Improving the pharmacologic management of pain in older adults: identifying the research gaps and methods to address them.

OBJECTIVE: There has been a growing recognition of the need for better pharmacologic management of chronic pain among older adults. To address this need, the National Institutes of Health Pain Consortium sponsored an "Expert Panel Discussion on the Pharmacological Management of Chronic Pain in Older Adults" conference in September 2010 to identify research gaps and strategies to address them. Specific emphasis was placed on ascertaining gaps regarding use of opioid and nonsteroidal anti-inflammatory medications because of continued uncertainties regarding their risks and benefits. DESIGN: Eighteen panel members provided oral presentations; each was followed by a multidisciplinary panel discussion. Meeting transcripts and panelists' slide presentations were reviewed to identify the gaps and the types of studies and research methods panelists suggested could best address them. RESULTS: Fifteen gaps were identified in the areas of treatment (e.g., uncertainty regarding the long-term safety and efficacy of commonly prescribed analgesics), epidemiology (e.g., lack of knowledge regarding the course of common pain syndromes), and implementation (e.g., limited understanding of optimal strategies to translate evidence-based pain treatments into practice). Analyses of data from electronic health care databases, observational cohort studies, and ongoing cohort studies (augmented with pain and other relevant outcomes measures) were felt to be practical methods for building an age-appropriate evidence base to improve the pharmacologic management of pain in later life. CONCLUSION: Addressing the gaps presented in the current report was judged by the panel to have substantial potential to improve the health and well-being of older adults with chronic pain.

Assessing pain in the elderly.

OBJECTIVE: Summarize practical strategies for recognizing and assessing pain in the long-term care population, particularly for cognitively impaired residents. DATA SOURCES: Live symposium presentation based on clinical practice and research and current clinical guidelines. CONCLUSIONS: Pain that is under-recognized and undertreated can result in significant physical and social disability in the elderly long-term care population. Proper assessment of pain is needed to diagnose and determine an appropriate and individualized treatment plan for each resident. Consultant pharmacists play critical roles as medication experts and members of the long-term care interdisciplinary team that can assist other team members in the assessment, treatment, and management of pain in older adults.

The relationship of reported pain severity to perceived effect on function of nursing home residents.

BACKGROUND: We examined whether questions addressing the effect of pain on day-to-day function add unique information to the standardized verbal descriptor scale for pain severity in nursing homes (NHs). METHODS: Interviews were conducted with 123 residents in two Veterans Affairs NHs. All participants were asked about pain presence. Residents reporting pain were asked about severity of worst pain (mild, moderate, severe, very severe/horrible), degree of bother (not at all, a little, a moderate amount, a great deal), and the effect of pain on daily function (whether pain made it hard to "sleep," "get out of bed," or "spend time with other people" and whether activities were limited because of pain). RESULTS: Fifty-one percent of participants reported pain. The correlation between pain severity report and overall count of activity interference was significant (Spearman's rho=.449, p=.001). In general, for each activity, the proportion reporting interference increased as severity increased. Fischer's exact test showed significant association only for "hard to get out of bed" (p=.0175) and "hard to sleep" (p=.0211). As expected, residents reporting "mild" pain reported less activity interference than those reporting "very severe" pain. The association between pain and activity interference was more variable and less predictable among residents with "moderate" or "severe" pain. CONCLUSION: Questions addressing the effect of pain on day-to-day functions are an important addition to standardized pain assessments, particularly for persons who report intermediate levels of pain severity because the perceived effect on daily function may vary most among individuals at these levels.

The self-administered 24-item geriatric pain measure (GPM-24-SA): psychometric properties in three European populations of community-dwelling older adults.

OBJECTIVE: To explore the feasibility and psychometric properties of a self-administered version of the 24-item Geriatric Pain Measure (GPM-24-SA). DESIGN: Secondary analysis of baseline data from the Prevention in Older People-Assessment in Generalists' practices trial, an international multi-center study of a health-risk appraisal system. PARTICIPANTS: One thousand seventy-two community dwelling nondisabled older adults self-reporting pain from London, UK; Hamburg, Germany; and Solothurn, Switzerland. OUTCOME MEASURES: GPM-24-SA as part of a multidimensional Health Risk Appraisal Questionnaire including self-reported demographic and health-related information. RESULTS: Among the 1,072 subjects, 655 had complete GPM-24-SA data, 404 had 30% missing GPM-24-SA data. In psychometric analyses across the three European populations with complete GPM-24-SA data, the measure exhibited stable internal consistency, good convergent, divergent and discriminant validity, and produced stable pain measurements. However, factor analysis indicated differences in the GPM-24-SA across sites with discrepancies mainly related to items of a single subscale that failed to load appropriately. Analyses including imputation for subjects with

Rheumatic diseases in the elderly: assessing chronic pain.

