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Pain management of older adults after discharge from outpatient surgery
Pain Management of Older Adults After Discharge From Outpatient Surgery yyy Judith Ann Kemper, PhD, RN, LTC
y
From the Jewish Hospital College of Nursing and Allied Health at Washington University Medical Center, St. Louis, MO, Oklahoma National Guard, Oklahoma City, Oklahoma Address correspondence and reprint requests to Judith Ann Kemper, PhD, RN, LTC, 1637 Award Drive, Ballwin, MO 63021. E-mail: [email protected] © 2002 by the American Society of Pain Management Nurses 1524-9042/02/0304-0003$35.00/0 doi: 10.1053/jpmn.2002.126222
ABSTRACT:
Older adults manage their pain at home after outpatient surgery. Yet the experience and management of postoperative pain outside the hospital is largely unknown. The purpose of this study was to examine older adults’ experiences of postoperative pain and their methods of pain management after discharge from outpatient surgery. A telephone-based interview of 93 older adults (ages 60-84) showed that pain intensity reached a level of 5 (0 to 10 scale) for 66% of participants on the first morning and for 42% on the third evening after discharge. Pain interfered with activities for almost one-fourth of the participants. Reasons for high pain intensity scores included improper and inadequate dosage of pain medication. More than half of the participants chose to take only one pain tablet at a time and 66% waited until their pain intensity reached a rating of 5 or above before taking their analgesic medication. The participants who took pain medications at higher levels of pain intensity reported taking larger amounts of medication but receiving less pain relief. This finding substantiates the idea that it takes a larger dose of pain medication to decrease severe pain. Pain management instructions did not make a difference in the way pain was managed. Overall, findings indicate that older postoperative patients are not adequately medicating themselves for pain after discharge. Furthermore, when participants were asked, “From this list of nonpharmacologic activities, which activities helped relieve pain?” the most frequently selected answer was “to stay still or not move.” This finding requires further investigation to determine if older adults are using immobility as a way to control their pain. © 2002 by the American Society of Pain Management Nurses
Improvements in anesthesia and surgical procedures made ambulatory or outpatient surgery a viable option for older adults (Chung, Mezei, & Tong, 1999). With Medicare regulations requiring conservation of resources and minimization in length of hospitalization, increasing numbers of older people have outpatient surgery. One result is that patients are required to manage their pain at home. Yet the experience and management of postoperative pain outside the hospital setting is largely unknown. This lack of knowledge is of particular Pain Management Nursing, Vol 3, No 4 (December), 2002: pp 141-153
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concern for the older adult who may have different needs and require special strategies for optimal pain control. Even with the publication of the Agency for Health Care Policy and Research’s Clinical practice guideline on acute pain management: Operative or medical procedures (Acute Pain Management Guideline Panel, 1992), studies (Devine et al., 1999; Feldt, Ryden, & Miles, 1998) continue to report that many hospitalized patients are undertreated for postoperative pain and that physicians, nurses, and older patients themselves are reluctant to administer sufficient amounts of analgesics to adequately control postoperative pain (Celia, 2000; Lay, Puntillo, Miaskowski, & Wallhagen, 1996; Pellino, 1997). After outpatient surgery, pain is one of the primary variances that increases time to discharge (Chung, Ritchie, & Su, 1997; Lewis, Wahl, Yust, & Kaplan, 2000) and contributes to readmission (Fortier, Chung, & Su, 1998). Hunter and colleagues (1998) reported that 47% of 553 outpatient surgery patients judged their immediate postoperative course to be worse than they had expected. Studies across all age groups report that 36% to 67% of clients experienced moderate to severe pain at home after outpatient surgery (Beauregard, Pomp, & Choiniere, 1998; Rawal, Hylander, Nydahl, Olofsson, & Gupta, 1997). Because patients are expected to manage their pain, nurses need to know and understand the variables that keep patients from obtaining optimal pain control. Furthermore, research findings report a significant deficit in nurses’ knowledge regarding pain management in the elderly (Sloman, Ahern, Wright, & Brown, 2001). Gathering information about older adults’ self-reports of pain status and management is a prerequisite to designing effective postoperative pain control strategies. The Model for Symptom Management framed this study (Dodd et al., 2001). This model assumes that all troublesome symptoms need managing and that symptom management and the resulting outcomes are often the responsibility of the patient. Symptoms are identified and examined on the basis of three dimensions: the symptom experience, symptom management strategies, and symptom outcomes. This study explored variables associated with two of the three dimensions—symptom experience and symptom management. These variables were pain description, location, pain rating, interference rating, and pharmacologic and nonpharmacologic symptom management strategies.
PURPOSE The purpose of this exploratory study was to examine older individuals’ experiences of postoperative pain
and their methods of pain management after discharge from outpatient surgery. This study was designed to answer the following research questions: 1. How do older adults describe their pain after discharge from outpatient surgery? 2. What pharmacologic or nonpharmacologic pain management strategies are used by older adults after discharge from outpatient surgery? 3. What demographic variables, access to medication and access to medication information variables, side effect variables, or treatment variables influence postoperative pain and pain management of older adults after discharge from outpatient surgery?
METHODS Sample and Settings A convenience sample was recruited from two Midwestern metropolitan hospital– based outpatient surgery departments that perform approximately 16,500 and 5,300 outpatient surgeries yearly. Inclusion criteria for the study were patients older than 60 years, planned discharge within 23 hours after outpatient surgery to a nonmedical facility, and ability to answer the questionnaire. Participants who were admitted for more than 23 hours for medical-surgical reasons were excluded from the study. Instruments The Pain Experience Interview (PEI) (Appendix), a structured scripted interview, was used to collect data from participants by telephone. It consisted of three parts: a pain management log, the Brief Pain Inventory (BPI), and investigator-developed questions. On the pain management log, participants recorded time and dosage of prescription and over-the-counter pain medications and pain intensity at time of medication administration. The BPI is a reliable and well-validated self-report instrument frequently used with diverse populations of people experiencing pain (Daut, Cleeland, & Flanery, 1983). The nine-item BPI measures pain location, pain intensity (0 to 10 scale), pain interference with daily activities (0 to 10 scale), and relief obtained (0% to 100% scale). Investigator-developed questions consisted of checklists on each variable based on a literature review and discussions with pain research experts and gerontologic nurse practitioners (Kemper, 1998). Each list was followed with an open-ended question to elicit other answers not found on the list. Three openended questions were included at the end of the second interview to determine if information was missed on the structured interview. The three questions in-
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cluded: (1) What did you find most helpful about how to control pain? (2) What concerned you most about your pain or pain management? (3) Is there anything else you would like to tell me about pain or pain management? Three experts in the field of pain management reviewed the PEI for content validity and the tool was field-tested on five older individuals (65 to 88 years old) for comprehension and ability to answer the questions over the telephone (Kemper, 1998). Procedures.Approval was obtained from both hospitals’ institutional review boards. Participants were recruited after arriving for laboratory work or surgery and signed a written consent. Participants were given a copy of the PEI enlarged to a size 14 font and instructed that these were the questions they would be asked over the telephone. Participants were instructed to record pain medications taken and pain intensity at the time of administration on the pain management log for 3 days after discharge. After surgery, a chart review was done to collect demographic and treatment data. Participants were interviewed by telephone on the first morning and third evening after discharge and information was recorded on the PEI. Data Analysis Data were entered into SPSS for Windows, Release 6.0. Descriptive statistics were computed for all variables. Independent t-tests were done to determine differences over time and between groups (i.e., gender, participants receiving instruction versus those who did not). Groups were compared for differences in total amount and percentage of medication administered, number of pain descriptors, pain intensity ratings, number of nonpharmacologic activities, relief obtained, reluctance to call doctor, interference ratings, and number of side effects. Correlations were done to explore relationships between variables: age, pain intensity rating, number of pain descriptors, amount of analgesic prescribed, amount of analgesic taken, pain intensity at time of medication administration, relief obtained, number of nonpharmacologic activities, interference ratings, and side effects. The comments on the open-ended questions were examined for reoccurring themes not covered in the structured interview.
