Transcript Introduction

long-term care
Chronic Pain in the Nursing
Home Resident
Presenter:
Gwendolyn Buhr, MD
http://careinaging.duke.edu/longterm
care
Chronic Pain in the Nursing
Home Resident
Key Principles
http://careinaging.duke.edu/longterm
care
Pain Prevalence in the Nursing
Home
 Overall 45% to 80%
 Nationwide, 14.7% of all nursing home
residents were in persistent pain
 In north Carolina in 1999, 40% of
nursing home residents who were in pain
at the first MDS assessment were still in
pain at the next assessment 60 to 180
days later
long-term care network
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Pain Management in the
Nursing Home
 Data gathered from 1,492 nursing
facilities in 5 states
 Of 13,625 residents >65 years with cancer
– 24% - 38% reported daily pain
– 16% received non-opioid medications,
adjuvants or both
– 26% received strong opioids (morphine)
– 26% did not receive any analgesic agent
long-term care network
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Legal Consequences of Poorly
Managed Pain
 1990: North Carolina, $15 million
– Settled on appeal for undisclosed amount
– Nursing home failed to treat cancer pain
– Nurses did not give prescribed medications
 1997: Virginia, $200 thousand
– Hospital failed to treat cancer pain
 2001: California, $1.5 million
– Hospital settled (undisclosed)
long-term care network
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Morbidity of Poorly Managed
Pain
 Sleep disturbance
 Malnutrition
 Decline in social and recreational
activities
 Physical function decline: falls
 Depression, anxiety, impaired cognition
 Decreased quality of life
 Increased health care utilization/costs
long-term care network
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Pain and Dementia
 No evidence that pain transmission is
impaired in dementia
 Controversy about central nervous
system changes that influence
interpretation of pain transmission
ASSUME PAIN PREVALENCE AND
SEVERITY SAME AS IN
COGNITIVELY INTACT ELDERS
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Pain and Dementia
 Decreased verbal pain report
 Decreased analgesic use
 Significant untreated pain
 Complaints of pain are reliable
– 83% able to quantify their pain with a scale
 Noncommunicative dementia patients
– Pain identified much less frequently
long-term care network
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AMDA Clinical Practice
Guideline
 Pain assessment
– On admission
– At each quarterly review
– At any time that change in patient’s
condition prompts a new MDS
– Any time that pain is suspected
long-term care network
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Pain in the Cognitively
Impaired
 Do not assume that assessment is
impossible
 Ask simple yes/no questions
– Are you uncomfortable? Do you feel pain?
Hurt? Aching?
 Use a scale if possible
– Clear explanation, give time to grasp task
 Ask about present pain
long-term care network
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Pain in Dementia
 Learn a given patient’s baseline activities
and behavior
 Document changes
 Could this be due to pain?
 Screaming
 Difficult behaviors
 Attempt an analgesic trial
long-term care network
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WHO 3-step Ladder
3 Severe
2 Moderate
Strong
Opioid
Opioid
1 Mild
“around the
Non-narcotic “around the
clock”
clock”
“around the
± adjuvants
± adjuvants
clock”
± adjuvants
long-term care network
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Step Approach to Pain
Management
Non-opioids
•Acetaminophen
•NSAIDS
•Ibuprofen
•naproxen
•COX-2
1 Mild
Non-narcotic
“around the
clock”
± adjuvants
long-term care network
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Step Approach to Pain
Management
Adjuvants
•Calcitonin
•Corticosteroids
•Anticonvulsants
•Topical agents
•Antidepressants
1 Mild
Non-narcotic
“around the
clock”
± adjuvants
long-term care network
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Different Types of Pain Require
Different Treatments
 Somatic — localized tissue destruction
– Arthritis, bone pain, pain after surgery,
trauma
 Visceral — stretching internal organs
– Bowel obstruction, angina, urinary
retention, constipation
 Neuropathic — injury to nerves
– Diabetic foot pain, shingles, pinched nerves
long-term care network
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Step Approach to Pain
Management
Opioids
•Tramadol
•Tylenol #3
•Tylenol #4
•Vicodin
•Percocet
Strong Opioids
•Morphine
•Dilaudid
•MSContin
•OxyContin
•Transdermal fentanyl 3 Severe
2 Moderate
Strong
Opioid
Opioid
1 Mild
“around the
“around
the
Non-narcotic
clock”
clock”
“around the
± adjuvants
±
adjuvants
clock”
± adjuvants
long-term care network
http://careinaging.duke.edu/longtermcare
Medications Not Recommended
in the Nursing Home
 NSAIDs: indomethacin (Indocin),
piroxicam (Feldene), tolmetin (Tolectin),
meclofenamate
 Opioids: butorphanol (Stadol),
propoxyphene (Darvoset), meperidine
(Demerol), nalbuphine (Nubain),
pentazocine (Talwin)
long-term care network
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Current Status of Treating Pain
in the Nursing Home
Characteristics of residents receiving at least one
analgesic (n=2,065)
 Pain type: chronic 77%, acute 20%
 40.6% had no pain assessment
 Most residents received no nonpharmacologic
treatment: 69.4%
 Most analgesics prescribed PRN: 63.2%
 Propoxyphene was the most commonly
prescribed opioid: 55.8%
long-term care network
http://careinaging.duke.edu/longtermcare