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Utilizing Pain Assessment Scales Increases the Frequency of Diagnosing Pain Among Elderly Nursing Home Residents
450
Journal of Pain and Symptom Management
Vol. 21 No. 6 June 2001
Original Article
Utilizing Pain Assessment Scales Increases the Frequency of Diagnosing Pain Among Elderly Nursing Home Residents Hosam K. Kamel, MD, Mohsen Phlavan, MD, Behnam Malekgoudarzi, MD, Philip Gogel, BS and John E. Morley, MB, BCh Division of Geriatric Medicine (H.K.K., P.G., J.E.M.), Saint Louis University School of Medicine, St. Louis, Missouri; Department of Medicine (M.P., B.M.), Nassau County Medical Center, East Meadow, New York; and GRECC Veterans Administration Medical Center (J.E.M.), St. Louis, Missouri, USA
Abstract To study the effect of utilizing a combination of three easily-administered pain assessment instruments on the frequency of diagnosing pain among elderly nursing home residents, a cross-sectional study was conducted at two academic skilled nursing facilities: an 899-bed facility in Long Island, New York, and a 201-bed facility in Maryland Heights, Missouri. A total of 305 randomly selected elderly ( 60 years) subjects were enrolled in this study. The study involved medical records abstracting and patient interviews. Pain was assessed in 150 (49%) subjects using the question “Do you have pain?” (Group 1). In the remaining 155 (51%) subjects (Group 2), pain was assessed using three pain assessment instruments: the visual analog scale, the behavior (faces) scale, and the pain descriptive scale. The overall frequency of diagnosing pain was greater in the subjects in Group 2 compared to the subjects in Group 1 (30% vs. 15%, P 0.01). Using the three pain assessment scales greatly increased the frequency of diagnosing pain among the old-old ( 85 years) residents (32% Group 2 vs. 6% Group 1, P 0.001). The frequency of diagnosing pain among cognitively impaired residents showed a similar trend (16% Group 2 vs. 10% Group 1, P 0.2). These data indicate that using three easily-administered pain assessment scales increased the frequency of diagnosing pain among nursing home residents. J Pain Symptom Manage 2001;21:450–455. © U.S. Cancer Pain Relief Committee, 2001. Key Words Pain, assessment, elderly, dementia, nursing home
Introduction Pain is a prevalent condition among the elderly population in United States. Pain has been reported in 25–50% of older persons living in the community,1–3 and in as many as 45–80% of
Address reprint requests to: Hosam K. Kamel, MD, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104, USA. Accepted for publication: August 4, 2000. © U.S. Cancer Pain Relief Committee, 2001 Published by Elsevier, New York, New York
nursing home residents.4–8 No physiologic changes in pain perception in the elderly have been demonstrated.9 In fact, older adults may experience more pain than younger people,10,11 although they may be less likely to complain of it.12 The consequences of chronic pain among older individuals are multiple. Depression,13–16 decreased socialization,17 sleep disturbances,18 impaired ambulation,19 agitated behavior,20 and increased health utilization and costs,19 have all been linked to pain in older adults. Pain assessment is generally complicated by 0885-3924/01/$–see front matter PII S0885-3924(01)00287-1
Vol. 21 No. 6 June 2001
Pain Assessment in the Nursing Home
the fact that pain is a subjective experience for which there are no objective biological markers available. Similar to other internal states, pain is usually assessed using self-reported measures.21 There are several added barriers to the evaluation of pain in elderly persons. Memory or sensory impairment, depression, and cognitive decline may all complicate pain assessment in older individuals.22 Elderly persons in general, and those with cognitive impairment in particular, have been shown to underreport pain.23,24 Different studies, however, indicate that cognitively impaired individuals are often able to report pain experience, and that their self-reports of pain are often as reliable as those of cognitively intact persons.25–27 Chronic pain in the long-term care setting is often underrecognized and undertreated.18 In a study of 13,625 elderly nursing home patients with cancer, 26% of patients with daily pain did not receive any analgesic agent. Residents older than 85 years, (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.13–1.73); and those with cognitive impairment, (OR, 1.23; 95% CI, 1.05– 1.44) were less likely to receive analgesic agents than their counterparts.28 Typical nursing home residents present many challenges to an adequate assessment of pain. Multiple concurrent illnesses and a high prevalence of cognitive impairment make pain evaluation a difficult task.29 Pain assessment instruments such as visual analog, word descriptor, and numerical scales have not been validated in older adults.22,30,31 In addition, a high prevalence of visual, hearing, motor, and cognitive impairments may impede the direct adaptation of many of these instruments to nursing home patients. Behavioral scales based on facial grimace and posturing have been investigated in infants in postoperative recovery rooms,32 but not in older adults. This study investigates the effect of utilizing a combination of three easily administered pain assessment instruments (the visual analog scale,33 the behavior scale,34 and the pain descriptive scale22) on the frequency of diagnosing pain among elderly ( 60 years) nursing home residents.