RESULTS Sample Characteristics Of the 126 participants recruited 93 (74%) completed the study. The participants ranged in age from 60 to 84 years (M ⫽ 69.6, standard deviation [SD], 6.6). Additional characteristics of the sample are found in Table 1.
TABLE 1. Sample Characteristics Variable Gender Male Female Race White Black Other Martial status Married Widowed Single/divorced Type of surgery Hernia Hand Laparoscopic cholecystectomy TURP Rectal Foot Arthroscopy knee Shoulder/elbow Miscellaneous
n
%
49 44
53 47
75 14 4
80 15 4
68 17 8
73 18 4
23 15 14 12 6 6 4 4 6
25 16 15 13 7 7 5 5 7
Symptom Experience Results related to the symptom experience included choice of word descriptors (Table 2), location of pain (Table 2), pain intensity rating (Table 3), and interference from pain (Table 4). Overall, the most frequently chosen descriptors were “soreness,” “discomfort,” “painful,” “aching,” and “hurting” (see Table 2). Additional descriptors were chosen by 40% of the participants. These descriptors could be classified into two categories: description of severity (for example, unrelenting, debilitating, shattering, searing, and pervasive) or source and cause (for example, gastrointestinal and activity). Pain descriptors were chosen even when some individuals rated their pain at 0 or responded “none” when asked to identify a pain location. For example, 19 participants chose 0 as their worst pain intensity, yet 7 of these chose a pain descriptor. Overall, 89% experienced pain at the surgical site with 18 different participants (19%) complaining of pain in a nonsurgical site—most commonly the back (n ⫽ 6). Pain intensity for the past 24 hours was obtained for “worst,” “least,” “average,” and “now” on a scale of 0 to 10. Pain intensity decreased from the first morning to the third evening (see Table 3). Yet research (Serlin, Mendoza, Nakamura, Edwards, & Cleeland, 1995) has demonstrated pain ratings higher than 4 interfere substantially with a person’s activities and mood. On the first postoperative day, 66% of the participants rated their worst pain at a level of 5 or
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TABLE 2. Symptom Experience: Pain Description and Pain Location First Morning
Third Evening
N
N
(%)
63 43 33 39 32 21 22 8
(68) (46) (36) (42) (34) (23) (24) (8)
(%)
Pain Description Soreness 70 (75) Discomfort 56 (60) Painful 49 (46) Aching 44 (47) Hurting 43 (46) Heaviness 25 (27) Burning 23 (25) Cramping 8 (8) Mean number of pain descriptors chosen Pain location Surgical site 75 (81) Nonsurgical site 5 (5) Both sites 7 (8)
70 2 10
above. On the third evening, 39 of them (42%) still rated their worst pain level at 5 or above. Using a scale of 0 to 10, participants identified interference with daily activities caused by pain. Responses are reported in Table 4. Even on the third evening, pain caused substantial interference. More than one-third of the sample rated an interference of 5 or above (scale 0-10) for work and general activities. Almost a quarter of the sample rated interference with enjoyment of life at level 5 or above. Symptom Management Only one participant did not receive a prescription for pain medication because he told his doctor he “didn’t need anything and wouldn’t use it.” However, when asked to describe any discomfort he stated, “Can’t tell a lady the words I’d use” and rated his pain an 11. Only Pyridium was prescribed for four subjects. The remaining 88 participants (95%) had opioids prescribed as needed. Dosage frequency was ordered as needed
First Morning
Third Evening
Mean
(SD)
Mean
(SD)
3.4
(1.8)
2.7
(2.0)
(75) (2) (11)
every 4 hours (58%), every 4 to 6 hours (28%) or every 6 hours (31%). Most prescriptions were for 1 to 2 tablets (n ⫽ 75) but 12 participants received orders for only 1 tablet at a time. After discharge, 18 participants (19%) did not fill their prescriptions for a variety of reasons. Eight participants stated they didn’t think they would need it. One of them stated, “What does the doctor think he is doing? I’m a senior citizen and have not worked for 17 years. It costs $84 for 30 pills.” Eighty-four participants administered a variety of oral analgesics. The majority took either an opioid/ acetaminophen (APAP) combination (n ⫽ 66) with 13 of these individuals also taking a nonsteroidal antiinflammatory drug (NSAID) or APAP. Fifteen took only a NSAID or APAP and three took only Pyridium. The percentage of analgesic taken was calculated by dividing the amount of analgesic taken by the maximum amount of analgesic prescribed for the time period. Only a small percentage (38%) of the prescribed opioid was taken the first 24 hours and even less (26%)
TABLE 3. Symptom Experience: Pain Intensity Ratings for First Morning and Third Evening First Morning
Third Evening
Variable
Range*
Mean
(SD)
Range*
Mean
(SD)
t Value
p Value
Worst pain Least pain Average pain Now pain
0-10 0-7 0-10 0-8
5.5 1.6 3.4 2.1
(2.9) (1.6) (2.2) (2.0)
0-10 0-8 0-8.5 0-8
3.8 1.2 2.3 1.6
(2.8) (1.5) (1.9) (1.7)
⫺6.55 1.43 ⫺6.03 ⫺2.77
.001 .002 .001 .007
*Range depicts the range of responses given by participants on a scale of 0 to 10.
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TABLE 4. Symptom Experience: Interference Ratings* First Morning Interference Items
n
Normal work General activities Walking ability Enjoyment of life Sleep Mood Relationships
62 90 91 91 93 92 91
Third Evening
Mean
(SD)
n
5.4 4.7 3.3 3.0 2.5 2.1 1.7
(4.2) (3.8) (3.5) (3.5) (3.2) (2.8) (2.8)
74 87 82 93 93 92 93
Mean
(SD)
t Value
p Value
3.6 3.1 1.7 2.3 1.8 1.5 0.7
(3.7) (3.3) (2.6) (3.1) (2.7) (2.3) (1.7)
⫺3.63 ⫺4.29 ⫺5.87 ⫺2.04 ⫺1.99 ⫺2.05 ⫺3.53
.001 .000 .000 .044 .050 .043 .001
*Sample size varies because the participants whose response indicated that interference was caused by the surgery or doctor’s orders were not included in the analysis.
