Uplifts and hassles are related to worsening in chronic fatigue syndrome: a prospective study.

BACKGROUND: Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS. METHODS: Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N = 128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts. RESULTS: No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups (p < 0.001). Non-social hassles intensity showed an increasing slope for the worsened group (p = 0.03) and a decreasing slope (p = 0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social (p = 0.01) uplifts. CONCLUSION: Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial registration ClinicalTrials.gov ID: NCT02948556.

Uplifts and hassles are related to worsening in chronic fatigue syndrome A prospective study.

Background: Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS. Methods: Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N=128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts. Results: No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups ( p <.001). Non-social hassles intensity showed an increasing slope for the worsened group ( p =.03) and a decreasing slope ( p =0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social ( p =0.01) uplifts. Conclusion: Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial Registration: ClinicalTrials.gov ID: NCT02948556.

Lessening the Impact of Opioid Misuse at a Federally Qualified Health Center in New York: Outcomes of an Integrated Workforce Training Program.

The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.

Assessing Pain in Older Adults: Caregivers play a key role in recognizing and documenting pain at home.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Horgas, A.L., et al. Assessing Pain in Older Adults. Am J Nurs 2022; 122 (12): 42-48.

Sex differences in post-exercise fatigue and function in myalgic encephalomyelitis/chronic fatigue syndrome.

To assess biobehavioral sex differences in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) utilizing a low burden exercise protocol, 22 females and 15 males with ME/CFS and 14 healthy controls underwent two six-min walk tests. Fifteen daily assessments were scheduled for fatigue and function ratings and heart monitoring. Six-min walk tests were conducted on days 8 and 9. The ME/CFS group showed high self-report fatigue and impaired physical function, whereas healthy controls did not show fatigue or function abnormalities. In patients, no significant post-exercise changes were found for heart rate variability (HRV); however, heart rate decreased in ME/CFS males from Day 14 to Day 15 (p = 0.046). Female patients showed increased fatigue (p = 0.006) after the initial walk test, but a downward slope (p = 0.008) in fatigue following the second walk test. Male patients showed a decrease in self-report work limitation in the days after exercise (p = 0.046). The healthy control group evidenced a decrease in HRV after the walk tests from Day 9-14 (p = 0.038). This pilot study did not confirm hypotheses that females as compared to males would show slower exercise recovery on autonomic or self-report (e.g. fatigue) measures. A more exertion-sensitive test may be required to document prolonged post-exertional abnormalities in ME/CFS.Trial registration: NCT NCT03331419.

Assessing Pain in Older Adults.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Nonimprovement in Chronic Fatigue Syndrome: Relation to Activity Patterns, Uplifts and Hassles, and Autonomic Dysfunction.

OBJECTIVE: To test a model of nonimprovement in chronic fatigue syndrome (CFS) using self-report activity patterns (e.g., "push-crash"), uplifts and hassles, and a biological measure of cardiac autonomic function. Activity pattern impacts on symptoms and objective measures of autonomic and physical activity were also examined. METHODS: This prospective study in CFS collected all data remotely, including 6 months of weekly web diaries that recorded symptom ratings, activity patterns, and hassles and uplifts. In addition, 6 months of weekly heart monitoring and 3 months of daily waking actigraphy data were collected. Improvement or nonimprovement status was assessed using semistructured interviews at the 6-month follow-up. RESULTS: A total of 148 individuals (87.2% female) were enrolled, and 12.2% were lost to follow-up. Participants reporting nonimprovement ( n = 92), as compared with improvement ( n = 38), showed greater autonomic dysfunction (lower heart rate variability, group difference = 5.93 [SE = 2.73] milliseconds; p = .032) and lower mean intensity of behavioral uplifts (group difference = 0.14 [SE = 0.16]; p = .043), but no significant differences in any activity pattern, including push-crash, limiting activity, and healthy pacing. CONCLUSIONS: This study provided evidence for linking patient-reported nonimprovement to a biological variable indexing autonomic dysfunction and a behavioral measure indicating a deficit in psychological uplifts. These findings suggest a possible marker of illness trajectory that could potentially advance the biomedical underpinnings of CFS.Trial Registration:ClinicalTrials.gov ID: NCT02948556.

Development and testing of a standardized pain interview assessment for use in post-acute care.

OBJECTIVES: Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner. METHODS: We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items. RESULTS: For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility. CONCLUSION: Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

Development and Validation of the Achieving Effective & Safe Opioid Prescribing-Advanced Practice Registered Nurse (AESOP-APRN) Survey: A Pilot Study.