Methods Design, Setting, Subjects This is a cross-sectional study of two groups of elderly subjects ( 60 years) residing in two
451
academic skilled nursing facilities. Group 1 (n 150) was randomly selected from an 899-bed facility located in Long Island, New York, and group 2 (n 155) was randomly selected from a 201-bed facility located in Maryland Heights, Missouri. The study involved chart reviews by medical residents and medical students trained in medical record abstracting. Data on age, sex, race, and presence of dementia were abstracted from medical charts of subjects in both study groups. Additional data were abstracted form the medical charts of subjects in group 1 (n 150) on the presence of insomnia, agitation, loss of appetite, and weight loss, as well as on functional status, medical conditions, and number of medications. All subjects were also interviewed and assessed for the presence of pain. Charts were only reviewed after assessing subjects for the presence of pain. None of the study personnel was involved in the care of study subjects. In group 1, pain was assessed using the question “Do you have pain?” In group 2, pain was assessed using a combination of three standard pain assessment instruments: the visual analog scale,33 the behavior (faces) scale,34 and the pain descriptive scale.22 Pain was diagnosed if pain experience was detected by one or more of the three scales. In addition, cognitive function was assessed in 114 (74%) subjects from group 2 using the Folstein Mini-Mental State exam (MMSE).35 The two groups of study subjects were assessed by two different groups of study personnel. Study personnel who assessed group 2 subjects were trained by a board-certified geriatrician on how to administer the pain assessment scales as well as on how to conduct the MMSE test. The study was approved by both the Nassau County Medical Center and the Saint Louis University School of Medicine institutional review boards.
Statistical Analysis
All results are reported as mean ( SD) unless specified otherwise. Parameteric group mean data were analyzed by the student’s t-test or analysis of variance. When there was a significant difference demonstrated by analysis of variance, post-hoc analysis was performed by the Newman-Keuls procedure for subgroup analysis. Non-parametric group data were compared using the chi-square test. Statistical procedures were performed with the statistical package
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Statistica for Windows (Statsoft Inc., Tulsa, OK 1997). Significance was defined as a two-tailed P 0.05.
Results The characteristics of the study subjects are shown in Table 1. The prevalence of pain in group 1 subjects was 15%. Table 2 shows the frequencies of pain experience in this group of subjects in relation to age, sex, race, functional status, total number of medications, total number of medical conditions, as well as the presence of dementia, depression, constipation, diagnosis of diabetes, hyperglycemia, malnutrition, and of a biochemical evidence of dehydration. The old-old subjects ( 85 years) were less likely to report pain compared to younger subjects (6% vs. 19%, P 0.05). Similarly, residents with the diagnosis of dementia were less likely to report pain compared to those without dementia (10% vs. 25%, P 0.05). On the other hand, bedridden residents (50% vs. 13%, P 0.01), and those with constipation (32% vs. 12%, P 0.05) were more likely to report pain compared to their counterparts. Although the frequency of diagnosing pain was not related to the diagnosis of diabetes mellitus, residents with hyperglycemia (fasting blood glucose [FBG] 126 mg/dl)36 reported pain more frequently than those with FBG levels 126 mg/dl (30% vs. 11%, P 0.05). Subjects who reported pain had greater mean ( SEM) FBG levels compared to subjects who did not report pain (118 6, 103 5, P 0.05). The frequency of diagnosing pain in this group of subjects was not related to race, sex,
Vol. 21 No. 6 June 2001
or to presence of protein-energy malnutrition (defined as serum albumin 3.5 g/dl).37 The total number of medications, mean SE (13 5 in subjects with pain vs. 6 2 in those without pain, P 0.01), but not the total number of medical conditions, was associated with the frequency of diagnosing pain in this group of subjects. Residents who reported pain were more likely to also have insomnia (9% vs. 2%, P 0.05), but not agitation, loss of appetite, or weight loss (Table 3). In group 2 subjects, the utilization of the visual analog,32 the behavior (faces),33 and the pain descriptive scales,22 was associated with increased frequency of diagnosing pain in subjects compared to those in group 1 (30% vs. 15%, P 0.01). The effect was most apparent among the old-old residents (32% group 2 vs. 6% group 1, P 0.001). There was a similar trend among the cognitively impaired residents (16% group 2 vs. 10% group 1, P 0.2). These findings are summarized in Table 4. The Folstein MMSE was performed on 74% (n 115) of subjects in this group (the rest of the subjects refused to cooperate with the testing). The MMSE scores were greater among the residents in whom the diagnosis of pain was made compared to the residents in whom the diagnosis of pain was not made (mean SD, 22 6 vs. 17 8, P 0.001).