after that. More than half of the sample (n ⫽ 50) administered their opioid analgesic 1 tablet at a time; 66% waited until their pain was at an intensity rating of 5 or above before taking any pain medication. Approximately one-fourth of the participants indicated that their pain was relieved 50% or less. Strategies selected by participants that helped relieve pain are depicted in Table 5. From the list of nonpharmacologic activities in Table 5, 61% of the participants identified “to stay still or not move” as a strategy that helped relieved their pain. When asked which strategy was the most effective, the single most effective pain relief activity identified was taking pain medication (n ⫽ 36) with immobility coming in second (n ⫽ 30). TABLE 5. Strategies Chosen That Helped Relieve Pain (n1 ⴝ 90; n2 ⴝ 86) First Morning
Third Evening
Activities
n1
(%)
n2
(%)
Medication administration Immobility Stay still/not move Go to bed or try to sleep Distraction Watch television Talk to someone Think about something else Pray or meditate Listen to music Miscellaneous Walk or pace the floor Work to stay busy Massage the painful area Use cold application Use heat
68
76
65
76
55 49
61 54
38 31
44 36
44 39 35 30 18
49 43 39 33 20
42 30 33 25 20
49 35 38 29 23
18 10 10 10 6
20 11 11 11 7
12 13 13 14 10
14 15 15 16 12
Relationships between variables were explored: pain intensity rating, number of pain descriptors, amount of analgesic administered, pain intensity at time of medication administration, relief obtained, number of nonpharmacologic activities, and interference ratings. Correlations for the third evening are reported in Tables 6 and 7. In the text, the first morning is noted as r1, the third evening as r2. A mild to moderate inverse relationship was found between relief obtained and average pain intensity rating (r1 ⫽ ⫺.38, r2 ⫽ ⫺.54), supporting the theory that as less relief was identified, pain intensity was higher. The amount of opioids administered correlated positively with pain intensity ratings (r1 ⫽ .50, r2 ⫽ .28) demonstrating that patients with higher pain intensity ratings self-administered higher amounts of pain medication. Pain intensity at the time medication was taken showed a substantial to moderate correlation with average pain intensity ratings (r1 ⫽ .72, r2 ⫽ .66), indicating that the higher their pain intensity was when they administered their medication, the higher the pain intensity during the day. Pain intensity ratings correlated highly with interference on general activities, usual work, walking, and sleep, indicating the higher the pain intensity, the higher the interference rating. As expected, the interference ratings correlated inversely with relief obtained; that is, the greater the relief obtained, the lesser the interference with daily activities. Yet, there was a direct correlation between the amount of medication participants self-administered and the interference ratings. Participants who had the highest degree of interference also took the greatest amount of medication. Constipation was the most common reason identified as causing reluctance to take pain medication (Table 8). From a list of common side effects, 56 participants (60%) identified having at least one side effect from their pain medication. The most frequent
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TABLE 6. Correlation Coefficients for Average Pain Intensity, Pain Intensity Rating at Time of Medication Administration, Relief Obtained, Amount of Medication Administered and Interference Ratings on the Third Evening
Activities Mood Walking Work Relations Sleep Enjoyment
Pain Intensity
Pain Rating at Administration
Relief Obtained
Medication Amount
.69‡ .48‡ .53‡ .65‡ .32‡ .50† .45‡
.45‡ .25* .35‡ .45‡ .18 .63† .36†
–.47‡ –.32† –.14 –.38† –.12 –.09 –.20
.35‡ .31† .15 .31† .30† .28† .35†
*p ⬍ .05. † p ⬍ .01 ‡ p ⬍ .001
side effects identified by the participants who administered opioids were constipation (48%), drowsiness (27%), and nausea (10%). Other variables that influenced pain and pain management were explored. When asked if they received instructions for pain management, more than one-third of the participants (n ⫽ 34), did not remember receiving instructions regarding pain management. Participants who reported adequate pain management instruction (n ⫽ 51) did not differ significantly in the way they managed pain from those who did not recall receiving instructions (n ⫽ 34) or who felt they did not receive enough instructions (n ⫽ 8). Instructions were received from the physician (n ⫽ 27), the nurse (n ⫽ 19), both the physician and the nurse (n ⫽ 10), or the pharmacist (n ⫽ 1). When asked, on a scale of 0 to 10, how reluctant they would be to contact a physician or nurse about pain, men were found to be more reluctant than women to call the physician (t ⫽ 2.19, p ⫽ .03). One-quarter of the participants (n ⫽ 22) rated their reluctance toward calling their doctor at 5 or above.
Many of the other participants gave a qualifier such as “if pain is out of control” or “if I have a whole lot of pain.” This supported the finding that 13 participants stated their pain medication was not strong enough, but only 2 contacted their doctor. Also when asked, “Who they would contact if they had questions regarding pain management?” 67% stated they would call their doctor whereas 16% stated they would turn to a friend or family member who was medically trained. Only two individuals stated they would contact the hospital. The three open-ended questions were examined for any reoccurring information that was not addressed in the questionnaire. No additional information was identified in analysis.
DISCUSSION Symptom Experience The participants used a variety of words to describe their pain experiences. If an affirmative answer on any of the pain descriptors is an indication of discomfort, there were very few participants (4%) without discom-
TABLE 7. Correlation Coefficients for Pain Intensity, Amount of Medication Administered, Relief Obtained, Pain Rating at Time of Medication Administration on Third Evening
Medication amount Relief obtained Rating at administration *p ⬍ .05 † p ⬍ .01 ‡ p ⬍ .001
Average Pain
Medication Amount
Relief Obtained
.28† –.54‡ .66‡
— –.03 .16
— — –.28*
Pain Management of Older Adults
TABLE 8. Reasons For Reluctance to Take Medication (n1 ⴝ 93; n2 ⴝ 89) First Morning
Third Evening
Variable
n1
(%)
n2
(%)
Constipation Nausea Interaction with other drugs Concern over addiction Drowsiness/sedation Decreased ability to concentrate Possible confusion Other
20 12 9 7 6 6 3 12
21.5 12.9 9.7 7.5 6.5 6.5 3.2 12.9
21 12 4 4 3 5 1 10
23.6 13.5 4.5 4.5 4.0 5.4 1.0 11.2
fort. A quarter of the participants who rated their pain as 0 still chose pain descriptors from a list of synonyms indicating that they used other words for pain. Feldt, Ryden, and Miles (1998) also found that more subjects responded affirmatively to the words “discomfort,” “soreness,” “painful,” and “hurting” then to their original question of “Do you have pain?” Manz, Mosier, Nusser-Gerlach, Bergstrom, and Agrawal (2000) found that elderly clients did not respond to the question “Are you in pain?” but then indicated pain on an assessment tool. Therefore, asking an older person “Are you in pain?” or to just rate their pain may not elicit an accurate response. This finding illustrates a need to expand the terminology to include words such as “sore,” “uncomfortable,” and “aching” when assessing pain in older individuals and to telephone them postoperatively to evaluate progress. Nineteen percent of the participants had pain in a nonsurgical site that was aggravated by the surgery. Closs, Fairlough, Tierney, and Currie (1993) reported similar findings in which almost one-fourth of the 100 orthopedic surgical patients ages 70 and older reported nonsurgical back pain and one-fifth reported joint pain. Although most postoperative pain is caused by the surgical incision, there are other causes for pain after surgery. This finding has implications for positioning and handling patients during surgery and in recovery. Many participants in this study reported considerable interference from pain. Approximately onefourth of the participants reported an interference score of 5 or above on enjoyment of life. The greatest interference was with normal work, general activity, and walking. The importance of immediate resumption of unrestricted activity was reported by Bellis (1992) after 27,267 inguinal herniorrhaphy cases. He states “to delay vigorous ambulation invites disaster because pulmonary complications usually have their