BACKGROUND: Advanced practice registered nurses (APRNs) are essential partners in the management of pain, both in primary care and in pain specialty practices. One of the more controversial treatment practices surrounds the use of opioid analgesic medication for the relief of pain in persons with chronic pain. Although several guidelines have been developed, the extent and impact of APRN knowledge, attitudes, and values about pain management and opioid prescribing practices are not known. In addition, regulatory mandates may encumber APRN scope of pain management practice. AIMS: This manuscript describes the development and pilot testing of the Achieving Effective & Safe Opioid Prescribing-APRN (AESOP-APRN) Survey conceptualized to address these topics. DESIGN: Instrument development. PARTICIPANTS/SUBJECTS: Advanced practice registered nurses. METHODS: Phase I addressed development, content validity determination, and survey refinement. APRN-focused discussion groups, expert review, and analysis of content were conducted. In phase II, pilot testing was conducted to determine reliability. RESULTS: APRNs are aware of regulatory restrictions to practice and potential implications on patient outcomes. The Initial Content Validity Index suggested refinement of survey questions. After content revision, final ratings were acceptable. A sample of APRNs (N = 23) completed the survey. Cronbach's α range (.65-.91) suggests acceptable internal consistency for a new survey. CONCLUSIONS: Even at this initial phase, the newly developed AESOP-APRN Survey accurately represents the underlying thematic concepts of interest; however further psychometric analyses are required, and instrument refinement is possible. Additional study should include analysis of members from a variety of health care disciplines, as was the intention of the development of the Core Competencies for Pain Management from which many items were derived.

Complementary and Integrative Therapies for Persistent Pain Management in Older Adults: A Review.

Management of persistent pain in older adults is challenging given the prevalence of multiple comorbid painful conditions, polypharmacy, age-related changes restricting pharmacological options, and socioeconomic factors. The influences of these factors along with current concern for the use of opioid analgesics highlight the importance of incorporating complementary and integrative medicine approaches. Evidence suggests efficacy and satisfaction with integrating complementary pain management strategies for older adults, especially yoga, massage, and natural products. Nurses and other providers, given their emphasis on holistic care, are in a unique position to lead the transformation of pain management to a patient-centered, self-management style that integrates complementary therapies. [Journal of Gerontological Nursing, 42(12), 40-48.].

The Current State of Perioperative Pain Management: Challenges and Potential Opportunities for Nurses.

Achievement of adequate postoperative pain management is a critical challenge in health care, with an estimated three out of four adult surgical patients reporting moderate to extreme pain after surgery. Overreliance on opioids in acute care settings has persisted, despite well-known adverse side effects frequently associated with this class of drugs. Furthermore, patients with a history of chronic opioid use present additional challenges in terms of postsurgical pain management. Advances in the development of newer analgesic agents and anesthetic techniques may be useful in surgical patients with a history of chronic opioid use and in the overall surgical patient population. Systemic inefficiencies and problematic medical practice patterns can also have negative effects on perioperative pain management. As the surgical patient's primary advocate, perioperative nurses play an important role in overcoming these diverse challenges and addressing the problems associated with inadequately controlled postsurgical pain.

The Role of the Perioperative Nurse in Improving Surgical Patients' Clinical Outcomes and Satisfaction: Beyond Medication.

For the perioperative nurse, the management of postsurgical pain includes various responsibilities, such as performing postsurgical pain assessments as an essential first step, facilitating recovery from surgery, and maximizing patient satisfaction during the postsurgical period. In addition, nurses are responsible for providing patient education regarding pain management, the quality of which may strongly influence patient satisfaction. External and internal challenges exist in perioperative care processes, however, and addressing these challenges will promote the overall goal of providing high-quality care.

Cognitive behavioral therapy for chronic pain is effective, but for whom?

Moderator analyses are reported for posttreatment outcomes in a large, randomized, controlled effectiveness trial for chronic pain for hip and knee osteoarthritis (N = 256). Pain Coping Skills Training, a form of cognitive behavioral therapy, was compared to usual care. Treatment was delivered by nurse practitioners in patients' community doctors' offices. Consistent with meta-analyses of pain cognitive behavioral therapy efficacy, treatment effects in this trial were significant for several primary and secondary outcomes, but tended to be small. This study was designed to examine differential response to treatment for patient subgroups to guide clinical decision-making for treatment. Based on existing literature, demographic (age, sex, race/ethnicity, and education) and clinical variables (disease severity, body mass index, patient treatment expectations, depression, and patient pain coping style) were specified a priori as potential moderators. Trial outcome variables (N = 15) included pain, fatigue, self-efficacy, quality of life, catastrophizing, and use of pain medication. Results yielded 5 significant moderators for outcomes at posttreatment: pain coping style, patient expectation for treatment response, radiographically assessed disease severity, age, and education. Thus, sex, race/ethnicity, body mass index, and depression at baseline were not associated with level of treatment response. In contrast, patients with interpersonal problems associated with pain coping did not benefit much from the treatment. Although most patients projected positive expectations for the treatment prior to randomization, only those with moderate to high expectations benefited. Patients with moderate to high osteoarthritis disease severity showed stronger treatment effects. Finally, the oldest and most educated patients showed strong treatment effects, while younger and less educated did not.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial.