Discussion The Agency for Health Care Policy and Research highlighted the fact that most pain research has systematically excluded elderly persons.38,39 The validity of many pain assessment instruments was established in younger adults
Table 1 Characteristics of Study Subjects Characteristic Number of subjects Source Age Mean ( SD) Range Sex Male n (%) Female n (%) Race White n (%) Black n (%) Other n (%)
Group 1
Group 2
150 899-bed academic nursing home in New York
155 201-bed academic nursing home in Missouri
81 9 years 60–98 years
83 8 years 60–102 years
49 (33%) 101 (67%)
25 (16%) 130 (84%)
105 (70%) 38 (25%) 7 (5%)
139 (90%) 16 (10%) 0 (0%)
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Table 2 The Effect of Different Factors on the Frequency of Diagnosing Pain in Group 1 Subjects Group 1 Subjects n 150 Age 60–85 years (n 98) 85 years (n 52) Sex Male (n 49) Female (n 101) Race White (n 105) Black (n 38) Functional status Bedridden (n 6) Ambulatory (n 144) Dementia (n 102) No dementia (n 48) Diabetic (n 36) Non-diabetic (n 114) FBGa 126 mg/dl (n 123) FBG 126 mg/dl (n 23) Malnutritionb (n 78) No malnutrition (n 59) Dehydrationc (n 83) No dehydration (n 61) Constipation (n 22) No constipation (n 127) Number of medications (M SEM) Fasting blood glucose (mg/dl) (M SEM) Number of medical conditionsd (M SD)
Subjects with Pain n 22 (15%)
P
19 (19%) 3 (6%)
0.02
10 (20%) 12 (12%)
0.2
14 (13%) 6 (16%)
0.7
3 (50%) 19 (13%) 10 (10%) 12 (25%) 6 (17%) 16 (14%) 14 (11%) 7 (30%) 9 (12%) 9 (15%) 10 (12%) 12 (20%) 7 (32%) 15 (12%) 13 5 103 5 52
0.0001 0.01 0.7 0.02 0.5 0.2 0.01 6 2 0.002 118 6 0.02 6 2 0.5
Fasting blood glucose. is defined as serum albumin 3.5 g/dl. cDehydration is defined as BUN/Cr 20. dNumber of medical conditions was based on information abstracted from medical charts. aFBG
bMalnutrition
with little if any research done in older individuals. In addition, the high prevalence of visual, hearing, motor, and cognitive impairments may impede the direct adaptation of many of these instruments in nursing home populations. The role of skilled nursing facilities in caring for older adults is becoming increasingly important due to the decline in hospital length of stay, and the aging of the population.40 Five percent of persons older than age 65 live in a nursing home at any one time, approximately one-third of all individuals in the United States will pass through a long-term care facility before they die, and large numbers will die there.41 At the present time, resident assessment in the nursing home is largely based on the 350-item Minimum Data Set (MDS).42 The MDS items address several aspects including sociodemographic information, functional dependence, cognitive functioning, clinical diagnoses, treatment provided, as well as an extensive arrays of signs and symptoms. The
recording of pain experience, however, is not a special focus of the MDS.43,44 In this study, we compared two methods of pain assessment in two groups of elderly nursing home residents. In the first group of residents, pain was assessed by asking the question “Do you have pain?” In the second group of residents, assessments were made by administering three pain assessment scales: the visual analog scale,32 the behavior (faces) scale,33 and the pain descriptive scale.22 These scales were chosen because they are easily administered and because they utilize different methods in assessing pain: verbal communication (pain descriptive scale), visual communication (visual analog scale), and assessment of behavior (faces scale). The results from this study highlight several important points. The utilization of three easily administered pain assessment scales resulted in increased frequency of diagnosing pain in the nursing home, especially among the old-old residents, compared to just asking the question
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Table 3 The Frequency of Different Associated Symptoms Among Subjects in Group 1 Who Reported Pain
Symptom Agitation Loss of appetite Insomnia Weight loss
Frequency in Subjects with Pain (n 22) n (%) 1 (5) 1 (5) 2 (9) 3 (14)
Frequency in Subjects without Pain (n 128) n (%)
P
3 (2) 3 (2) 2 (2) 8 (6)
0.5 0.5 0.04 0.2
“Do you have pain?” Several factors may have contributed to this observation. Older adults may use different terminology to describe pain. They often describe discomfort, hurting, or aching, rather than use the specific word pain.1 In addition, nursing home residents often believe that pain is to be expected with aging and that complaining of pain may negatively affect their care.5 They may also fear the meaning of pain and associate its presence with death or disease progression. The presence of sensory or cognitive impairments may also affect pain assessments using direct questioning. The frequency of diagnosing pain in group 2 subjects correlated positively with the MMSE scores. That is, subjects with lesser degrees of cognitive impairment (higher MMSE scores) were more likely to report pain when using these three assessment scales compared to subjects with lower MMSE scores (more severe cognitive impairment). Isolated effects of individual pain assessment scales on the frequency of diagnosing pain were not evaluated in this study. One of the limitations of this study is that, with the exception of pain experience, all the other data were abstracted from medical charts and may have been affected by the variation in the accuracy of documentation especially in relation to the presence of associated symptoms Table 4 The Frequency of Diagnosing Pain Among the Two Study Subject Groups Pain Frequency, n (%)