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inception during the first 24 hours after the operation” (p. 168). Thus one of the goals of postoperative pain management is to provide analgesia sufficient to support activities. Nurses must assist patients in setting a comfort level goal that allows for mobility. Then, patients must be taught to administer adequate analgesic to support comfortable movement and not use immobility as a mechanism to control pain Interference with sleep deserves mention. Twentyone percent of participants reported sleep interference above a level 5. Similarly, Rawal et al. (1997) reported that 20% (n ⫽ 1035, ages 5 to 88) of their participants had difficulty sleeping because of severe pain after daytime surgery. Interference with sleep and its resultant fatigue may decrease the motivation to engage in physical activities necessary for recovery. Symptom Management Findings indicated that several factors contributed to the inadequate management of pain. Medication was prescribed on an “as needed” basis. One participant said, “I wish the doctor would have just told me to take my medication instead of just saying take it as I needed it. The pain got away from me and I had a horrible night. I should have stayed in the hospital where they would have treated me.” This finding supports the recommendation that pain medication should be given at regular intervals after surgery for 24 to 36 hours (Acute Pain Management Guideline Panel, 1992; Gloth, 2001). Although the findings indicate an underuse of analgesics, they may also indicate a lack of understanding of the role and importance of analgesics and pain relief in assisting the body to return to its optimal functioning as soon as possible. The majority of the participants took pain medication but more than half of the sample took only 1 tablet at a time. Sixty-six percent waited until their pain intensity was a 5 or above before administering medication. Those patients who waited to administer medication until they had higher levels of pain intensity (level 5 or above) also reported administering larger amounts of medication but receiving less relief. Furthermore, only a small percentage of the available pain medication was selfadministered. This result was similar to findings obtained by Bell and Reeves (1999), who reported only one-third of the prescribed medication was used postoperatively by older inpatients. Low administration rates would not necessarily mean that pain was undertreated if the pain intensity ratings were low. However, 66% of the participants on the first postdischarge day and 42% of the participants on the third postdischarge evening rated their pain at 5 or above. These findings are similar to those of Callesen, et al. (1998),
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who found that after outpatient hernia repair, 66% of the patients experienced moderate to severe pain on movement on the first day and 33% on the sixth day. Patients need to be informed that pain relief is a desired outcome and encouraged to take pain medications on a routine schedule to control pain rather than waiting until pain becomes severe. Several factors contributed to the reluctance of participants to take the optimal amount of pain medication. The most common reason stated for such reluctance was concern about developing constipation. This concern is real because constipation was identified by 48% of individuals taking opioid medications. Patients should be instructed on techniques to decrease constipation such as increasing intake of water and fruits and vegetables, maintaining mobility, and if prescribed, administering a laxative. Although previous studies reported that fear of addiction made participants reluctant to take medication (Beauregard, Pomp, & Choiniere, 1998; Knoer, Faut-Callahan, Paice, & Short, 1999), that finding was not supported in this study. Only 7% answered that addiction made them reluctant to take their medication. The most frequently selected nonpharmacologic pain relief activity was immobility. This finding is somewhat bothersome because the complications of immobility are well-documented (Faria, 1998). Further research needs to be done to determine if older adults are using immobility as a way to control pain. Currently, many hospitals give patients instructions to call their doctors if they have any questions regarding pain management. According to the findings in this study, this practice needs to be evaluated for older individuals. Twenty percent of the participants taking medication did not feel like their medication strength was right. Yet the majority of these participants did not contact the doctor to get a different prescription. In the current study, participants reported that they were not reluctant to contact the doctor but many participants qualified their answers
with comments about pain severity. This finding suggests that, in reality, they were reluctant to contact the doctor unless their pain was severe. Given these findings, pain management instructions are important. Yet only 55% percent of the sample remembered receiving instructions regarding pain management and 14% of these participants did not feel like they received enough instructions. More importantly the participants who reported receiving adequate pain management instructions did not differ in the way pain was managed or the outcome from the participants who did not receive instructions. Because one of the goals of outpatient surgeries is to discharge patients as quickly as possible, many institutions are providing written instructions to the patients, but many participants in this study stated they had written instructions but had not read them. Teaching methods need to be evaluated to find the most appropriate teaching methods to accommodate older individuals. Nurses have the ability to influence pain management through pain management instruction, but more participants reported receiving instructions from the doctors on pain control than from the nurse. One finding limits the generalizability of the results of the study. The majority of the sample (93%) had insurance that may have helped cover the expense of the pain medication. Yet, several participants reported expense as a barrier. The severity and duration of pain after outpatient surgery must not be underestimated. Alternatives need to be explored to give patients support for pain management at home, especially because patients may be reluctant to contact their doctors for questions regarding pain control.
ACKNOWLEDGMENT The author wishes to thank Dr. Margie Edel at St. Louis University and Dr. Betty Ferrell at City of Hope, Duarte, California, for their assistance and encouragement. Funded by Edna Malen Scholarship for Graduate Education and the Ruth and Al Kopolow Nursing Research Award.
Pain Management of Older Adults
REFERENCES Acute Pain Management Guideline Panel. (1992). Acute pain management: Operative or medical procedures and trauma. Clinical Practice Guideline. (Agency for Health Care Policy and Research Publication No. 92-0032). Rockville, MD: AHCPR, Public Health Service, U.S. Department of Health and Human Services. Beauregard, L., Pomp, A., & Choiniere, M. (1998). Severity and impact of pain after day-surgery. Canadian Journal of Anaesthesia, 45, 304-311. Bell, M. L., & Reeves, K. A. (1999). Postoperative pain management in the non-Hispanic white and Mexican American older adult. Seminars in Perioperative Nursing, 8, 7-11. Bellis, C. J. (1992). Immediate return to unrestricted work after inguinal herniorrhaphy. Personal experiences with 27,267 cases, local anesthesia, and mesh. Internal Surgery, 77, 167-169. Callesen, T., Bech, K., Nielsen, R., Andersen, J., Hesselfeldt, P., Roijaaer, O., & Kehlet, H. (1998). Pain after groin hernia repair. British Journal of Surgery, 85, 1412-1414. Celia, B. (2000). Age and gender differences in pain management following coronary artery bypass surgery. Journal of Gerontological Nursing, 26(5), 7-13. Chung, F., Mezei, G., & Tong, D. (1999). Adverse events in ambulatory surgery. A comparison between elderly and younger. Canadian Journal of Anaesthesia, 46(4), 309321. Chung, F., Ritchie, E., & Su, J. (1997). Postoperative pain in ambulatory surgery. Anesthesia and Analgesia, 85(4), 808-816. Closs, S. J., Fairlough, H., Tierney, A., & Currie, C. (1993). Pain in elderly orthopaedic patients. Journal of Clinical Nursing, 2, 41-45. Daut, R. L., Cleeland, C. S., & Flanery, R. C. (1983). Development of the Wisconsin brief pain questionnaire to assess pain in cancer and other diseases. Pain, 17, 197210. Devine, E. C., Bevsek, S. A., Brubakken, K., Johnson, B. P., Ryan, P., & Sliefert, M. K. (1999). AHCPR clinical practice guideline on surgical pain management: Adoption and outcomes. Research in Nursing and Health, 22, 119130. Dodd, M., Janson, S., Facione, N., Noreen, F., Faucett, J., Froelicher, E. S., Humphreys, J., Lee, K., Miaskowski, C., Puntillo, K., Rankin, S., & Taylor, D. (2001). Advancing the science of symptom management. Journal of Advanced Nursing 33(5), 668-676. Faria, S. H. (1998). Patient assessment. Assessment of immobility hazards. Home Care Provider, 3(4), 189-191.
