Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial.

PURPOSE: Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018). PARTICIPANTS: Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included. INTERVENTION: In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses. METHODS: Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD). RESULTS: Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05). CONCLUSION: While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Quality of life in nursing home residents with pain: pain interference, depression and multiple pain-related diseases as important determinants.

AIM: Quality of life is an essential outcome parameter in geriatric research and presents an important indicator for the evaluation of care treatments. The present study analyses potential impact factors on health-related quality of life (HRQOL) of nursing home residents (NHR) who are in pain. METHODS: Data came from the cRCT 'PIASMA'. Statistical analyses of 146 respondents were carried out by multiple linear regressions based on the EQ-5D index (Euroquol Quality of Life) as dependent variable. Potential impact factors were applied and categorised in five blocks: pain intensity and interference (according to the Brief Pain Inventory), intervention effect, sex and age, pain-related diagnoses, and scales regarding depressive symptoms and cognitive impairment (based on the Geriatric Depression Scale and the Mini-Mental State Examination). RESULTS: On average, residents showed a pain intensity of 18.49, a pain interference of 29.61, a MMSE score of 22.84, a GDS score of 5.65 and an EQ-5D index of 0.52. Residents with more diagnoses, more depressive symptoms, and a higher pain interference showed a significantly reduced HRQOL. CONCLUSION: Findings underline the importance of identifying and applying treatment options for both pain (especially interference) and depressive disorders to maintain HRQOL of NHR.

[painApp-mobile pain monitoring in the home care setting]. / painApp ­ mobiles Schmerzmonitoring in der häuslichen Versorgung.

BACKGROUND: The use of a scientifically developed App for pain management in the home care setting is not yet established in Germany. The documentation of pain-specific data by the patients and the transfer into a web portal to be examined by the attending physician can help close the existing communication gap in pain management between consultations. OBJECTIVES: The aim of the study was to develop a mobile health (mHealth) solution for optimizing pain management in the home care setting. The research questions focus on design and technical issues concerning layout and navigation of the painApp as well as user-relevant questions concerning pain management, such as pain at rest and pain during movement, taking pain medication and patient satisfaction with their pain situation. MATERIALS AND METHODS: Within a 12-month period, the user-centered development and practice-based testing of the application painApp involved patients aged ≥ 65 years. Within a formative evaluation, a total of four data collections and a final survey took place. During the same period, a web portal was developed and tested the documentation of the patient pain-specific data from the painApp with the participation of general practitioners. RESULTS AND CONCLUSIONS: The development of the painApp as a prototype was realized in the study with high acceptability by the patients. The painApp is able to establish digital communication with the general practitioner without any technical problems and allows the physician access to patient data in real time.

Pain in older adults with dementia : A survey across Europe on current practices, use of assessment tools, guidelines and policies.

BACKGROUND: We aimed to explore the existing use of pain assessment tools and guidelines, and develop understanding of the practical considerations required to facilitate their use within the nursing home, hospital and community settings. METHODS: A self-administered web-based survey was conducted with nurses, health and social care workers with an interest in the assessment of pain in older adults with cognitive impairment. The survey was distributed to participants in Austria, Belgium, Denmark, Germany, The Netherlands, Switzerland and United Kingdom. RESULTS: Only a minority of staff reported use of (inter-)national or local standards or specific pain assessment tools in daily practice. A range of tools were reported as being used, which varied across country. While participants generally reported that these pain assessment tools were easy/very easy to use, many participants reported that they were difficult to interpret. Assessment is generally performed whilst providing nursing care. This was highlighted in 70-80% of all participating countries. While many of these tools rely on facial expression of pain, facial expressions were considered to be the least useful in comparison to other items. Furthermore findings showed that nurses employed in long-term care settings did not feel that they were educated enough in pain assessment and management. CONCLUSION: Our findings suggest that pain education is required across all countries surveyed. This should include a focus on guidelines and standards for assessment and subsequent management of pain. Findings suggest that clinical staff find interpreting facial expressions in relation to pain more difficult.

[Challenges for home care services in the pain management of cancer patients : A qualitative study]. / Herausforderungen ambulanter Pflegedienste im Schmerzmanagement von Tumorpatienten : Eine qualitative Untersuchung.