This article discusses the assessment of chronic pain in older patients. First, the epidemiology and impact of chronic pain in the elderly are addressed. Next, common barriers to pain assessment are reviewed. An effective approach to pain assessment in the older patient is described, including the important pearls of history-taking and the physical examination, as well as recommendations for the evaluation of functional status and psychosocial well-being. The article concludes with a review of multidimensional and unidimensional pain assessment tools, and a discussion of methods for pain assessment in the cognitively impaired.

An interdisciplinary expert consensus statement on assessment of pain in older persons.

This paper represents an expert-based consensus statement on pain assessment among older adults. It is intended to provide recommendations that will be useful for both researchers and clinicians. Contributors were identified based on literature prominence and with the aim of achieving a broad representation of disciplines. Recommendations are provided regarding the physical examination and the assessment of pain using self-report and observational methods (suitable for seniors with dementia). In addition, recommendations are provided regarding the assessment of the physical and emotional functioning of older adults experiencing pain. The literature underlying the consensus recommendations is reviewed. Multiple revisions led to final reviews of 2 complete drafts before consensus was reached.

Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic.

PURPOSE: To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic. METHODS: We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies. RESULTS: Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff). CONCLUSION: An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.

Palliative Care Professional Development for Critical Care Nurses: A Multicenter Program.

BACKGROUND: Integrating palliative care into intensive care units (ICUs) requires involvement of bedside nurses, who report inadequate education in palliative care. OBJECTIVE: To implement and evaluate a palliative care professional development program for ICU bedside nurses. METHODS: From May 2013 to January 2015, palliative care advanced practice nurses and nurse educators in 5 academic medical centers completed a 3-day train-the-trainer program followed by 2 years of mentoring to implement the initiative. The program consisted of 8-hour communication workshops for bedside nurses and structured rounds in ICUs, where nurse leaders coached bedside nurses in identifying and addressing palliative care needs. Primary outcomes were nurses' ratings of their palliative care communication skills in surveys, and nurses' identification of palliative care needs during coaching rounds. RESULTS: Each center held at least 6 workshops, training 428 bedside nurses. Nurses rated their skill level higher after the workshop for 15 tasks (eg, responding to family distress, ensuring families understand information in family meetings, all P < .01 vs preworkshop). Coaching rounds in each ICU took a mean of 3 hours per month. For 82% of 1110 patients discussed in rounds, bedside nurses identified palliative care needs and created plans to address them. CONCLUSIONS: Communication skills training workshops increased nurses' ratings of their palliative care communication skills. Coaching rounds supported nurses in identifying and addressing palliative care needs.

ICU Bedside Nurses' Involvement in Palliative Care Communication: A Multicenter Survey.

CONTEXT: Successful and sustained integration of palliative care into the intensive care unit (ICU) requires the active engagement of bedside nurses. OBJECTIVES: To describe the perspectives of ICU bedside nurses on their involvement in palliative care communication. METHODS: A survey was designed, based on prior work, to assess nurses' perspectives on palliative care communication, including the importance and frequency of their involvement, confidence, and barriers. The 46-item survey was distributed via e-mail in 2013 to bedside nurses working in ICUs across the five academic medical centers of the University of California, U.S. RESULTS: The survey was sent to 1791 nurses; 598 (33%) responded. Most participants (88%) reported that their engagement in discussions of prognosis, goals of care, and palliative care was very important to the quality of patient care. A minority reported often discussing palliative care consultations with physicians (31%) or families (33%); 45% reported rarely or never participating in family meeting discussions. Participating nurses most frequently cited the following barriers to their involvement in palliative care communication: need for more training (66%), physicians not asking their perspective (60%), and the emotional toll of discussions (43%). CONCLUSION: ICU bedside nurses see their involvement in discussions of prognosis, goals of care, and palliative care as a key element of overall quality of patient care. Based on the barriers participants identified regarding their engagement, interventions are needed to ensure that nurses have the education, opportunities, and support to actively participate in these discussions.

Multidimensional attitudes of medical residents and geriatrics fellows toward older people.

