Pain Patterns and Treatment Among Nursing Home Residents With Moderate-Severe Cognitive Impairment.

OBJECTIVES: To examine the frequency and severity of pain and use of pain therapies among long-term care residents with moderate to severe dementia and to explore the factors associated with increased pain severity. DESIGN: Prospective individual data were collected over 1 to 3 days for each participant. SETTING: Sixteen long-term care facilities in Alabama, Georgia, Pennsylvania, and New Jersey. PARTICIPANTS: Residents with moderate to severe cognitive impairment residing in a long-term care facility for at least 7 days were enrolled (N = 205). Residents were 47% female, predominantly white (69%), and 84 years old, on average (SD = 10 years). MEASUREMENTS: A comprehensive pain assessment protocol was used to evaluate pain severity and characteristics through medical record review, interviews with nursing home staff, physical examinations, as well as pain observation tools (Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale and Pain Intensity Measure for Persons With Dementia). Known correlates were also assessed (agitation, depression, and sleep). RESULTS: Experts' pain evaluations indicated that residents' usual pain was mild (mean = 1.6/10), and most experienced only intermittent pain (70%). However, 45% of residents experienced moderate to severe worst pain. Of residents, 90% received a pain therapy, with acetaminophen (87%) and opioids (32%) commonly utilized. Only 3% had a nondrug therapy documented in the medical record. The only resident characteristic that was significantly associated with pain severity was receipt of an opioid in the past week. CONCLUSION: Using a comprehensive pain assessment protocol, we found that most nursing home residents with moderate to severe dementia had mild usual, intermittent pain and the vast majority received at least one pain therapy in the previous week. Although these findings reflect improvements in pain management compared with older studies, there is still room for improvement in that 45% of the sample experienced moderate to severe pain at some point in the previous week. J Am Geriatr Soc 68:794-802, 2020.

Literacy-Adapted Cognitive Behavioral Therapy Versus Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial.

Background: Chronic pain is common and challenging to treat. Although cognitive behavioral therapy (CBT) is efficacious, its benefit in disadvantaged populations is largely unknown. Objective: To evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care. Design: Randomized controlled trial. (ClinicalTrials.gov: NCT01967342). Setting: Community health centers serving low-income patients in Alabama. Patients: Adults (aged 19 to 71 years) with mixed chronic pain. Interventions: CBT and EDU delivered in 10 weekly 90-minute group sessions. Measurements: Self-reported, postintervention pain intensity (primary outcome) and physical function and depression (secondary outcomes). Results: 290 participants were enrolled (70.7% of whom were women, 66.9% minority group members, 72.4% at or below the poverty level, and 35.8% reading below the fifth grade level); 241 (83.1%) participated in posttreatment assessments. Linear mixed models included all randomly assigned participants. Members of the CBT and EDU groups had larger decreases in pain intensity scores between baseline and posttreatment than participants receiving usual care (estimated differences in change scores-CBT: -0.80 [95% CI -1.48 to -0.11]; P = 0.022; EDU: -0.57 [CI, -1.04 to -0.10]; P = 0.018). At 6-month follow-up, treatment gains were not maintained in the CBT group but were still present in the EDU group. With regard to physical function, participants in the CBT and EDU interventions had greater posttreatment improvement than those receiving usual care, and this progress was maintained at 6-month follow-up. Changes in depression (secondary outcome) did not differ between either the CBT or EDU group and the usual care group. Limitations: Participants represented a single health care system. Self-selection bias may have been present. Conclusion: Simplified group CBT and EDU interventions delivered at low-income clinics significantly improved pain and physical function compared with usual care. Primary Funding Source: Patient-Centered Outcomes Research Institute.

Pain Catastrophizing, rather than Vital Signs, Associated with Pain Intensity in Patients Presenting to the Emergency Department for Pain.

This study examined the relationships of self-reported pain intensity with vital signs, pain catastrophizing, and state anxiety in patients presenting to the emergency department (ED) for acute pain, exacerbations of chronic pain, or acute pain with concurrent chronic (combined) pain, comparing the pattern of relationships among these three pain groups. One hundred fifty-eight patients presenting to the ED for pain were recruited. Vital signs and self-reported pain intensity were obtained at triage, then participants completed self-report measures of pain catastrophizing, state anxiety, and demographic information. No significant associations were found between vital signs and pain intensity at triage in any of the pain groups. Pain catastrophizing was significantly associated with self-reported pain intensity in the acute pain group (r = .34, p < .05) and combined pain group (r = .30, p < .05), and state anxiety was significantly associated with self-reported pain intensity in with the acute pain group (r = .27, p < .05). When pain catastrophizing and state anxiety were used in a stepwise multiple regression analysis to predict self-reported pain intensity in the acute pain group, only pain catastrophizing emerged as a unique predictor (ß = .405, p < .01). Consistent with previous research, vital signs were not associated with self-reported pain intensity in patients presenting to the ED for pain, including those with chronic pain. Given the significant association of pain catastrophizing and pain intensity among patients presenting to the ED for acute pain, brief measurement of pain catastrophizing may inform pain treatment in the ED.