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Feldt, K. S., Ryden, M. B., & Miles, S. (1998). Treatment of pain in cognitive intact older patients with hip-fractures. Journal of American Geriatrics Society, 46, 10791085. Fortier, J., Chung, F., & Su, J. (1998). Unanticipated admission after ambulatory surgery—A prospective study. Canadian Journal of Anaesthesia 45, 612-619. Gloth, F. M. (2001) Principles of perioperative pain management in older adults. Clinics in Geriatric Medicine, 17, 553-573. Hunter, J. D., Chamblers, W. A., & Penny, K. I. (1998). Minor morbidity after day-case surgery. Scottish Medical Journal, 43, 54-56. Kemper, J. A. (1998). Postoperative pain and pain management of the older individual following discharge from outpatient surgery. Unpublished doctoral dissertation, St. Louis University. Knoer, D. V., Faut-Callahan, M., Paice, J., & Short, S. (1999). Research. Utilization. Preoperative PCA teaching program to manage postoperative pain. MEDSURG Nursing 8(1) 25-33, 36. Lay, T. D., Puntillo, K. A., Miaskowski, C. A., & Wallhagen, M. I. (1996). Analgesics prescribed and administered to intensive care cardiac surgery patients: Does patient age make a difference? Progress in Cardiovascular Nursing, 11(4), 17-24. Lewis, C. K., Wahl, J., Yust, K., & Kaplan, S. (2000). Same-day surgery managed care: Monitoring patient and system variances. Journal of Perianesthesia Nursing, 15(1) 12-19. Manz, B. D., Mosier, R., Nusser-Gerlach, M. A., Bergstrom, N., & Agrawal, S. (2000). Pain assessment in the cognitive impaired and unimpaired elderly. Pain Management Nursing, 1, 106-115. Pellino, T. A. (1997). Relationships between patient attitudes, subjective norms, perceived control, and analgesic use following elective orthopedic surgery. Research in Nursing and Health, 20, 97-105. Rawal, N., Hylander, J., Nydahl, P. A., Olofsson, I., & Gupta, A. (1997). Survey of postoperative analgesia following ambulatory surgery. Acta Anaesthesiology Scandinavica, 41(8), 1017-1022. Sloman, R., Ahern, M., Wright, A., & Brown, L. (2001). Nurses’ knowledge of pain in the elderly. Journal of Pain and Symptom Management, 21, 317-322. Serlin, R. C., Mendoza, T. R., Nakamura, Y., Edwards, K. R., & Cleeland, C. S. (1995). When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain 16(2), 277-284.
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Judith A. Kemper
PAIN EXPERIENCE INTERVIEW
Pain Management of Older Adults
151
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Judith A. Kemper
Pain Management of Older Adults
153
y
From the Jewish Hospital College of Nursing and Allied Health at Washington University Medical Center, St. Louis, MO, Oklahoma National Guard, Oklahoma City, Oklahoma Address correspondence and reprint requests to Judith Ann Kemper, PhD, RN, LTC, 1637 Award Drive, Ballwin, MO 63021. E-mail: [email protected] © 2002 by the American Society of Pain Management Nurses 1524-9042/02/0304-0003$35.00/0 doi: 10.1053/jpmn.2002.126222
ABSTRACT:
Older adults manage their pain at home after outpatient surgery. Yet the experience and management of postoperative pain outside the hospital is largely unknown. The purpose of this study was to examine older adults’ experiences of postoperative pain and their methods of pain management after discharge from outpatient surgery. A telephone-based interview of 93 older adults (ages 60-84) showed that pain intensity reached a level of 5 (0 to 10 scale) for 66% of participants on the first morning and for 42% on the third evening after discharge. Pain interfered with activities for almost one-fourth of the participants. Reasons for high pain intensity scores included improper and inadequate dosage of pain medication. More than half of the participants chose to take only one pain tablet at a time and 66% waited until their pain intensity reached a rating of 5 or above before taking their analgesic medication. The participants who took pain medications at higher levels of pain intensity reported taking larger amounts of medication but receiving less pain relief. This finding substantiates the idea that it takes a larger dose of pain medication to decrease severe pain. Pain management instructions did not make a difference in the way pain was managed. Overall, findings indicate that older postoperative patients are not adequately medicating themselves for pain after discharge. Furthermore, when participants were asked, “From this list of nonpharmacologic activities, which activities helped relieve pain?” the most frequently selected answer was “to stay still or not move.” This finding requires further investigation to determine if older adults are using immobility as a way to control their pain. © 2002 by the American Society of Pain Management Nurses
Improvements in anesthesia and surgical procedures made ambulatory or outpatient surgery a viable option for older adults (Chung, Mezei, & Tong, 1999). With Medicare regulations requiring conservation of resources and minimization in length of hospitalization, increasing numbers of older people have outpatient surgery. One result is that patients are required to manage their pain at home. Yet the experience and management of postoperative pain outside the hospital setting is largely unknown. This lack of knowledge is of particular Pain Management Nursing, Vol 3, No 4 (December), 2002: pp 141-153
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concern for the older adult who may have different needs and require special strategies for optimal pain control. Even with the publication of the Agency for Health Care Policy and Research’s Clinical practice guideline on acute pain management: Operative or medical procedures (Acute Pain Management Guideline Panel, 1992), studies (Devine et al., 1999; Feldt, Ryden, & Miles, 1998) continue to report that many hospitalized patients are undertreated for postoperative pain and that physicians, nurses, and older patients themselves are reluctant to administer sufficient amounts of analgesics to adequately control postoperative pain (Celia, 2000; Lay, Puntillo, Miaskowski, & Wallhagen, 1996; Pellino, 1997). After outpatient surgery, pain is one of the primary variances that increases time to discharge (Chung, Ritchie, & Su, 1997; Lewis, Wahl, Yust, & Kaplan, 2000) and contributes to readmission (Fortier, Chung, & Su, 1998). Hunter and colleagues (1998) reported that 47% of 553 outpatient surgery patients judged their immediate postoperative course to be worse than they had expected. Studies across all age groups report that 36% to 67% of clients experienced moderate to severe pain at home after outpatient surgery (Beauregard, Pomp, & Choiniere, 1998; Rawal, Hylander, Nydahl, Olofsson, & Gupta, 1997). Because patients are expected to manage their pain, nurses need to know and understand the variables that keep patients from obtaining optimal pain control. Furthermore, research findings report a significant deficit in nurses’ knowledge regarding pain management in the elderly (Sloman, Ahern, Wright, & Brown, 2001). Gathering information about older adults’ self-reports of pain status and management is a prerequisite to designing effective postoperative pain control strategies. The Model for Symptom Management framed this study (Dodd et al., 2001). This model assumes that all troublesome symptoms need managing and that symptom management and the resulting outcomes are often the responsibility of the patient. Symptoms are identified and examined on the basis of three dimensions: the symptom experience, symptom management strategies, and symptom outcomes. This study explored variables associated with two of the three dimensions—symptom experience and symptom management. These variables were pain description, location, pain rating, interference rating, and pharmacologic and nonpharmacologic symptom management strategies.