All subjects Subjects with dementia Subjects older than 85 years
Group 1 (n 150)
Group 2 (n 155)
P
22/150 (15)
47/155 (30)
0.001
10/102 (10)
9/55 (16)
0.2
3/52 (6)
22/69 (32)
0.0004
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(e.g. loss of appetite, agitation, and insomnia). In addition, the observed association between polypharmacy and increased frequency of reported pain may have been confounded by the fact that pain medications may have contributed to the occurrence of polypharmacy. Information on types and number of pain medications was not recorded in this study. Similar consideration may apply to the observed association between constipation and pain experience, since constipation may be caused by opioid analgesics used to treat pain. Another potential weakness of this study is that we were unable to adjust for the possible effect of vision and hearing impairments on reporting pain experience. Although none of the subjects carried a diagnosis of being blind or deaf, we did not perform formal assessments of visual or hearing functions. Finally, 26% of subject in group 2 refused to cooperate with the MMSE testing. The characteristics of these subjects may have been substantially different from the 115 subjects who cooperated with the MMSE testing which may have biased the observed relation between MMSE scores and the frequency of diagnosing pain in group 2 subjects.
References 1. American Geriatrics Society Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. AGS clinical practice guidelines. J Am Geriatr Soc 1998;46:635-651 2. Ferrell BA. Pain management in elderly people. J Am Geriatr Soc 1991;39:64–73. 3. Ferrell BA, Ferrell BR. Principles of pain management in older people. Compr Ther 1991;17:53–58. 4. Shapiro RS. Liability issues in the management of pain. J Pain Symptom Manage 1994;9:1–7. 5. Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatric Soc 1990;38:409–414. 6. Roy R, Michael T. A survey of chronic pan in an elderly population. Can Fam Physician Med Fam Can 1986;32:513–516. 7. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10:591–598. 8. Lau-Ting C, Phoom WO. Aches and pains among Singapore elderly. Singapore Med J 1988;29: 164–167. 9. Kwentus JA, Harkins SW, Lignon N, et al. Current concept of geriatric pain and its treatment. Geriatrics 1985;40:48–57. 10. Corran TM, Gibson SJ, Ferrell MJ, Helme RD.
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Comparison of chronic pain experience between young and elderly patients. In: Gebhart GF, Hammond DL, Jensen TS, eds. Proceedings of the 7th World Congress on PIN, Vol 2: Progress in PIN research and management, Seattle, WA: IASP Press, 1994:895–906.
28. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly patients with cancer. JAMA 1998;279:1877–1882.
11. Institute of Medicine. Approaching death: improving care at the end of life. Washington, DC: National Academy Press, 1997:51–86.
30. Ohnhaus E, Adlev R. Methodologic problems in the measurement of pain: a comparison between verbal rating scales and the visual analog scale. Pain 1975;1:379–384.
12. Melding PS. Is there such a thing as geriatric pain? Pain 1991;46:119–121. 13. Megni G, Mchetti M, Moreschi C, et al. Chromic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination: I. Epidemiologic follow-up study. Pain 1993;53:163–168. 14. Dworkin SF, Von Korff M, LeResche L. Multiple pains and psychiatric disturbance: an epidemiologic investigation. Arch Gen Psychiatry 1990;47:239–244. 15. Parmelee PA, Katz IR, Lawton MP. The relation of pain to depression among institutionalized aged. J Gerontol 1991;46:15–21. 16. Roy R. A psychological perspective on chronic pain and depression in the elderly. Soc Work Health Care 1986;12:27–36. 17. Lavsky-Shulan M, Wallace RB, Kohourt FJ, et al. Prevalence and function correlates of low back pain in the elderly: The Iowa 65 Rural Health Study. J Am Geriatr Soc 1985;33:23–28. 18. Ferrell BA. Care of cancer patients in nursing home. Oncology 1992;6(Suppl):141–145. 19. Ferrell BA. Pain evaluation and management in the nursing home. Ann Intern Med 1995;123:681–687. 20. Cohen-Mansfield J, Marx MS, Werner P. Agitation in elderly persons: an integrative report of findings in a nursing home. Int Psychogeriatr 1988;4:221–240. 21. Chronic pain management in the long-term care setting. AMDA clinical practice guidelines. American Medical Director Association, 1999. 22. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10;591–589. 23. Parmelee PA, Smith B, Katz IR. Pain complains and cognitive status among elderly institution residents. J Am Geriatr Soc 1993;41:517–522. 24. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status among elderly institution residents. J Am Geriatr Soc 1993;41:517–522. 25. Stein WM, Ferrell BA. Pain in the nursing home. Clin Geriat Med 1996;12:601–613. 26. Hurley AC, Volicer BJ, Hanrahan PA, et al. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992;15:369–377. 27. Parke B. Realizing the presence of pain in cognitively impaired older adults: gerontological nurses’ways of knowing. J Gerontol Nurs 1998; 24(6):21–8.