OBJECTIVES: To examine dimensions of a validated instrument measuring geriatric attitudes of primary care residents and performances on these dimensions between residents and fellows. DESIGN: Cross-sectional and longitudinal studies. SETTING: An academic medical center. PARTICIPANTS: Two hundred thirty-eight primary care residents (n=177) and geriatrics fellows (n=61) participated in the study from 1995 to 2000. MEASUREMENTS: A 14-item, 5-point Likert scale previously validated for measuring primary care residents' attitudes toward older people and geriatric patient care was used. RESULTS: Factor analysis showed four dimensions of the scale, labeled Social Value, Medical Care (MC), Compassion (CP), and Resource Distribution, which demonstrated acceptable reliability. Both groups of subjects showed significantly (P<.001) positive (mean>3) attitudes across the dimensions and times, except for residents, who had near-neutral (mean=3) attitudes on MC. Residents' mean attitude scores on the overall scale and the MC and CP subscales were significantly (P<.001) lower than those of fellows over time. Residents and fellows showed different change patterns in attitudes over time. Residents' attitudes generally improved during the first 2 years of training, whereas fellows' attitudes declined slightly. Personal experience was a strong predictor of residents' attitudes toward older patients. Ethnicity, academic specialty, professional experience, and career interest in geriatrics were also associated with residents' attitude scores. CONCLUSION: The multidimensional analysis of the scale contributes to better understanding of medical trainees' attitudes and sheds light on educational interventions.

Rheumatic diseases in the elderly: assessing chronic pain.

This article will discuss the assessment of chronic pain in older patients. First, the epidemiology and impact of chronic pain in the elderly will be addressed. Next, common barriers to pain assessment will be reviewed. An effective approach to pain assessment in the older patient will then be described, including important pearls for history-taking and the physical examination, as well as recommendations for the evaluation of functional status and psychosocial well-being. The article will conclude with a review of multidimensional and unidimensional pain assessment tools and a discussion of methods for pain assessment in the cognitively impaired.

Development and validation of a geriatric knowledge test for medical students.

OBJECTIVES: To assesses the reliability and validity of a geriatrics knowledge test designed for medical students. DESIGN: Cross-sectional studies. SETTING: An academic medical center. PARTICIPANTS: A total of 343 (86% of those sampled) medical students participated in the initial study, including 137 (76%) first-year, 163 (96%) third-year, and 43 (86% of those sampled) fourth-year students in the 2000-2001 academic year. To cross-validate the instrument, another 165 (92%) third-year and 137 (76%) first-year students participated in the study in the 2001-2002 academic year. MEASUREMENTS: An 18-item geriatrics knowledge test was developed. The items were selected from a pool of 23 items. An established instrument assessing the clinical skills of medical students was included in the validation procedure. RESULTS: The instrument demonstrated good reliability (Cronbach alpha=0.80) and known-groups and concurrent validity. Geriatrics knowledge scores increased progressively with the higher level of medical training (mean percentage correct=31.3, 65.3, and 66.5 for the first-year, third-year, and fourth-year classes, respectively, P<.001). A significant (P<.01) relationship was found between the third-year students' geriatrics knowledge and their clinical skills. Similar results, except the relationship between knowledge and clinical skills, were found in the cross-validation study, supporting the reliability and known-groups validity of the test. CONCLUSION: The 18-item geriatrics knowledge test demonstrated sound reliability and validity. The average scores of the student groups indicated substantial room for growth. The relationship between geriatrics knowledge and overall clinical skills needs further investigation.

Pharmacotherapy of pain in depressed older adults.

OBJECTIVES: To examine pharmacotherapy for pain in a sample of 1,801 depressed older primary care patients. DESIGN: Cross-sectional survey data collected from 1999 to 2001. SETTING: Eighteen primary care clinics belonging to eight healthcare organizations in five states. PARTICIPANTS: One thousand eight hundred one patients aged 60 and older who met diagnostic criteria for major depression or dysthymia. MEASUREMENTS: Diagnoses or treatment for chronic pain, functional impairment from pain, and use of over-the-counter and prescription analgesic medications. RESULTS: One thousand four hundred sixteen (79%) participants reported functional impairment from pain in the previous month, and 1,024 (57%) reported a diagnosis of or treatment for chronic pain in the previous 3 years. Fifty-one percent of those with recent functional impairment from pain reported any analgesic use, ranging from 31% to 75% across the participating healthcare organizations. Opioid analgesic use varied from 5% to 34%. Predictors of analgesic use included a history of chronic pain or arthritis and the degree of functional impairment from pain in the previous month. Differences in analgesic use across participating organizations remained significant after adjusting for clinical and demographic covariates. CONCLUSION: Most depressed older adults in the sample reported recent functional impairment from pain and a history of chronic pain, but almost half of those with functional impairment from pain did not report using analgesic medications. Participating organizations varied substantially in their use of analgesics, suggesting that there is room to improve the quality of pain management in depressed older adults.

Adherence to pressure ulcer prevention guidelines: implications for nursing home quality.

OBJECTIVES: This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs. DESIGN: Review of NH medical records. SETTING: A geographically diverse sample of 35 Veterans Health Administration NHs. PARTICIPANTS: A nested random sample of 834 residents free of PU on admission. MEASUREMENTS: Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical. RESULTS: Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P <.001) and from 24% to 75% across the six key recommendations (P <.001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated. CONCLUSIONS: NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.