PURPOSE The purpose of this exploratory study was to examine older individuals’ experiences of postoperative pain
and their methods of pain management after discharge from outpatient surgery. This study was designed to answer the following research questions: 1. How do older adults describe their pain after discharge from outpatient surgery? 2. What pharmacologic or nonpharmacologic pain management strategies are used by older adults after discharge from outpatient surgery? 3. What demographic variables, access to medication and access to medication information variables, side effect variables, or treatment variables influence postoperative pain and pain management of older adults after discharge from outpatient surgery?
METHODS Sample and Settings A convenience sample was recruited from two Midwestern metropolitan hospital– based outpatient surgery departments that perform approximately 16,500 and 5,300 outpatient surgeries yearly. Inclusion criteria for the study were patients older than 60 years, planned discharge within 23 hours after outpatient surgery to a nonmedical facility, and ability to answer the questionnaire. Participants who were admitted for more than 23 hours for medical-surgical reasons were excluded from the study. Instruments The Pain Experience Interview (PEI) (Appendix), a structured scripted interview, was used to collect data from participants by telephone. It consisted of three parts: a pain management log, the Brief Pain Inventory (BPI), and investigator-developed questions. On the pain management log, participants recorded time and dosage of prescription and over-the-counter pain medications and pain intensity at time of medication administration. The BPI is a reliable and well-validated self-report instrument frequently used with diverse populations of people experiencing pain (Daut, Cleeland, & Flanery, 1983). The nine-item BPI measures pain location, pain intensity (0 to 10 scale), pain interference with daily activities (0 to 10 scale), and relief obtained (0% to 100% scale). Investigator-developed questions consisted of checklists on each variable based on a literature review and discussions with pain research experts and gerontologic nurse practitioners (Kemper, 1998). Each list was followed with an open-ended question to elicit other answers not found on the list. Three openended questions were included at the end of the second interview to determine if information was missed on the structured interview. The three questions in-
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cluded: (1) What did you find most helpful about how to control pain? (2) What concerned you most about your pain or pain management? (3) Is there anything else you would like to tell me about pain or pain management? Three experts in the field of pain management reviewed the PEI for content validity and the tool was field-tested on five older individuals (65 to 88 years old) for comprehension and ability to answer the questions over the telephone (Kemper, 1998). Procedures.Approval was obtained from both hospitals’ institutional review boards. Participants were recruited after arriving for laboratory work or surgery and signed a written consent. Participants were given a copy of the PEI enlarged to a size 14 font and instructed that these were the questions they would be asked over the telephone. Participants were instructed to record pain medications taken and pain intensity at the time of administration on the pain management log for 3 days after discharge. After surgery, a chart review was done to collect demographic and treatment data. Participants were interviewed by telephone on the first morning and third evening after discharge and information was recorded on the PEI. Data Analysis Data were entered into SPSS for Windows, Release 6.0. Descriptive statistics were computed for all variables. Independent t-tests were done to determine differences over time and between groups (i.e., gender, participants receiving instruction versus those who did not). Groups were compared for differences in total amount and percentage of medication administered, number of pain descriptors, pain intensity ratings, number of nonpharmacologic activities, relief obtained, reluctance to call doctor, interference ratings, and number of side effects. Correlations were done to explore relationships between variables: age, pain intensity rating, number of pain descriptors, amount of analgesic prescribed, amount of analgesic taken, pain intensity at time of medication administration, relief obtained, number of nonpharmacologic activities, interference ratings, and side effects. The comments on the open-ended questions were examined for reoccurring themes not covered in the structured interview.
RESULTS Sample Characteristics Of the 126 participants recruited 93 (74%) completed the study. The participants ranged in age from 60 to 84 years (M ⫽ 69.6, standard deviation [SD], 6.6). Additional characteristics of the sample are found in Table 1.
TABLE 1. Sample Characteristics Variable Gender Male Female Race White Black Other Martial status Married Widowed Single/divorced Type of surgery Hernia Hand Laparoscopic cholecystectomy TURP Rectal Foot Arthroscopy knee Shoulder/elbow Miscellaneous
n
%
49 44
53 47
75 14 4
80 15 4
68 17 8
73 18 4
23 15 14 12 6 6 4 4 6
25 16 15 13 7 7 5 5 7
Symptom Experience Results related to the symptom experience included choice of word descriptors (Table 2), location of pain (Table 2), pain intensity rating (Table 3), and interference from pain (Table 4). Overall, the most frequently chosen descriptors were “soreness,” “discomfort,” “painful,” “aching,” and “hurting” (see Table 2). Additional descriptors were chosen by 40% of the participants. These descriptors could be classified into two categories: description of severity (for example, unrelenting, debilitating, shattering, searing, and pervasive) or source and cause (for example, gastrointestinal and activity). Pain descriptors were chosen even when some individuals rated their pain at 0 or responded “none” when asked to identify a pain location. For example, 19 participants chose 0 as their worst pain intensity, yet 7 of these chose a pain descriptor. Overall, 89% experienced pain at the surgical site with 18 different participants (19%) complaining of pain in a nonsurgical site—most commonly the back (n ⫽ 6). Pain intensity for the past 24 hours was obtained for “worst,” “least,” “average,” and “now” on a scale of 0 to 10. Pain intensity decreased from the first morning to the third evening (see Table 3). Yet research (Serlin, Mendoza, Nakamura, Edwards, & Cleeland, 1995) has demonstrated pain ratings higher than 4 interfere substantially with a person’s activities and mood. On the first postoperative day, 66% of the participants rated their worst pain at a level of 5 or
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TABLE 2. Symptom Experience: Pain Description and Pain Location First Morning
Third Evening
N
N
(%)
63 43 33 39 32 21 22 8
(68) (46) (36) (42) (34) (23) (24) (8)
(%)
Pain Description Soreness 70 (75) Discomfort 56 (60) Painful 49 (46) Aching 44 (47) Hurting 43 (46) Heaviness 25 (27) Burning 23 (25) Cramping 8 (8) Mean number of pain descriptors chosen Pain location Surgical site 75 (81) Nonsurgical site 5 (5) Both sites 7 (8)
70 2 10
above. On the third evening, 39 of them (42%) still rated their worst pain level at 5 or above. Using a scale of 0 to 10, participants identified interference with daily activities caused by pain. Responses are reported in Table 4. Even on the third evening, pain caused substantial interference. More than one-third of the sample rated an interference of 5 or above (scale 0-10) for work and general activities. Almost a quarter of the sample rated interference with enjoyment of life at level 5 or above. Symptom Management Only one participant did not receive a prescription for pain medication because he told his doctor he “didn’t need anything and wouldn’t use it.” However, when asked to describe any discomfort he stated, “Can’t tell a lady the words I’d use” and rated his pain an 11. Only Pyridium was prescribed for four subjects. The remaining 88 participants (95%) had opioids prescribed as needed. Dosage frequency was ordered as needed
First Morning
Third Evening
Mean
(SD)
Mean
(SD)
3.4
(1.8)
2.7
(2.0)
(75) (2) (11)
every 4 hours (58%), every 4 to 6 hours (28%) or every 6 hours (31%). Most prescriptions were for 1 to 2 tablets (n ⫽ 75) but 12 participants received orders for only 1 tablet at a time. After discharge, 18 participants (19%) did not fill their prescriptions for a variety of reasons. Eight participants stated they didn’t think they would need it. One of them stated, “What does the doctor think he is doing? I’m a senior citizen and have not worked for 17 years. It costs $84 for 30 pills.” Eighty-four participants administered a variety of oral analgesics. The majority took either an opioid/ acetaminophen (APAP) combination (n ⫽ 66) with 13 of these individuals also taking a nonsteroidal antiinflammatory drug (NSAID) or APAP. Fifteen took only a NSAID or APAP and three took only Pyridium. The percentage of analgesic taken was calculated by dividing the amount of analgesic taken by the maximum amount of analgesic prescribed for the time period. Only a small percentage (38%) of the prescribed opioid was taken the first 24 hours and even less (26%)
TABLE 3. Symptom Experience: Pain Intensity Ratings for First Morning and Third Evening First Morning
Third Evening
Variable
Range*
Mean
(SD)
Range*
Mean
(SD)
t Value
p Value
Worst pain Least pain Average pain Now pain
0-10 0-7 0-10 0-8
5.5 1.6 3.4 2.1
(2.9) (1.6) (2.2) (2.0)
0-10 0-8 0-8.5 0-8
3.8 1.2 2.3 1.6
(2.8) (1.5) (1.9) (1.7)
⫺6.55 1.43 ⫺6.03 ⫺2.77
.001 .002 .001 .007
*Range depicts the range of responses given by participants on a scale of 0 to 10.