BACKGROUND: People with cancer are increasingly supported by home care services. Pain is a relevant symptom of these diseases and nurses of home care services are involved in the treatment. The German National Expert Standard "Pain management in nursing" includes evidence-based recommendations for the implementation of adequate pain management. Considering the given structural conditions of home care services, nurses describe both barriers and challenges with the implementation. METHODS: By means of five guideline-based discussion groups, nurses of 14 home care services were questioned about the challenges they had experienced in pain management. The questioning focuses on the level of implementation of the recommendation for each aspect: pain assessment, pharmacological pain therapy, non-pharmacological pain therapy, pain-related side effects, information, training, and counseling in the care of people with cancer. A qualitative content analysis was conducted. RESULTS: On the one hand, the results illustrate a need for further knowledge and possibilities, e.g., for the assessment of pain as a multidimensional phenomenon and, on the other hand, that the conditions for continuous pain monitoring of cancer patients in home care services are limited. The need for short-term reconciliation with the treatment team and the practitioners proved to be more difficult than the cooperation with the palliative care network. Involvement of family members is important to ensure uninterrupted treatment. CONCLUSIONS: Beside knowledge and competencies regarding nursing care, structures and processes for interprofessional pain management need further development and research.

Drug-based pain management in people with dementia after hip or pelvic fractures: a systematic review protocol.

BACKGROUND: Studies show that people with dementia do not receive the same amount of analgesia after a hip or pelvic fracture compared to those without cognitive impairment. However, there is no systematic review that shows to what extent and how drug-based pain management is performed for people with dementia following a hip or pelvic fracture. The aim of this systematic review is to identify studies addressing drug-based pain management for people with dementia who have had a hip or pelvic fracture for which they had either an operation or conservative treatment. We will analyse to what extent and how the drug-based pain treatment for people with dementia is performed across all settings and how it is assessed in the studies. METHODS: The development of this systematic review protocol was guided by the PRISMA-P requirements, which will be taken into consideration during the review procedure. MEDLINE, EMBASE, CINAHL, Web of Knowledge and ScienceDirect will be searched, using keywords such as "analgesia", "dementia", "cognitive impairment", "pain treatment", "hip fracture" or "pelvic fracture". Publications published up to January 2016 will be included. The data extraction and a content analysis will be carried out systematically, followed by a critical appraisal. DISCUSSION: This review will provide a valuable overview on the current evidence on drug-based pain management for PwD in all settings who were conservatively treated after a hip or pelvic fracture. The review may expose a need to enhance pain management for PwD. It may also provide motivation for healthcare providers and policymakers to give this topic their attention and to facilitate further research by considering aspects of care transitions in all settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016037309.

[Diagnostics of pain in old age. Perspectives on a multidimensional phenomenon]. / Diagnostik von Schmerzen im Alter. Perspektiven auf ein multidimensionales Phänomen.

Old people's experience of pain differs markedly from that of younger people. Old people not only suffer from pain more often but also the pain is predominantly chronic in nature. In many cases older patients experience pain from more than one cause at any time due to multimorbidity. Against this backdrop this article examines the question of how diagnostic procedures of pain have to be specific for older patients and how these requirements are currently met in clinical practice. Diagnostic procedures in older persons need to be rooted in a biopsychosocial understanding of pain that also takes into account that the pain experience is always made up of several pain dimensions. A comprehensive understanding of pain communication also has to be taken into account as well as age-specific influences. In older persons pain assessment needs to encompass motivational affective, sensory discriminative and cognitive evaluative aspects. If pain assessment is limited to pain severity or the observation of pain behavior only, important information is lacking and important biographical, health-related, phenomenological and care-specific information cannot be used for the benefit of the patient. Different dimensions of pain cannot be used variably but need to be regarded as complementing elements; however, this approach is currently not always possible to follow through in clinical practice especially with age-related illnesses, such as dementia. Currently, only the geriatric pain interview (Geriatrisches Schmerzinterview) is available as a multidimensional tool for the assessment of pain in older people. There is a clear need for more and extended research and development of tools and processes to comprehensively assess pain in older persons.

[Pain in nursing homes]. / Schmerz in Einrichtungen der stationären Altenhilfe.

Elderly live in nursing homes if the necessary need for care cannot be realized in the home care setting. Dementia syndrome (60 % of nursing home residents) has a prominent role. Pain is a frequent problem in nursing homes, affecting functionality and quality of life. Studies often show inadequate pain therapy. Not only is the presentation of pain often atypical, but pharmacological and invasive pain therapy is limited by multimorbidity and increased risk of side effects. Nonpharmacological pain therapy is part of nursing therapy; however, the effect on nursing home residents has been insufficiently studied. This situation necessitates interprofessional coordination of all team members, in which the nursing pain assessment and the realization of both pharmacological and nonpharmacological pain therapy are very important.

[Pain management in patients with cancer. Perspectives of various network participants]. / Schmerzmanagement bei Menschen mit Tumorerkrankung. Die Sicht einzelner Netzwerkakteure.