29. Nishikawa ST, Ferrell BA. Pain assessment in the elderly. Clin Geriat Issues Long Term Care 1993;1: 15–28.
31. Herr KA, Mobily PR. Comparative of selected pain assessment tools for use with the elderly. Appl Nurs Res 1993;6:39–46. 32. Barrier G, Attia J, Mayer MN, et al. Measurement of post-operative pain and narcotic administration in infants using a new clinical scoring system. Intensive Care Med 1989;14(Suppl 1):S37–39. 33. Herr KA, Mobily PR, Kohout FJ, Wagenaaar D. Evaluation of the faces pain scale for use with the elderly. Pain 1998;14:29–38. 34. Follick MJ, Ahern DK, Laser-Wolston N. Evaluation of a daily activity for chronic pain patients. Pain 1984;19:373–382. 35. Folstein MF, Folstein SE, McHugh PR. “Mini-mental State”. A practical method for grading the cognitive state for the clinician. J Psych Res 1975;12:189–198. 36. American Diabetes Association. Clinical practice recommendation 1998. Diabetes Care 1998; 21(Suppl 1):S1–S98. 37. Rudman D, Fellwer AG. Protein calorie undernutrition in the nursing home. J Am Geriatr Soc 1989;37:173–183. 38. Acute Pain Management: Operative of Medical Procedures and Trauma. Rockville, MD:U.S] Department of Health and Human Services, Public Health Service, Agency of Health Care Policy and Research 1992. 39. Jacox A, Carr DB, Payne R, et al. Management of Cancer Pain. Rockville, MD:U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research: 1994. Clinical Practice Guidelines no. 9. AHCPR Publication no. 94-0592. 40. Kahn KL, Keeler EB, Sherwood MJ, et al. Comparing outcomes of care before and after implementation of DRG-based prospective payment system. JAMA 1990;264:1984–1988. 41. Steel K, Ribbe M, Ahronheim J, et al. Incorporating education on palliative care into the longterm care setting. JAGS 1999;47:904–907. 42. Schroll M. Effect of systematic geriatric assessment. Lancet 1997;350:604–605. 43. Minimum Data Set Plus Training Manual. Natick, Mass: Eliot Press; 1991. 44. Morris JN, Hawes C, Fries BE, et al. Designing the national resident assessment for nursing homes. Gerontologist 1990;30:293–297.
Journal of Pain and Symptom Management
Vol. 21 No. 6 June 2001
Original Article
Utilizing Pain Assessment Scales Increases the Frequency of Diagnosing Pain Among Elderly Nursing Home Residents Hosam K. Kamel, MD, Mohsen Phlavan, MD, Behnam Malekgoudarzi, MD, Philip Gogel, BS and John E. Morley, MB, BCh Division of Geriatric Medicine (H.K.K., P.G., J.E.M.), Saint Louis University School of Medicine, St. Louis, Missouri; Department of Medicine (M.P., B.M.), Nassau County Medical Center, East Meadow, New York; and GRECC Veterans Administration Medical Center (J.E.M.), St. Louis, Missouri, USA
Abstract To study the effect of utilizing a combination of three easily-administered pain assessment instruments on the frequency of diagnosing pain among elderly nursing home residents, a cross-sectional study was conducted at two academic skilled nursing facilities: an 899-bed facility in Long Island, New York, and a 201-bed facility in Maryland Heights, Missouri. A total of 305 randomly selected elderly ( 60 years) subjects were enrolled in this study. The study involved medical records abstracting and patient interviews. Pain was assessed in 150 (49%) subjects using the question “Do you have pain?” (Group 1). In the remaining 155 (51%) subjects (Group 2), pain was assessed using three pain assessment instruments: the visual analog scale, the behavior (faces) scale, and the pain descriptive scale. The overall frequency of diagnosing pain was greater in the subjects in Group 2 compared to the subjects in Group 1 (30% vs. 15%, P 0.01). Using the three pain assessment scales greatly increased the frequency of diagnosing pain among the old-old ( 85 years) residents (32% Group 2 vs. 6% Group 1, P 0.001). The frequency of diagnosing pain among cognitively impaired residents showed a similar trend (16% Group 2 vs. 10% Group 1, P 0.2). These data indicate that using three easily-administered pain assessment scales increased the frequency of diagnosing pain among nursing home residents. J Pain Symptom Manage 2001;21:450–455. © U.S. Cancer Pain Relief Committee, 2001. Key Words Pain, assessment, elderly, dementia, nursing home
Introduction Pain is a prevalent condition among the elderly population in United States. Pain has been reported in 25–50% of older persons living in the community,1–3 and in as many as 45–80% of
Address reprint requests to: Hosam K. Kamel, MD, Division of Geriatric Medicine, Saint Louis University School of Medicine, 1402 S. Grand Blvd., M238, St. Louis, MO 63104, USA. Accepted for publication: August 4, 2000. © U.S. Cancer Pain Relief Committee, 2001 Published by Elsevier, New York, New York
