reported nonpharmacological
strategies used in the acute care setting were relaxation (eg, breathing,
meditation, imagery, music), activity modification, massage, and heat or cold
application (Wells et al., 2008).
Older adult patients should be encouraged to
use nonpharmacological treatment in combination with pharmacological treatment.
Types of Non-Pharmacological Treatment Strategies
Nonpharmacological pain treatment strategies generally fall into
two major categories: physical pain relief modalities and psychological pain
relief modalities. Physical pain relief modalities include, but are not limited
to, transcutaneous electrical nerve stimulation (TENS), physical therapies, use
of heat and cold, massage, and movement.
Psychological pain relief modalities
focus on changes in the person’s perception of the pain and improvement of
coping strategies (Rudy, Hanlon, & Markham, 2002). These include
relaxation, distraction, guided imagery, and hypnosis.
Cognitive behavioral
treatment, meditation, and biofeedback are strategies used for persistent pain.
Various types of dietary supplements are also commonly used nonpharmacological
pain treatments among older adults. To date, a few of these nonpharmacological
strategies have been empirically evaluated for their effectiveness in pain
management (Wells et al., 2008).
For persistent pain, several physical strategies such as exercise,
electrical stimulation (eg. TENS), and low-level laser therapy have been
evaluated, but the results are equivocal (Furlan, Imamura, Dryden, & Irvin,
2009).
The AGS Panel on Exercise and Osteoarthritis (2001) provided guidelines
of exercise prescriptions for older adults with osteoarthritis pain.
Recommendations should be individualized based on the person’s comorbidities,
adherence, personal preference, and feasibility of exercise.
Massage therapy
may be effective to manage chronic low back pain and can be more beneficial
when it is combined with education and exercise (Furlan et al., 2009). Despite
many trials of tai chi, the effectiveness of this intervention for chronic pain
in older adults is still inconclusive because of methodological issues in the
studies (Hall, Maher, Latimer, & Ferreira, 2009).
Electrical stimulation,
including TENS, has shown significant benefits for shoulder pain after stroke
(Price & Pandyan, 2001).
Psychological pain relief modalities, such as cognitive behavioral
therapy, biofeedback, and meditation, are commonly used for persistent pain
(Middaugh & Pawlick, 2002).
Cognitive behavioral treatments, including
relaxation, guided imagery, and meditation, have also shown significant
improvement in pain and mobility due to osteoarthritis among older adults
(Baird, Murawski, & Wu, 2010).
In the acute care setting, relaxation,
massage, and music are often used to help manage acute pain (Wells et al.,
2008). Each of these nondrug approaches has demonstrated mixed results, largely
because of individual patient preferences and methodological differences in how
the studies were conducted.
Thus, there is no conclusive evidence that these
modalities relieve pain. Instead, they should be considered on an
individualized basis, depending on patient preference and response, and as an
adjunct to pharmacological treatment.
In summary, nonpharmacological treatments are widely used comfort
measures to help manage pain. These approaches are challenging to study because
it is difficult to find a convincing placebo and to control the dose of the
treatment.
In addition, studies have contributed inconsistent findings because
of differences in study designs, inconsistent measures, and mixed intervention
durations.
Despite the lack of rigorous support for these nondrug approaches,
older adults express interest in using these strategies to manage their pain
(Dunn & Horgas, 2000; Herr, 2002b; Horgas & Elliott, 2004). Thus,
nurses should consider all possible options for managing pain and discuss these
approaches with their older adult patients.
Special Considerations of Using
Nonpharmacological Treatment for Older AdultsIndividuals vary widely in their preferences for and ability to use
nonpharmacological interventions to manage pain. Spiritual and/or religious
coping strategies, for instance, must be consistent with individual values and
beliefs.
Other strategies, such as guided imagery, biofeedback, or relaxation,
may not be feasible for cognitively impaired older adults. Therefore, it is
important for health care providers to consider a broad array of
nonpharmacological pain management strategies and to tailor selections to the
individual.
It is also important to gain individual and family input about the
use of home and folk remedies because use of herbals or home remedies is often
not disclosed to health care providers and may result in negative drug-herb
interactions (Yoon & Horne, 2001; Yoon , Horne, & Adams, 2004; Yoon
& Schaffer, 2006).
Improving Pain Management In Care Settings
Nurses have a critical role in assessing and managing pain. The
promotion of comfort and relief of pain is fundamental to nursing practice and,
as integral members of interdisciplinary health care teams, nurses must work
collaboratively to effectively assess and treat pain.
Given the prevalence of
pain in older adults and the burgeoning aging population seeking care in our
health care systems, this nursing role is vitally important. In addition,
nurses have the primary responsibility to teach the patient and family about
pain and how to manage it both pharmacologically and non-pharmacologically.
As
such, nurses must be knowledgeable about pain management in general, and about
managing pain in older adults in particular. Furthermore, nurses are
responsible for basing their practice on the best evidence available, and
helping to bridge the gap between evidence, recommendations, and clinical
practice.
Nurses, however, must work within an organizational climate that
supports and encourages efforts to improve pain management. These efforts must
go beyond simply distributing guidelines and recommendations because this
approach has not been effective (Dirks, 2010).
Some quality improvement
processes that should be considered in promoting improved pain management
include the following (Dirks, 2010):
1. Facilities/institutions must demonstrate and maintain strong
institutional commitment and leadership to improve pain management.
2. Facilities/institutions will establish an internal pain team of
committed and knowledgeable staff who can lead quality improvement efforts to
improve pain management practices.
3. Facilities/institutions must establish evidence of documentation
of pain assessment. intervention, and evaluation of treatment effectiveness.
This includes adding pain assessment and reassessment questions to flow sheets
and electronic forms.
4. Facilities/institutions will provide evidence of using a multispecialty
approach to pain management. This includes referral to specialists for specific
therapies (eg psychiatry, psychology, physical therapy, interdisciplinary pain
treatment specialists). Clinical pathways and decision support tools will be
developed to improve referrals and multispecialty consultation.
5. Facilities/institutions will provide evidence of pain management
resources for staff (eg, educational opportunities; print materials, access to
web-based guidelines and information).