Using a healing touch intervention in older adults with persistent pain: a feasibility study.

The purposes of this pilot study were to determine the feasibility of using a Healing Touch (HT) intervention with noncommunity-dwelling older adults experiencing persistent pain and to determine an HT protocol. Data were collected at multiple time points from 20 noncommunity-dwelling older adults experiencing pain. Residents were assigned to the HT group that included techniques specific for pain or a Presence Care group. Outcome variables included measures for pain, activities of daily living, and quality of life. The pain measures showed decreases that were not statistically significant for both groups. The measure for activities of daily living showed a non-statistically significant improvement over time for the HT group. Quality of life decreased for the HT group and improved for the Presence Care group although not significantly. The practitioners were able to complete all seven of the 30- minute HT sessions. The findings indicated that both groups showed some improvement in their pain scores with other measures being variable. HT is a feasible intervention for the elderly with pain. Overall, the findings highlight the complex nature of pain in older adults.

Healing touch for older adults with persistent pain.

The purpose of this report was to provide an in-depth review of responses from older adults residing in long-term care facilities receiving Healing Touch (HT) for pain management. Persistent pain is common in this population and, while the mainstay for pain management is analgesics, HT may provide supportive therapy. Twenty older adults from 5 facilities in the southwestern United States participated in the study, with 12 receiving the active intervention of HT and 8 receiving the control of presence care. A convergent mixed-methods approach was used in this secondary report, using the providers' descriptions of 84 HT sessions and quantitative findings to provide an in-depth within-case analysis. Outcome measures included quantitative measures of pain, daily living, and quality of life, as well as qualitative descriptors of the HT sessions. The findings suggest that the experience is highly varied and on a continuum from no perceived or noticeable benefit to a decrease in pain and improvement in other physiological and psychosocial symptoms. Therefore, HT may be beneficial for some older adults within long-term care facilities as an adjunct for chronic pain.

Behavioral indicators of postoperative pain in older adults with delirium.

The undertreatment of postoperative pain in older adults with delirium is attributed, in part, to the inability to complete self-report pain assessment instruments. Patients' loss of verbal skills to self-report pain and the lack of reliable and valid postoperative pain assessment instruments for use in older adults with delirium prompted the design of a study to identify common and subtle behavioral indicators of pain. Sixteen experienced registered nurses participating in four focus groups identified behavioral indicators of pain.Transcript analysis resulted in 89 behaviors indicative of pain. Seven researchers with expertise in pain and cognitive impairment in older adults reached 80% agreement on 22 behavioral indicators. The behavioral indicators were classified within one of four pain behavior categories (nonverbal cues/behaviors, vocalizations, facial expressions, and change in usual behavior), and each behavioral indicator was identified as common or subtle. Findings provide evidence of content validity for the pain behaviors.

Evaluation of musculoskeletal pain management practices in rural nursing homes compared with evidence-based criteria.

Chronic pain, mainly associated with musculoskeletal diagnoses, is inadequately and often inappropriately treated in nursing home residents. The purpose of this descriptive study is to identify the musculoskeletal diagnoses associated with pain and to compare pain management of a sample of nursing home residents with the 1998 evidence-based guideline proposed by the American Geriatrics Society (AGS). The sample consists of 215 residents from 13 rural Iowa nursing home homes. The residents answered a series of face-to-face questions that addressed the presence/absence of pain and completed the Mini Mental State Examination (MMSE). Data on pain were abstracted from the Minimum Data Set (MDS). Analyses included descriptive statistics, cross tabulations, and one-way analysis of variance. Residents' responses to the face-to-face pain questions yielded higher rates of pain compared with the MDS pain data. Resident records showed that acetaminophen was the most frequently administered analgesic medication (30.9%). Propoxyphene, not an AGS-recommended opioid, was also prescribed for 23 residents (10.7%). Of the 70 residents (32.6%) expressing daily pain, 23 (32.9%) received no scheduled or pro re nata analgesics. There was no significant difference between MMSE scores and number of scheduled analgesics. Additionally, residents' self-reported use of topical agents was not documented in the charts. The findings suggest that the 1998 AGS evidence-based guideline for the management of chronic pain is inconsistently implemented.

Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review.

To improve assessment and management of pain in nonverbal older adults with dementia, an effective means of recognizing and evaluating pain in this vulnerable population is needed. The purpose of this review is to critically evaluate the existing tools used for pain assessment in this population to provide recommendations to clinicians. Ten pain assessment tools based on observation of behavioral indicators for use with nonverbal older adults with dementia were evaluated according to criteria and indicators in five areas: conceptualization, subjects, administration, reliability, and validity. Results indicate that although a number of tools demonstrate potential, existing tools are still in the early stages of development and testing. Currently, there is no standardized tool based on nonverbal behavioral pain indicators in English that may be recommended for broad adoption in clinical practice.

