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Pain Assessment and Treatment in Geriatric Populations

June 15, 2021
Study points to the need for additional nursing training in treatment decision-making when it comes to pain management in elderly patients, especially those with dementia.

Assessing and treating pain in people with dementia poses unique challenges. Typically in pain management, assessment relies on patients’ report of their pain, explains Theresa Mallick-Searle, MS, RN-BC, ANP-BC, a nurse practitioner in the Division of Pain Medicine at Stanford Health Care. “In patients who have dementia, either mild to moderate or moderate to severe, you just don't get the same kind of verbal feedback,” she told PPM. Yet pain is one of the primary causes of reduction of quality of life (QoL) in people with dementia.1

Little research has focused on nursing and pain management, especially among the geriatric patient population. (iStock).

 

A team of researchers based in in Barcelona, Spain, designed a study to determine how pain was being assessed and treated in this vulnerable population.2 They did so after finding few studies focused on nursing and nursing records of pain and pain management – primarily to do with oncology or post-surgical pain – but no research on the records of pain treated in adult acute geriatric units. They homed in on how nurses were assessing and managing pain among elderly patient populations.

Assessing Pain Geriatric Populations: Study Methods

The retrospective descriptive study2 led by Alicia Minaya-Freire examined electronic health records of 111 patients with dementia who were admitted to an acute geriatric unit at a university hospital in Barcelona, from January to March of 2018. Subjects were all 85 years or older, with a mean age of 87, and had been diagnosed with cognitive impairment. The subjects, 62 of whom were women, were admitted for infection, fracture or other osteoarticular problem, cardiovascular issues, or respiratory problems. Two subjects were admitted for a condition other than the above.

To assess pain, they used the numerical pain rating scale (NRS) by which patients ranked their own pain from 9 to 10, with 0 being “no pain” and 10 being “as bad as it can be,” and the Pain Assessment in Advance Dementia (PAINAD) scale, by which pain is assessed using observational markers, such as facial expression, body language, character of vocalization, breathing ability, and ability to be consoled. The researchers reviewed care documentation for the entire stay of each person, and analyzed sociodemographics, pain variables, and administration of pain medications.

Frequency of Pain Assessment and Treatment: Findings

The researchers found that nurses in the unit assessed the pain of 88% of the patients upon admittance and reassessed patients an average of 1.9 times per day during their stay, 39% of those assessments taking place during the late shift.

Minaya-Freire’s team pointed out that this frequency was higher than some prior research on pain assessment in nursing homes,3 and similar to results found in a 2015 study on pain management nursing.4

“Even so, the AGU’s [Acute Geriatrics Unit]  person-centered care model treats pain as a geriatric syndrome and defines patient comfort as the aim of nursing care," they wrote in their paper. "In this context, the fact that nurses did not assess pain with the same frequency during the various shifts may indicate that pain management in the unit is less than optimal and that probably not all nurses consider the need of pain assessment in patient with dementia.”2

Pain Interventions Linked to Self-Reports When Treating Geriatric Patients

Further, the team found that nonpharmacological interventions (eg, position change, cold application) were documented for only 12% of the patients. The authors did point out, however, that this does not necessarily mean none were offered.

The reason for admission seemed to influence both the type and number of medications administered for pain, a finding in keeping with previous research on the number of annotations made by nurses regarding the presence or absence of pain. Patients with orthopedic conditions, those near end of life, and, perhaps unsurprisingly, women were given more medications for pain than other patients. (See also, gender gaps in pain medicine.)

Most intriguing was the finding that nurses were more likely to administer drugs for pain when patients self-reported higher intensity pain than when nurses observed higher intensity pain. Mallick-Searle points out that if a particular unit is accustomed to having many patients with dementia, they may get lulled into managing the dementia, per se, focusing on medicines for dementia rather than looking more closely at the pain. “But you can't separate out the two,” she clarifies,  “You have to treat them together.”

Pain Management Nursing and Training: Practical Takeaways

Overall, the authors say that their study suggests that nurses need more training in pain management. “I don’t think there's a lot of hours spent in RN or LPN training on pain assessment and management,” says Mallick-Searle. “It’s definitely a big need.” (See also, Mallick-Searle’s column on advanced practice in pain management.)

In addition to more training, Minaya-Freire’s team stressed the need for more studies on how pain scales are used to measure pain and more emphasis on pain as the fifth constant, measured with the same frequency as other vital signs. The authors added, “It is also important to analyze barriers and facilitators that influence pain management in patients with dementia from the perspective of nurses and try to find practical, tailored solutions for the acute geriatric setting in order to guarantee patients’ well-being,”2 they concluded.

 

 

Last updated on: July 7, 2021
Continue Reading:
Advanced Practice Matters: Needs Assessment in Pain Management Training
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