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PAIN CARE FOR THE OLDER ADULT IN
LONG TERM CARE
GLORIA MEEK ANP-BC, ACHPM, OCN
CONFLICT OF INTEREST DISCLOSURE
NO DISCLOSURES
OBJECTIVES
Describe what is long term careDiscuss older adult pain in long term careDiscuss resident centered care of the
older adult in long term careDescribe challenges of managing pain
THE STATE OF AGING AND HEALTH IN AMERICA
Demographic changes create an urgent need
--long life spans and aging baby boomers will combine to double the population of Americans aged 65 or older during the next 25 years to about 73 millions. By 2030, older adults will account for roughly 20% of the US population.
Center for Disease Control and Prevention. The State of Aging and Health in America 2013. Atlanta, GA. Centers for Disease Control and prevention, US Dept. of Health and Human Service, 2013.
AGING POPULATION
Oldest old persons 85 and older are projected to be the fastest growing part of the elderly population.
80’s, 90’s and 100 yrs.
U.S. Census Bureau.(2012). Population Division.
OLDER PERSON’S HEALTH
Life expectancy:
men at 65 years—17.9 years
women at 65 years—20.5 years
http://www.cdc./gov/nchs/fastats/older-american-health.htm
CENSUS PROJECTIONSAged over 60 years in millions
Missouri US 2010 1.14 56.922020 1.45 75.492030 1.64 91.12
Millions—
U.S. Census Bureau, Population Division, Interim State Population Projections, 2005
LONG TERM CARE: WHAT’S IN A NAME?
Nursing home?
Convalescent home?
Skilled nursing facility?
Care home?
Rest home?
Immediate care facility?
LONG TERM CARE SERVICE USERS AGE 65 AND OVER
Adult day service center participants: 63.5% (2012)
Home health agency patients: 94.% (2011)
Hospice patients: 94.5% (2011)
Nursing home residents: 85.1% (2012)
http://cdc.gov/nchs/fastats/older-american-health.htm
LONG TERM CARE: What are the issues?
People needing long term care, 43% are under 65
Two-thirds of long term care is paid for by Medicaid.
8% of Americans have long term care insurance
2010=40,000,000 older than 65
2050=88,000,000 “ “ “
Accessed February 2014 www.rwjf.org
WHO GOES TO LONG TERM CARE?
Previously, “services and support to help frail older adults and younger persons with disabilities maintain their daily lives.”
Now, “supportive services that meet the needs of older people and other adults whose capacity for self-care is limited because of a chronic illness, injury, physical, cognitive, or mental disability.”
National Health Care Statistics Report, Number 1 http://www.cdc.gov/nchs/nsltcp.htm
LONG TERM CARE
Rehabilitation from a hospital stay, brief extended
Recovery from an illness or injury
Recovery from surgery
Terminal medical condition
CUSTODIAL-RESIDENTIAL-NURSING HOME
Need for ongoing long term care—months or years
Permanent disabilities
Dementia care
PAIN…PAIN…PAIN
“An unpleasant sensory and emotional experience associated with actual or potential damage.” (1979)
www.iasp-pain.org
“Whatever the experiencing person says it is, existing whenever and where ever the person says it does.” (1968)
Margo McCaffery
PAIN…PAIN…PAIN
“Pain is an unpleasant subjective experience that can be communicated to others either through self report when possible or through a set of pain-related behaviors.”
Kaaselainen and Crook, 2003
EPIDEMIOLOGY OF PAIN IN LONG TERM CARE
Community-dwelling older adults with pain is about 25-50%
Nursing home residents: 45-80, 85% have untreated pain
http://www.annalsoflongtermcare.com/article/managing- chronic-pain-older-adult-long-term-care
American Geriatric Society Panel on the Persistent Pain in Older
Persons
Focused on “older frail” population
Musculoskeletal disorders, degenerative spine conditions and arthritis
Post herpetic neuralgia
Cancer pain
www.americangeriatrics.org
FRAILITY
Affects between 5-10% of those who are >70, more common in women.
Over time leads to increased death rates, poor function and increased hospitalization.
“Medical syndrome, characterized by diminished strength, endurance, reduced physiologic function that increases an individual’s vulnerability for developing increased dependence and/or death.”