nursing home residents.4–8 No physiologic changes in pain perception in the elderly have been demonstrated.9 In fact, older adults may experience more pain than younger people,10,11 although they may be less likely to complain of it.12 The consequences of chronic pain among older individuals are multiple. Depression,13–16 decreased socialization,17 sleep disturbances,18 impaired ambulation,19 agitated behavior,20 and increased health utilization and costs,19 have all been linked to pain in older adults. Pain assessment is generally complicated by 0885-3924/01/$–see front matter PII S0885-3924(01)00287-1
Vol. 21 No. 6 June 2001
Pain Assessment in the Nursing Home
the fact that pain is a subjective experience for which there are no objective biological markers available. Similar to other internal states, pain is usually assessed using self-reported measures.21 There are several added barriers to the evaluation of pain in elderly persons. Memory or sensory impairment, depression, and cognitive decline may all complicate pain assessment in older individuals.22 Elderly persons in general, and those with cognitive impairment in particular, have been shown to underreport pain.23,24 Different studies, however, indicate that cognitively impaired individuals are often able to report pain experience, and that their self-reports of pain are often as reliable as those of cognitively intact persons.25–27 Chronic pain in the long-term care setting is often underrecognized and undertreated.18 In a study of 13,625 elderly nursing home patients with cancer, 26% of patients with daily pain did not receive any analgesic agent. Residents older than 85 years, (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.13–1.73); and those with cognitive impairment, (OR, 1.23; 95% CI, 1.05– 1.44) were less likely to receive analgesic agents than their counterparts.28 Typical nursing home residents present many challenges to an adequate assessment of pain. Multiple concurrent illnesses and a high prevalence of cognitive impairment make pain evaluation a difficult task.29 Pain assessment instruments such as visual analog, word descriptor, and numerical scales have not been validated in older adults.22,30,31 In addition, a high prevalence of visual, hearing, motor, and cognitive impairments may impede the direct adaptation of many of these instruments to nursing home patients. Behavioral scales based on facial grimace and posturing have been investigated in infants in postoperative recovery rooms,32 but not in older adults. This study investigates the effect of utilizing a combination of three easily administered pain assessment instruments (the visual analog scale,33 the behavior scale,34 and the pain descriptive scale22) on the frequency of diagnosing pain among elderly ( 60 years) nursing home residents.
Methods Design, Setting, Subjects This is a cross-sectional study of two groups of elderly subjects ( 60 years) residing in two
451
academic skilled nursing facilities. Group 1 (n 150) was randomly selected from an 899-bed facility located in Long Island, New York, and group 2 (n 155) was randomly selected from a 201-bed facility located in Maryland Heights, Missouri. The study involved chart reviews by medical residents and medical students trained in medical record abstracting. Data on age, sex, race, and presence of dementia were abstracted from medical charts of subjects in both study groups. Additional data were abstracted form the medical charts of subjects in group 1 (n 150) on the presence of insomnia, agitation, loss of appetite, and weight loss, as well as on functional status, medical conditions, and number of medications. All subjects were also interviewed and assessed for the presence of pain. Charts were only reviewed after assessing subjects for the presence of pain. None of the study personnel was involved in the care of study subjects. In group 1, pain was assessed using the question “Do you have pain?” In group 2, pain was assessed using a combination of three standard pain assessment instruments: the visual analog scale,33 the behavior (faces) scale,34 and the pain descriptive scale.22 Pain was diagnosed if pain experience was detected by one or more of the three scales. In addition, cognitive function was assessed in 114 (74%) subjects from group 2 using the Folstein Mini-Mental State exam (MMSE).35 The two groups of study subjects were assessed by two different groups of study personnel. Study personnel who assessed group 2 subjects were trained by a board-certified geriatrician on how to administer the pain assessment scales as well as on how to conduct the MMSE test. The study was approved by both the Nassau County Medical Center and the Saint Louis University School of Medicine institutional review boards.