BACKGROUND: High healthcare needs are evident for pain caused by cancer. Those affected are not only looking for help in acute inpatient structures but also for a much larger part in outpatient care structures. To avoid mistreatment, undertreatment or overtreatment of pain in people with cancer, it is necessary to differentiate the tasks and roles of different providers while highlighting the specific aspects of pain management within the given network structures. MATERIALS AND METHODS: Aspects, such as pain assessment and the necessary scope of action in pain treatment are illustrated from the perspective of nurses from home care services, primary physicians as well as the general or special ambulatory palliative care (AAPV or SAPV) on the basis of initial survey results and a documentation analysis. RESULTS: Ambulatory care nurses (93 %) and primary caregivers (64 %) use pain assessment scales. The kind of scales used varies. The ability to provide adequate pain care for patients in the immediate care situation is reported as given by more than half of the nurses (56.6 %). CONCLUSIONS: In order to ensure an adequate pain therapy targeted interprofessional coordination is required between outpatient and primary physicians with respect to aspects of pain assessment, scope of action and accessibility.

[Pain assessment in elderly nursing home residents: methods paper for the S3-guideline development]. / Schmerzassessment bei älteren Menschen in der vollstationären Altenhilfe : Methodenpapier zur S3-Leitlinie.

In Germany, there is currently no guideline for pain assessment in elderly people. Pain management in nursing home residents is, however, legally required. For this particular group, especially for people with dementia, suitable interdisciplinary orientations for health care are lacking in Germany. The working group "Pain and Age" of the German Pain Society ("Deutschen Schmerzgesellschaft") in conjunction with the German Centre for Neurodegenerative Diseases ("Deutschen Zentrum für Neurodegenerative Erkrankungen"), Witten, has embarked on the development of interdisciplinary S3-Guideline for "Pain Assessment in Elderly People in Nursing Homes", based on the methodology suggested by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V."), the German Agency for Quality in Medicine ("Ärztliche Zentrum für Qualität in der Medizin"), and that described in the DELBI ("Deutschen Leitlinien-Bewertungsinstrument"). Delegates of the 38 scientific societies and interest groups currently participating can contribute to the contents on three different levels. The present article outlines the methods for developing the guideline.

[Health services research project "action alliance pain-free city Münster" : Objectives and methods]. / Versorgungsforschungsprojekt "aktionsbündnis schmerzfreie stadt Münster" : zielsetzung und methodik.

Inadequate pain care in health care facilities is still a major concern. Due to structural and organizational shortcomings the potential of modern analgesia is far from being exhausted. The project "Action Alliance Pain-free City Münster" is designed to analyze the multiprofessional pain management in health care facilities in the model City of Münster in an epidemiologic study and aims to optimize pain management in accordance with nursing standards and medical guidelines. Hospitals, nursing homes, outpatient nursing services, hospices and pain care centers will be examined. After an analysis of the current state on the basis of a pre-test, the necessary optimization measures will be developed and implemented. Subsequently, the pain management will be reevaluated in a post-test. In partly still unexplored health care areas of Germany, epidemiologic data will be generated, barriers to the implementation of standards and guidelines revealed and measures of improvements developed and tested. In addition, interface problems between the evaluated sectors will be identified. In this article the objective and the methods of the project are described.

[Joint contractures in older age. A systematic literature review]. / Erworbene Kontrakturen der Gelenke im höheren Lebensalter. Eine systematische Literaturanalyse.

BACKGROUND: Free movement of the limbs is a prerequisite of mobility and autonomy in old age. The prevalence of contractures in international studies has been reported to range between 15% and 70%. The wide variation might be explained by different definitions and diagnostic criteria, settings, and participants' characteristics. Contractures lead to additional nursing demands. In Germany, contracture risk assessment and prevention have been recently defined as a quality indicator of nursing home care that should be regularly monitored by expert raters of the statutory health insurance system. Therefore, it is necessary to have a clear definition of contracture. The goal of this literature review was to identify definitions of contractures used in controlled trials. METHODS: A systematic literature search of controlled trials investigating contracture as primary, secondary, or adverse outcome was conducted using the databases PubMed, CINAHL, Embase, and the Cochrane Library. The search was limited to articles published after 1985 and written in English or German language. Publications were excluded, if animals, children, or congenital contracture were investigated. Two reviewers independently screened the abstracts and extracted data from full publications. Disagreement was solved by consensus involving a third reviewer. RESULTS: Initially, 544 publications were identified; 37 controlled studies fulfilled the inclusion criteria and were included. A total of 33 studies investigated contracture as primary outcome, three as secondary outcome, and one as adverse outcome. Five studies clearly defined the term contracture. However, all these definitions are different. In 31 studies, only the diagnostic criteria were mentioned and one study mentioned neither a definition nor specific diagnostic criteria. CONCLUSION: The majority of clinical trials investigating contracture as outcome parameter do not provide a clear definition. However, the success of contracture prevention and treatment in clinical trials and practice can only be judged in the presence of a clear definition. Thus, it appears especially difficult to use contracture as a quality indicator for nursing homes.