Journal of American Medical Directors Association, June 2013, Vol 14 (6), 392-397
THE PICTURE OF PAIN IN OLDER ADULTS
Acute—lasting fewer than 3 months. Disappears when underlying cause of the pain resolves.
Chronic—lasting longer than 3 months, or continues despite cause of pain resolved.
www.ConsultGeriRN.org
PAIN IN OLDER ADULTSPathologic load that accompanies “old age.”
Fibromyalgia and myofascial pain
Inflammatory pain associated with acute pain, following surgery or injury
Chronic inflammatory pain, arthritis
Mechanical pain created by pressure, stretching, injury
Neurogenic pain
Handbook of Pain Relief in Older Adults: An Evidence-Based Approach, edited by F.Michael Gloth III
CHRONIC CONDITIONS IN OLDER ADULTS
Nociceptive pain: low back pain osteoarthritis
osteoporosiscoronary artery disease
rheumatoid arthritic
• Neuropathic pain: neuropathies: peripheral post herpetic neuralgiatrigeminal neuralgiacentral post stroke
• Mixed pain: fibromyalgiamyofascial pain
UNRELIEVED ACUTE PAIN
Reduced function
Impaired ambulation
Increased risk for delirium, falls
Poor appetite
EFFECTS OF CHRONIC, PERSISTENT PAIN
Decreased appetite, weight loss
Increased agitation and resistance to care
Depression, Anxiety
Impaired ambulation, gait disturbance
Decreased socialization
Sleep disturbance
Increased caregiver burden
UNNECCESSARY SUFFERING
American Geriatric Guidelines for Persistent Pain, 2002
FEARS…MYTHS… THE END IS NEAR
“I’m in pain, I’m old—that’s normal for my age.”
“I didn’t want to bother anybody with my complaints.”
“I have pain, the cancer must be back.”
“Mother is getting up there in age, it’s normal for her to have pain.”
MYTHS COMPLICATING CARE
Pain is a natural part of getting older
Pain worsens over time
Stoicism leads to pain tolerance
Prescription analgesics are highly addictive
The Journal of Family Practice (2012)
ISSUES COMPLICATING PAIN MANAGEMENT
No consistent use of assessment tool
Residents with cognitive impairment, dementia, sensory impairment and disability
High turnover of nursing staff
Medications given by Certified Medication Technician, limited training
Limited presence of a physician or nurse practitioner
Annals of Long-Term Care, Managing Chronic Pain in Older Adults: Along Term Care Perspective, Vol 21, 12, Dec
2013
PAIN ASSESSMENT
3 ways to measure the present of pain in older adults
• Behavioral observation
• Self report
• Caregiver interview
AGS Panel on Pharmacological Management of Persistent Pain in Older Adults, 2009
PAIN ASSESSMENTComplete a medical history, physical
examination, review medication records
Pain history-characterization of current complaint, intensity, quality, location, pattern
Aggravating and relieving factors
Information from family members, nursing staff, therapy staff—physical, occupational
Farless, L.B., et al, Annals of Long-Term Care, 20, (5), May 2012
PAIN ASSESSEMENTP provoke and palliate; cause, makes better
Q quality; description
R region and radiate; show me where, does it go elsewhere
S severity, signs, symptoms; can you rate
T time; identify the occurrence and duration of pain
WHAT’S IN A WORD--PAIN
Aching
Dull feeling
Pressure
Burning
Shooting
Cramping
Sore
Uncomfortable
PAIN ASSESSMENT
“Tell me about you aches, soreness, discomfort or pain.”
“What would you rate your discomfort or pain, on a 0-10 scale, with 0 being no pain and 10 equal to the worst pain?
PAIN ASSESSMENT
Cognitively impaired:
• Behavior observations; facial expressions, verbalizations, vocalizations, body movements, changes in personal interactions, changes in activity patterns or routines and mental status changes
PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE
BEYOND PHYSICAL PAIN
Emotional=anxiety, depression or psychological distress
Social=isolation and abandonment associated with pain
Spiritual=the agonizing search for meaning, why me?