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TABLE 4. Symptom Experience: Interference Ratings* First Morning Interference Items
n
Normal work General activities Walking ability Enjoyment of life Sleep Mood Relationships
62 90 91 91 93 92 91
Third Evening
Mean
(SD)
n
5.4 4.7 3.3 3.0 2.5 2.1 1.7
(4.2) (3.8) (3.5) (3.5) (3.2) (2.8) (2.8)
74 87 82 93 93 92 93
Mean
(SD)
t Value
p Value
3.6 3.1 1.7 2.3 1.8 1.5 0.7
(3.7) (3.3) (2.6) (3.1) (2.7) (2.3) (1.7)
⫺3.63 ⫺4.29 ⫺5.87 ⫺2.04 ⫺1.99 ⫺2.05 ⫺3.53
.001 .000 .000 .044 .050 .043 .001
*Sample size varies because the participants whose response indicated that interference was caused by the surgery or doctor’s orders were not included in the analysis.
after that. More than half of the sample (n ⫽ 50) administered their opioid analgesic 1 tablet at a time; 66% waited until their pain was at an intensity rating of 5 or above before taking any pain medication. Approximately one-fourth of the participants indicated that their pain was relieved 50% or less. Strategies selected by participants that helped relieve pain are depicted in Table 5. From the list of nonpharmacologic activities in Table 5, 61% of the participants identified “to stay still or not move” as a strategy that helped relieved their pain. When asked which strategy was the most effective, the single most effective pain relief activity identified was taking pain medication (n ⫽ 36) with immobility coming in second (n ⫽ 30). TABLE 5. Strategies Chosen That Helped Relieve Pain (n1 ⴝ 90; n2 ⴝ 86) First Morning
Third Evening
Activities
n1
(%)
n2
(%)
Medication administration Immobility Stay still/not move Go to bed or try to sleep Distraction Watch television Talk to someone Think about something else Pray or meditate Listen to music Miscellaneous Walk or pace the floor Work to stay busy Massage the painful area Use cold application Use heat
68
76
65
76
55 49
61 54
38 31
44 36
44 39 35 30 18
49 43 39 33 20
42 30 33 25 20
49 35 38 29 23
18 10 10 10 6
20 11 11 11 7
12 13 13 14 10
14 15 15 16 12
Relationships between variables were explored: pain intensity rating, number of pain descriptors, amount of analgesic administered, pain intensity at time of medication administration, relief obtained, number of nonpharmacologic activities, and interference ratings. Correlations for the third evening are reported in Tables 6 and 7. In the text, the first morning is noted as r1, the third evening as r2. A mild to moderate inverse relationship was found between relief obtained and average pain intensity rating (r1 ⫽ ⫺.38, r2 ⫽ ⫺.54), supporting the theory that as less relief was identified, pain intensity was higher. The amount of opioids administered correlated positively with pain intensity ratings (r1 ⫽ .50, r2 ⫽ .28) demonstrating that patients with higher pain intensity ratings self-administered higher amounts of pain medication. Pain intensity at the time medication was taken showed a substantial to moderate correlation with average pain intensity ratings (r1 ⫽ .72, r2 ⫽ .66), indicating that the higher their pain intensity was when they administered their medication, the higher the pain intensity during the day. Pain intensity ratings correlated highly with interference on general activities, usual work, walking, and sleep, indicating the higher the pain intensity, the higher the interference rating. As expected, the interference ratings correlated inversely with relief obtained; that is, the greater the relief obtained, the lesser the interference with daily activities. Yet, there was a direct correlation between the amount of medication participants self-administered and the interference ratings. Participants who had the highest degree of interference also took the greatest amount of medication. Constipation was the most common reason identified as causing reluctance to take pain medication (Table 8). From a list of common side effects, 56 participants (60%) identified having at least one side effect from their pain medication. The most frequent
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TABLE 6. Correlation Coefficients for Average Pain Intensity, Pain Intensity Rating at Time of Medication Administration, Relief Obtained, Amount of Medication Administered and Interference Ratings on the Third Evening
Activities Mood Walking Work Relations Sleep Enjoyment
Pain Intensity
Pain Rating at Administration
Relief Obtained
Medication Amount
.69‡ .48‡ .53‡ .65‡ .32‡ .50† .45‡
.45‡ .25* .35‡ .45‡ .18 .63† .36†
–.47‡ –.32† –.14 –.38† –.12 –.09 –.20
.35‡ .31† .15 .31† .30† .28† .35†
*p ⬍ .05. † p ⬍ .01 ‡ p ⬍ .001
side effects identified by the participants who administered opioids were constipation (48%), drowsiness (27%), and nausea (10%). Other variables that influenced pain and pain management were explored. When asked if they received instructions for pain management, more than one-third of the participants (n ⫽ 34), did not remember receiving instructions regarding pain management. Participants who reported adequate pain management instruction (n ⫽ 51) did not differ significantly in the way they managed pain from those who did not recall receiving instructions (n ⫽ 34) or who felt they did not receive enough instructions (n ⫽ 8). Instructions were received from the physician (n ⫽ 27), the nurse (n ⫽ 19), both the physician and the nurse (n ⫽ 10), or the pharmacist (n ⫽ 1). When asked, on a scale of 0 to 10, how reluctant they would be to contact a physician or nurse about pain, men were found to be more reluctant than women to call the physician (t ⫽ 2.19, p ⫽ .03). One-quarter of the participants (n ⫽ 22) rated their reluctance toward calling their doctor at 5 or above.
Many of the other participants gave a qualifier such as “if pain is out of control” or “if I have a whole lot of pain.” This supported the finding that 13 participants stated their pain medication was not strong enough, but only 2 contacted their doctor. Also when asked, “Who they would contact if they had questions regarding pain management?” 67% stated they would call their doctor whereas 16% stated they would turn to a friend or family member who was medically trained. Only two individuals stated they would contact the hospital. The three open-ended questions were examined for any reoccurring information that was not addressed in the questionnaire. No additional information was identified in analysis.