A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients' doctors' offices (N=129 patients); the control group received usual care (N=127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.

Options for treating postherpetic neuralgia in the medically complicated patient.

Patients with postherpetic neuralgia (PHN) are often of advanced age or immunocompromised and likely to have ≥1 comorbid medical condition for which they receive ≥1 medication (polypharmacy). Comorbidities affecting renal or hepatic function can alter pharmacokinetics, thereby impacting the efficacy or tolerability of PHN analgesic therapies. Cardiovascular, cerebrovascular, or psychiatric comorbidities may increase patient vulnerability to potential adverse events associated with some PHN analgesic therapies. Because PHN is a localized condition, localized therapy with a topical analgesic (lidocaine patch 5% and capsaicin 8% patch or cream) may provide adequate efficacy while mitigating the risk of systemic adverse events compared with oral analgesics (eg, tricyclic antidepressants, anticonvulsants, opioids). However, combined therapy with a topical and an oral analgesic or with >1 oral analgesic may be needed for optimal pain management in some patients. This review summarizes how comorbidities and concomitant medications should be taken into account when selecting among available pharmacotherapies for PHN and provides recommendations for the selection of therapies that will provide analgesia while minimizing the risk of adverse events.

Strategies to reduce the tampering and subsequent abuse of long-acting opioids: potential risks and benefits of formulations with physical or pharmacologic deterrents to tampering.

Increased prescribing of opioid analgesics for chronic noncancer pain may reflect acceptance that opioid benefits outweigh risks of adverse events for a broadening array of indications and patient populations; however, a parallel increase in the abuse, misuse, and diversion of prescription opioids has resulted. There is an urgent need to reduce opioid tampering and subsequent abuse without creating barriers to safe, effective analgesia. Similar to the "magic bullet" concept of antibiotic development (kill the bacteria without harming the patient), the idea behind reformulating opioid analgesics is to make them more difficult to tamper with and abuse by drug abusers but innocuous to the compliant patient. As antibiotics exploit differences in bacterial and human physiology, tamper-resistant formulations depend on differences in the way drug abusers and compliant patients consume opioids. Most opioid abusers tamper with tablets to facilitate oral, intranasal, or intravenous administration, whereas compliant patients usually take intact tablets. Pharmaceutical strategies to deter opioid abuse predominantly focus on tablet tampering, incorporating physical barriers (eg, crush resistance) or embedded chemicals that render tampered tablets inert, unusable, or noxious. Deterring tampering and abuse of intact tablets is more challenging. At present, only a few formulations with characteristics designed to oppose tampering for abuse have received approval by the US Food and Drug Administration, and none has been permitted to include claims of abuse deterrence or tamper resistance in their labeling. This review discusses the potential benefits, risks, and limitations associated with available tamper-resistant opioids and those in development.

The role of the CNA Pain Assessment Tool (CPAT) in the pain management of nursing home residents with dementia.

Implementation and testing of the CPAT in two hundred fifteen dementia residents of three regional skilled nursing facilities. To examine the effect of incorporating the CPAT into an AMDA long-term care pain management clinical practice guideline on nursing home residents with dementia. To evaluate changes in CPAT scores after treatment for pain. A non-randomized pre and post intervention design was used. Main outcome measures of the number of falls, episodes of distressed behavior and rates of antipsychotic usage were compared pre and post CPAT/AMDA guideline implementation. CPAT score changes were calculated after pain management. Falls and verbally aggressive behavior were reduced post intervention but did not achieve statistical significance. Antipsychotic usage declined significantly post intervention. CPAT scores declined significantly after treatment for pain. The implementation of a CPAT/AMDA guideline in skilled nursing facilities may reduce falls, verbally aggressive behaviors and antipsychotic usage in residents with dementia. The CPAT is useful in evaluating the effects of pain treatment in nursing home residents with dementia.