Physical pain of a broken femur, emotional pain from being temporarily handicapped, social isolation, can’t attend normal activities, spiritual search for meaning of injury.
GUIDELINES: THE AMERICAN GERIATRIC SOCIETY
Clinical practice guideline: Pharmacological Management of Persistent Pain in Older Persons (2009)
Focus was on pharmacologic management of pain
Non-pharmacologic treatment recommendations were not updated in 2009.
www.americangeriatric.org
GUIDELINES: AMDA=THE SOCIETY FOR POST-ACUTE AND
LONG-TERM CARE MEDICINE
Dedicated to excellence in patient care and provides education, advocacy, information and professional development to promote the delivery of quality post-acute and long-term care medicine.
Pain Management guidelines specifically for LTC
Updated with revisions, 2003, 2009 and 2012
www.amda.com
MINIMUM DATA SET IN LONG TERM CARE
Federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes.
Resident assessment and care screening tool, usually completed by a registered nurse
Developed to improve patient care through systematic patient care planning.
Performed on admission, periodically with specific guidelines and time frames.
Transmitted electronically to the MDS database for each state. Then information is captured into the national database at CMS
www.cms.org
REAL STORIES..REAL PAIN..
Oh…MY ACHING KNEE!!!!!!!!!
• Ms. Lillie, 76 y/o, hsx DM, HTN, COPD, BMI 32, CKD, Stage 3.
• LTC resident for two years, “my knees hurt all the time.” Rates as “5-6.” “I manage.”
• Able to maneuver wheelchair in halls, very active in facility, attends activities, music, crafts, member of Resident’s Council.
• Reluctant to request pain medication, “I don’t need any more pills.”
MS. LILLIEExam: right knee warm, slight edema, pain with
extension, able to stand with assistance. Unable to walk long distances. No radiographic imaging available.
PRN Acetaminophen 650 mg po q 4 hrs prn.
Past month has received 5 doses
American Geriatric Society, acetaminophen is 1st line tx for osteoarthritis
EVIDENCE-BASED TREATMENT
AHRQ…choice for analgesic should take into account the trade-off between benefits and adverse effects.
Begin tx with acetaminophen, lowest effective or intermittent dosing. Prn not effective, try scheduled doses. For highly resistant pain, consider tramadol.
Topical NSAIDS..Diclofenac sodium gel 1%, 4xday on clean dry skin; apply, no shower or bath for ½ hr.
http://www.ahrq.gov
MS. LILLIE
Challenges---reluctance to adjust medications
Agreed to scheduled acetaminophen 650 mg po bid for 1 week, evaluate pain relief. “See how I feel.”
Requested ICY HOT
MR. BUDDYAdmitted from to facility following a TIA. Multiple
chronic conditions; DM, HTN, COPD. BMI-22. Weak, gait unsteady.
82 y/o, recent widower, volunteered 2x wk for Meals on Wheels.
Worked on General Motors assembly line for 30 yrs.
Veteran of Korean War
Requests to eat in room, has not attended any activities since admission.
MR. BUDDYLower extremity pain, burning. Difficulty
sleeping, worse since recent hospitalization. Worst=(8), best=(0-2), “usually after that strong pill,” Norco 5/325 mg po, 1 tab q 6 hrs prn or Tylenol 650 mg po q 4 hrs prn. Has been able to determine if pain requires strong pain medication.
Hospital initiated gabapentin 300 mg po q hs, two days before discharge.
MR. BUDDYPain syndromes, neuropathy, hsx of DM, past 20+
years. Arthritis, physical job in younger years.
Fear of unknown, will he be able to return home? Mood quiet, does not communicate in halls with other residents.
His goals of care, hopes are to return home, continue volunteer work.
Care plan discussion with PT, OT, ST for progress update. Has had steady improvement.
Therapist explained progression, opinion: return to home is possible with assistance.
MRS. RUBY61 y/o female with severe rheumatoid arthritis.
Hsx of diabetes. Has required escalating doses of opioids past two years. Rates pain in hands and feet, most days as “7-8.” Never less than”5.”
Exam: hands and feet with severe deformities, curvature of spine. Reluctance for facility staff to use wheelchair for trips to dining or activities. Previously able to use motorized scooter.