Statistical Analysis
All results are reported as mean ( SD) unless specified otherwise. Parameteric group mean data were analyzed by the student’s t-test or analysis of variance. When there was a significant difference demonstrated by analysis of variance, post-hoc analysis was performed by the Newman-Keuls procedure for subgroup analysis. Non-parametric group data were compared using the chi-square test. Statistical procedures were performed with the statistical package
452
Kamel et al.
Statistica for Windows (Statsoft Inc., Tulsa, OK 1997). Significance was defined as a two-tailed P 0.05.
Results The characteristics of the study subjects are shown in Table 1. The prevalence of pain in group 1 subjects was 15%. Table 2 shows the frequencies of pain experience in this group of subjects in relation to age, sex, race, functional status, total number of medications, total number of medical conditions, as well as the presence of dementia, depression, constipation, diagnosis of diabetes, hyperglycemia, malnutrition, and of a biochemical evidence of dehydration. The old-old subjects ( 85 years) were less likely to report pain compared to younger subjects (6% vs. 19%, P 0.05). Similarly, residents with the diagnosis of dementia were less likely to report pain compared to those without dementia (10% vs. 25%, P 0.05). On the other hand, bedridden residents (50% vs. 13%, P 0.01), and those with constipation (32% vs. 12%, P 0.05) were more likely to report pain compared to their counterparts. Although the frequency of diagnosing pain was not related to the diagnosis of diabetes mellitus, residents with hyperglycemia (fasting blood glucose [FBG] 126 mg/dl)36 reported pain more frequently than those with FBG levels 126 mg/dl (30% vs. 11%, P 0.05). Subjects who reported pain had greater mean ( SEM) FBG levels compared to subjects who did not report pain (118 6, 103 5, P 0.05). The frequency of diagnosing pain in this group of subjects was not related to race, sex,
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or to presence of protein-energy malnutrition (defined as serum albumin 3.5 g/dl).37 The total number of medications, mean SE (13 5 in subjects with pain vs. 6 2 in those without pain, P 0.01), but not the total number of medical conditions, was associated with the frequency of diagnosing pain in this group of subjects. Residents who reported pain were more likely to also have insomnia (9% vs. 2%, P 0.05), but not agitation, loss of appetite, or weight loss (Table 3). In group 2 subjects, the utilization of the visual analog,32 the behavior (faces),33 and the pain descriptive scales,22 was associated with increased frequency of diagnosing pain in subjects compared to those in group 1 (30% vs. 15%, P 0.01). The effect was most apparent among the old-old residents (32% group 2 vs. 6% group 1, P 0.001). There was a similar trend among the cognitively impaired residents (16% group 2 vs. 10% group 1, P 0.2). These findings are summarized in Table 4. The Folstein MMSE was performed on 74% (n 115) of subjects in this group (the rest of the subjects refused to cooperate with the testing). The MMSE scores were greater among the residents in whom the diagnosis of pain was made compared to the residents in whom the diagnosis of pain was not made (mean SD, 22 6 vs. 17 8, P 0.001).
Discussion The Agency for Health Care Policy and Research highlighted the fact that most pain research has systematically excluded elderly persons.38,39 The validity of many pain assessment instruments was established in younger adults
Table 1 Characteristics of Study Subjects Characteristic Number of subjects Source Age Mean ( SD) Range Sex Male n (%) Female n (%) Race White n (%) Black n (%) Other n (%)
Group 1
Group 2
150 899-bed academic nursing home in New York
155 201-bed academic nursing home in Missouri
81 9 years 60–98 years
83 8 years 60–102 years
49 (33%) 101 (67%)
25 (16%) 130 (84%)
105 (70%) 38 (25%) 7 (5%)
139 (90%) 16 (10%) 0 (0%)
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Table 2 The Effect of Different Factors on the Frequency of Diagnosing Pain in Group 1 Subjects Group 1 Subjects n 150 Age 60–85 years (n 98) 85 years (n 52) Sex Male (n 49) Female (n 101) Race White (n 105) Black (n 38) Functional status Bedridden (n 6) Ambulatory (n 144) Dementia (n 102) No dementia (n 48) Diabetic (n 36) Non-diabetic (n 114) FBGa 126 mg/dl (n 123) FBG 126 mg/dl (n 23) Malnutritionb (n 78) No malnutrition (n 59) Dehydrationc (n 83) No dehydration (n 61) Constipation (n 22) No constipation (n 127) Number of medications (M SEM) Fasting blood glucose (mg/dl) (M SEM) Number of medical conditionsd (M SD)
Subjects with Pain n 22 (15%)
P
19 (19%) 3 (6%)
0.02
10 (20%) 12 (12%)
0.2
14 (13%) 6 (16%)
0.7
3 (50%) 19 (13%) 10 (10%) 12 (25%) 6 (17%) 16 (14%) 14 (11%) 7 (30%) 9 (12%) 9 (15%) 10 (12%) 12 (20%) 7 (32%) 15 (12%) 13 5 103 5 52
0.0001 0.01 0.7 0.02 0.5 0.2 0.01 6 2 0.002 118 6 0.02 6 2 0.5
Fasting blood glucose. is defined as serum albumin 3.5 g/dl. cDehydration is defined as BUN/Cr 20. dNumber of medical conditions was based on information abstracted from medical charts. aFBG
bMalnutrition