The quality of medical care provided to vulnerable older patients with chronic pain.

OBJECTIVES: To assess the quality of chronic pain care provided to vulnerable older persons. DESIGN: Observational study evaluating 11 process-of-care quality indicators using medical records and interviews with patients or proxies covering care received from July 1998 through July 1999. SETTING: Two senior managed care plans. PARTICIPANTS: A total of 372 older patients at increased risk of functional decline or death identified by interview of a random sample of community dwellers aged 65 and older enrolled in these managed-care plans. MEASUREMENTS: Percentage of quality indicators satisfied for patients with chronic pain. RESULTS: Fewer than 40% of vulnerable patients reported having been screened for pain over a 2-year period. One hundred twenty-three patients (33%) had medical record documentation of a new episode of chronic pain during a 13-month period, including 18 presentations for headache, 66 for back pain, and 68 for joint pain. Two or more history elements relevant to the presenting pain complaint were documented for 39% of patients, and at least one relevant physical examination element was documented for 68% of patients. Treatment was offered to 86% of patients, but follow-up occurred in only 66%. Eleven of 18 patients prescribed opioids reported being offered a bowel regimen, and 10% of patients prescribed noncyclooxygenase-selective nonsteroidal antiinflammatory medications received appropriate attention to potential gastrointestinal toxicity. CONCLUSION: Chronic pain management in older vulnerable patients is inadequate. Improvement is needed in screening, clinical evaluation, follow-up, and attention to potential toxicities of therapy.

The management of pain in long-term care.

OBJECTIVE: The purpose of this paper is to present salient principles of pain management in nursing homes and other long-term care settings. METHODS: Review and author opinion. RESULTS: Pain is a common problem in nursing homes and other long-term care facilities. Often unrecognized and under-treated, pain is a major source of suffering and functional impairment. These patients present substantial barriers to pain assessment and management. Multiple concurrent disease processes, cognitive impairment and communication difficulties, and limited access to diagnostic technologies make assessment more difficult. Multiple medications, altered physiology and pharmacology and limited access to a variety of drug and non-drug interventions make treatment strategies more difficult to implement. DISCUSSION: Clinicians who care for patients receiving long-term care services must help establish a treatment plan that is reasonable given the limited resources and skills available in nursing homes and other long-term care facilities. Medication regimens should be simplified as much as possible. Contingency plans for pain management must be anticipated and made available so that delays do not occur during medication changes or dosage adjustments. Long-term care facilities need substantial support from physicians and other pain experts for education to continuously update their skills and knowledge. As the need for health systems for frail elderly persons continues to grow, it is important to provide comfort and effective pain control appropriate for these new settings.

Effects of a controlled exercise trial on pain in nursing home residents.

OBJECTIVES: To report preliminary data relevant to the effects of an exercise and toileting intervention on pain among incontinent nursing home (NH) residents. DESIGN: A randomized controlled intervention trial. SETTING AND PARTICIPANTS: Fifty-one incontinent residents in one skilled NH. INTERVENTION: The intervention was implemented by research staff for a total of 4 times a day (every 2 hours), 5 days a week, for 32 weeks. Residents were provided with incontinence care and assistance to either walk or, if nonambulatory, wheel their chairs, and to repeat sit-to-stand movements. MEASUREMENTS: Pain was measured in two ways at baseline and again at 32 weeks: (1) a count of the number of verbal expressions and pain behaviors during a standardized physical performance assessment; and (2) a modified Geriatric Pain Measure administered in a one-on-one interview format. RESULTS: There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. Both groups showed mild to moderate pain at baseline according to each of the two pain measures, while there were no significant changes in pain reports between groups over time based on either measure. There was, however, a trend for pain to increase in the intervention group. CONCLUSIONS: No significant changes in pain reports were attributable to exercise despite significant improvements in physical performance. In fact, there was a tendency for pain reports to increase with exercise. These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent NH residents. Care providers should consider that exercise to improve physical function may increase pain symptoms, requiring preemptive analgesia, other pain control strategies, or modified exercise techniques for this frail segment of the NH population.

The intersection of need and opportunity: assessing and capitalizing on opportunities to expand hospital-based palliative care services.

BACKGROUND: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution. It also helps a palliative care team decide which, among many potential opportunities and possible initiatives, is the one most likely to be supported by the institution and have a recognized and significant impact. SUBJECTS AND METHODS: We present five case studies to demonstrate how successful programs identify and address institutional needs to create opportunities for palliative care program growth. These case studies can serve as models for other programs seeking to develop or expand their palliative care services.