More withdrawn with increase pain
MRS. RUBYHas received methotrexate for many years, no longer
effective.
Pain regimen, Fentanyl 100 mcg/hr q 72 hrs, prn Dilaudid 5 mg q 6 hrs prn
Recommendations: consultation with Rheumatologist, consider treatment with biologic agent, improve pain control.
Humira recommended. Resident initially agreed to take, BUT read articles on the internet—would not agree to a trial course of the drug.
Referred to pain specialist by primary physician.
MS. ANNIE101 y/o female with senile dementia, nonverbal .Recent
combativeness, anxious with transfers, personal care.
History of spinal stenosis, CAD, CHF, CKD, no recent infections.
87 lbs., BMI=17, one month weight loss of 6 lbs., severe muscle wasting. LCTA, HRRR, Abd, soft. Right leg contracted. Skin intact. No constipation or UTI.
FAST (Functional Assessment Staging)=7F
PAINAD=6, moderate pain.
Current regimen is acetaminophen 650 mg po q 4 hrs prn, received only 4 doses in past wk.
MS. ANNIE
Decision makers, Durable Power of Attorney, niece and nephew. Weekly visits.
Level of care=Do Not Resuscitate, no hospitalizations.
Goals of care are comfort in facility, allow a natural death.
MS. ANNIE
For pain scheduled acetaminophen 650 mg po q 8 hrs, continue same prn. Limit 24 hr amount to 3 gm.
If no relief change add opioid, slow titration.
For anxiety, lorazepam 0.5 mg po bid prn, non pharmacological, reposition, presence
MS. JEANNIE76 y/o female, history of right breast cancer,
mastectomy in 1998. History of chronic lower back pain. Has had increased pain, rates as “7-8,” dull, increases with movement. At the same time, discovered new lump in left breast. “Might be my cancer coming back.” Multiple chronic conditions, HTN, DM, OA. Poor appetite. Weight loss of 18 lbs past 3 months.
Has lower extremity weakness, able to maneuver wheelchair. Has refused physical therapy.
MS. JEANNIEFine needle biopsy, new breast cancer on left
breast. Radiation recommended, treatments completed, follow-up test pending.
Current pain regimen, Fentanyl 12 mcg/hr q 72 hrs, past 3 months. Prn Percocet 5/325 mg po q 6 hrs prn. Requested 4 prn doses-7days.
Patient/staff education regimen, side-effects.
Bowel regimen changed to scheduled, not prn.
MS. JEANNIEPhysical therapy ordered--evaluation for wheel
chair positioning.
Social work providing support and counseling.
Dietician has ordered weekly weights, nutritional supplements.
Dietary Supervisor met with patient for diet review, adapt menu to residents requests.
Lack of activity destroys the good condition of every human being, while movement and methodical exercise save it and preserve it.
---PLATO
ROLE OF PHYSICAL THERAPY IN LONG TERM CARE PAINKey component of multidisciplinary pain control
Manual therapies, massage, joint mobilization and manipulation
Exercise, strengthening, stretching, motor control
Electrical stimulation, interferential current, TENS
Heat modalities, hot packs, ultrasound
Education, posture, pacing, remaining active
BARRIERS…CHALLENGES TO THE REPORTING OF PAIN IN
LONG TERM CARE RESIDENTS
No consistent use of assessment tools
Insufficient education and training of facility staff
Fears and myths about analgesic drugs
Resident and caregiver/family attitudes
CONCLUSION
• Use of long term care facilities will increase
• Facilities must develop a process for an individualized, accurate assessment of a resident’s pain
• Use of appropriate scales to measure pain performed routinely
• Follow established guidelines for pain management in long term care
CONCLUSION
Patient and families should engage in decisions with facility staff
Pain management is pharmacological and nonpharmacological
IT TAKES A VILLAGE, AN INTERDISCIPLINARY TEAM
Nursing staff, RNs, LPNs, CNAs
CMTs (certified medication technicians)
Therapy department, physical, occupational and speech therapies
Social workers
Activity/Recreation department
Housekeeper/maintenance departments
Primary Care Physicians, Psychiatry consultants
QUESTIONS—COMMENTS