Bioelectrical impedance analysis and other hydration parameters as risk factors for delirium in rural nursing home residents.

BACKGROUND: The study investigators conducted a vigorous screening protocol for delirium in rural long-term care (LTC) facilities for a period of 28 days focusing on Bioelectrical Impedance Analysis (BIA) and other hydration parameters as risk factors. METHODS: A two-stage cluster sampling procedure was used to randomly select participants (n = 313) from 13 LTC facilities located in southeastern Iowa, stratified on facility bed size. BIA was used to estimate intracellular water (ICW), extracellular water (ECW), and total body water (TBW) on four occasions--baseline and follow-up days 7, 14, and 28. Volume estimates were calculated as a percent of body weight (%WT). Serum electrolytes and hematology were also measured. Delirium was measured with four strict criteria: a NEECHAM Confusion Scale score < 25, Vigilance "A" score > 2, a Mini-Mental Status Examination < baseline, and a positive Confusion Assessment Method score. RESULTS: There were n = 69 delirium cases (22.0%). Blood urea nitrogen/creatinine ratios greater than 21:1 (odds ratio = 1.76, 95% confidence interval 1.02-3.06). No significant risk for delirium was associated with ICW, ECW, or TBW as a percent of body weight. CONCLUSIONS: Some changes were observed with a slight decrease in ICW between day 7 and day 14 of follow-up that tended to follow an increase in delirium events, but in general the BIA measures did not predict delirium events.

Caring for the incontinent elder: advanced practice nursing concepts.

Urinary incontinence (UI) in the older adult is a multisystem health problem that has an impact on the lives of millions of older adults. Advanced practice nurses (APNs) specializing in gerontology,family, and adult practice are equipped educationally with the expertise to prevent, assess, and manage this health problem. The emerging emphasis on UI prevention will help guide the practice of APNs in the future. APNs will serve older adults well in prevention and management of UI by capitalizing on their roles as expert clinicians, researchers, consultants, educators, and collaborators with the interdisciplinary teams.

The unequal burden of pain: confronting racial and ethnic disparities in pain.

CONTEXT: Pain has significant socioeconomic, health, and quality-of-life implications. Racial- and ethnic-based differences in the pain care experience have been described. Racial and ethnic minorities tend to be undertreated for pain when compared with non-Hispanic Whites. OBJECTIVES: To provide health care providers, researchers, health care policy analysts, government officials, patients, and the general public with pertinent evidence regarding differences in pain perception, assessment, and treatment for racial and ethnic minorities. Evidence is provided for racial- and ethnic-based differences in pain care across different types of pain (i.e., experimental pain, acute postoperative pain, cancer pain, chronic non-malignant pain) and settings (i.e., emergency department). Pertinent literature on patient, health care provider, and health care system factors that contribute to racial and ethnic disparities in pain treatment are provided. EVIDENCE: A selective literature review was performed by experts in pain. The experts developed abstracts with relevant citations on racial and ethnic disparities within their specific areas of expertise. Scientific evidence was given precedence over anecdotal experience. The abstracts were compiled for this manuscript. The draft manuscript was made available to the experts for comment and review prior to submission for publication. CONCLUSIONS: Consistent with the Institute of Medicine's report on health care disparities, racial and ethnic disparities in pain perception, assessment, and treatment were found in all settings (i.e., postoperative, emergency room) and across all types of pain (i.e., acute, cancer, chronic nonmalignant, and experimental). The literature suggests that the sources of pain disparities among racial and ethnic minorities are complex, involving patient (e.g., patient/health care provider communication, attitudes), health care provider (e.g., decision making), and health care system (e.g., access to pain medication) factors. There is a need for improved training for health care providers and educational interventions for patients. A comprehensive pain research agenda is necessary to address pain disparities among racial and ethnic minorities.

The development and testing of the PATCOA to assess pain in confused older adults.

The purposes of this study were to develop and evaluate the psychometric properties of an instrument with nonverbal cues to assess pain in confused older adults, and to describe the differences among selected demographic variables and scores on the pain and confusion measures. The Pain Assessment Tool in Confused Older Adults (PATCOA) was evaluated with 116 cognitively intact older adults undergoing orthopedic surgery. The interrater reliability for each nonverbal cue ranged from 56.5% to 100%, and the Spearman correlations were .16 to 1.00. Nine nonverbal pain cues were subjected to exploratory factor analysis. Four components explained 69.83% variance. Older adults reported significantly higher levels of pain on the visual analog scale, yet age was not related to the nonverbal pain cues. Women reported significantly more pain than did men. No significant gender differences were found regarding the display of nonverbal pain cues and the level of acute confusion, or with race and self-report of pain, display of nonverbal pain cues, or level of confusion. The development and testing of the PATCOA are initial steps that contribute to our knowledge about acute pain assessment in confused older adults.