DISCUSSION Symptom Experience The participants used a variety of words to describe their pain experiences. If an affirmative answer on any of the pain descriptors is an indication of discomfort, there were very few participants (4%) without discom-
TABLE 7. Correlation Coefficients for Pain Intensity, Amount of Medication Administered, Relief Obtained, Pain Rating at Time of Medication Administration on Third Evening
Medication amount Relief obtained Rating at administration *p ⬍ .05 † p ⬍ .01 ‡ p ⬍ .001
Average Pain
Medication Amount
Relief Obtained
.28† –.54‡ .66‡
— –.03 .16
— — –.28*
Pain Management of Older Adults
TABLE 8. Reasons For Reluctance to Take Medication (n1 ⴝ 93; n2 ⴝ 89) First Morning
Third Evening
Variable
n1
(%)
n2
(%)
Constipation Nausea Interaction with other drugs Concern over addiction Drowsiness/sedation Decreased ability to concentrate Possible confusion Other
20 12 9 7 6 6 3 12
21.5 12.9 9.7 7.5 6.5 6.5 3.2 12.9
21 12 4 4 3 5 1 10
23.6 13.5 4.5 4.5 4.0 5.4 1.0 11.2
fort. A quarter of the participants who rated their pain as 0 still chose pain descriptors from a list of synonyms indicating that they used other words for pain. Feldt, Ryden, and Miles (1998) also found that more subjects responded affirmatively to the words “discomfort,” “soreness,” “painful,” and “hurting” then to their original question of “Do you have pain?” Manz, Mosier, Nusser-Gerlach, Bergstrom, and Agrawal (2000) found that elderly clients did not respond to the question “Are you in pain?” but then indicated pain on an assessment tool. Therefore, asking an older person “Are you in pain?” or to just rate their pain may not elicit an accurate response. This finding illustrates a need to expand the terminology to include words such as “sore,” “uncomfortable,” and “aching” when assessing pain in older individuals and to telephone them postoperatively to evaluate progress. Nineteen percent of the participants had pain in a nonsurgical site that was aggravated by the surgery. Closs, Fairlough, Tierney, and Currie (1993) reported similar findings in which almost one-fourth of the 100 orthopedic surgical patients ages 70 and older reported nonsurgical back pain and one-fifth reported joint pain. Although most postoperative pain is caused by the surgical incision, there are other causes for pain after surgery. This finding has implications for positioning and handling patients during surgery and in recovery. Many participants in this study reported considerable interference from pain. Approximately onefourth of the participants reported an interference score of 5 or above on enjoyment of life. The greatest interference was with normal work, general activity, and walking. The importance of immediate resumption of unrestricted activity was reported by Bellis (1992) after 27,267 inguinal herniorrhaphy cases. He states “to delay vigorous ambulation invites disaster because pulmonary complications usually have their
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inception during the first 24 hours after the operation” (p. 168). Thus one of the goals of postoperative pain management is to provide analgesia sufficient to support activities. Nurses must assist patients in setting a comfort level goal that allows for mobility. Then, patients must be taught to administer adequate analgesic to support comfortable movement and not use immobility as a mechanism to control pain Interference with sleep deserves mention. Twentyone percent of participants reported sleep interference above a level 5. Similarly, Rawal et al. (1997) reported that 20% (n ⫽ 1035, ages 5 to 88) of their participants had difficulty sleeping because of severe pain after daytime surgery. Interference with sleep and its resultant fatigue may decrease the motivation to engage in physical activities necessary for recovery. Symptom Management Findings indicated that several factors contributed to the inadequate management of pain. Medication was prescribed on an “as needed” basis. One participant said, “I wish the doctor would have just told me to take my medication instead of just saying take it as I needed it. The pain got away from me and I had a horrible night. I should have stayed in the hospital where they would have treated me.” This finding supports the recommendation that pain medication should be given at regular intervals after surgery for 24 to 36 hours (Acute Pain Management Guideline Panel, 1992; Gloth, 2001). Although the findings indicate an underuse of analgesics, they may also indicate a lack of understanding of the role and importance of analgesics and pain relief in assisting the body to return to its optimal functioning as soon as possible. The majority of the participants took pain medication but more than half of the sample took only 1 tablet at a time. Sixty-six percent waited until their pain intensity was a 5 or above before administering medication. Those patients who waited to administer medication until they had higher levels of pain intensity (level 5 or above) also reported administering larger amounts of medication but receiving less relief. Furthermore, only a small percentage of the available pain medication was selfadministered. This result was similar to findings obtained by Bell and Reeves (1999), who reported only one-third of the prescribed medication was used postoperatively by older inpatients. Low administration rates would not necessarily mean that pain was undertreated if the pain intensity ratings were low. However, 66% of the participants on the first postdischarge day and 42% of the participants on the third postdischarge evening rated their pain at 5 or above. These findings are similar to those of Callesen, et al. (1998),
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who found that after outpatient hernia repair, 66% of the patients experienced moderate to severe pain on movement on the first day and 33% on the sixth day. Patients need to be informed that pain relief is a desired outcome and encouraged to take pain medications on a routine schedule to control pain rather than waiting until pain becomes severe. Several factors contributed to the reluctance of participants to take the optimal amount of pain medication. The most common reason stated for such reluctance was concern about developing constipation. This concern is real because constipation was identified by 48% of individuals taking opioid medications. Patients should be instructed on techniques to decrease constipation such as increasing intake of water and fruits and vegetables, maintaining mobility, and if prescribed, administering a laxative. Although previous studies reported that fear of addiction made participants reluctant to take medication (Beauregard, Pomp, & Choiniere, 1998; Knoer, Faut-Callahan, Paice, & Short, 1999), that finding was not supported in this study. Only 7% answered that addiction made them reluctant to take their medication. The most frequently selected nonpharmacologic pain relief activity was immobility. This finding is somewhat bothersome because the complications of immobility are well-documented (Faria, 1998). Further research needs to be done to determine if older adults are using immobility as a way to control pain. Currently, many hospitals give patients instructions to call their doctors if they have any questions regarding pain management. According to the findings in this study, this practice needs to be evaluated for older individuals. Twenty percent of the participants taking medication did not feel like their medication strength was right. Yet the majority of these participants did not contact the doctor to get a different prescription. In the current study, participants reported that they were not reluctant to contact the doctor but many participants qualified their answers
with comments about pain severity. This finding suggests that, in reality, they were reluctant to contact the doctor unless their pain was severe. Given these findings, pain management instructions are important. Yet only 55% percent of the sample remembered receiving instructions regarding pain management and 14% of these participants did not feel like they received enough instructions. More importantly the participants who reported receiving adequate pain management instructions did not differ in the way pain was managed or the outcome from the participants who did not receive instructions. Because one of the goals of outpatient surgeries is to discharge patients as quickly as possible, many institutions are providing written instructions to the patients, but many participants in this study stated they had written instructions but had not read them. Teaching methods need to be evaluated to find the most appropriate teaching methods to accommodate older individuals. Nurses have the ability to influence pain management through pain management instruction, but more participants reported receiving instructions from the doctors on pain control than from the nurse. One finding limits the generalizability of the results of the study. The majority of the sample (93%) had insurance that may have helped cover the expense of the pain medication. Yet, several participants reported expense as a barrier. The severity and duration of pain after outpatient surgery must not be underestimated. Alternatives need to be explored to give patients support for pain management at home, especially because patients may be reluctant to contact their doctors for questions regarding pain control.
ACKNOWLEDGMENT The author wishes to thank Dr. Margie Edel at St. Louis University and Dr. Betty Ferrell at City of Hope, Duarte, California, for their assistance and encouragement. Funded by Edna Malen Scholarship for Graduate Education and the Ruth and Al Kopolow Nursing Research Award.
Pain Management of Older Adults
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