with little if any research done in older individuals. In addition, the high prevalence of visual, hearing, motor, and cognitive impairments may impede the direct adaptation of many of these instruments in nursing home populations. The role of skilled nursing facilities in caring for older adults is becoming increasingly important due to the decline in hospital length of stay, and the aging of the population.40 Five percent of persons older than age 65 live in a nursing home at any one time, approximately one-third of all individuals in the United States will pass through a long-term care facility before they die, and large numbers will die there.41 At the present time, resident assessment in the nursing home is largely based on the 350-item Minimum Data Set (MDS).42 The MDS items address several aspects including sociodemographic information, functional dependence, cognitive functioning, clinical diagnoses, treatment provided, as well as an extensive arrays of signs and symptoms. The
recording of pain experience, however, is not a special focus of the MDS.43,44 In this study, we compared two methods of pain assessment in two groups of elderly nursing home residents. In the first group of residents, pain was assessed by asking the question “Do you have pain?” In the second group of residents, assessments were made by administering three pain assessment scales: the visual analog scale,32 the behavior (faces) scale,33 and the pain descriptive scale.22 These scales were chosen because they are easily administered and because they utilize different methods in assessing pain: verbal communication (pain descriptive scale), visual communication (visual analog scale), and assessment of behavior (faces scale). The results from this study highlight several important points. The utilization of three easily administered pain assessment scales resulted in increased frequency of diagnosing pain in the nursing home, especially among the old-old residents, compared to just asking the question
454
Kamel et al.
Table 3 The Frequency of Different Associated Symptoms Among Subjects in Group 1 Who Reported Pain
Symptom Agitation Loss of appetite Insomnia Weight loss
Frequency in Subjects with Pain (n 22) n (%) 1 (5) 1 (5) 2 (9) 3 (14)
Frequency in Subjects without Pain (n 128) n (%)
P
3 (2) 3 (2) 2 (2) 8 (6)
0.5 0.5 0.04 0.2
“Do you have pain?” Several factors may have contributed to this observation. Older adults may use different terminology to describe pain. They often describe discomfort, hurting, or aching, rather than use the specific word pain.1 In addition, nursing home residents often believe that pain is to be expected with aging and that complaining of pain may negatively affect their care.5 They may also fear the meaning of pain and associate its presence with death or disease progression. The presence of sensory or cognitive impairments may also affect pain assessments using direct questioning. The frequency of diagnosing pain in group 2 subjects correlated positively with the MMSE scores. That is, subjects with lesser degrees of cognitive impairment (higher MMSE scores) were more likely to report pain when using these three assessment scales compared to subjects with lower MMSE scores (more severe cognitive impairment). Isolated effects of individual pain assessment scales on the frequency of diagnosing pain were not evaluated in this study. One of the limitations of this study is that, with the exception of pain experience, all the other data were abstracted from medical charts and may have been affected by the variation in the accuracy of documentation especially in relation to the presence of associated symptoms Table 4 The Frequency of Diagnosing Pain Among the Two Study Subject Groups Pain Frequency, n (%)
All subjects Subjects with dementia Subjects older than 85 years
Group 1 (n 150)
Group 2 (n 155)
P
22/150 (15)
47/155 (30)
0.001
10/102 (10)
9/55 (16)
0.2
3/52 (6)
22/69 (32)
0.0004
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(e.g. loss of appetite, agitation, and insomnia). In addition, the observed association between polypharmacy and increased frequency of reported pain may have been confounded by the fact that pain medications may have contributed to the occurrence of polypharmacy. Information on types and number of pain medications was not recorded in this study. Similar consideration may apply to the observed association between constipation and pain experience, since constipation may be caused by opioid analgesics used to treat pain. Another potential weakness of this study is that we were unable to adjust for the possible effect of vision and hearing impairments on reporting pain experience. Although none of the subjects carried a diagnosis of being blind or deaf, we did not perform formal assessments of visual or hearing functions. Finally, 26% of subject in group 2 refused to cooperate with the MMSE testing. The characteristics of these subjects may have been substantially different from the 115 subjects who cooperated with the MMSE testing which may have biased the observed relation between MMSE scores and the frequency of diagnosing pain in group 2 subjects.
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