Want to know more

PAIN
Nursing Standard of Practice Protocol: Pain Management in Older Adults

Ann L. Horgas, RN PhD FGSA FAAN, Saunjoo L. Yoon, PhD, RN, Mindy Grall, PhD APRN BC

Evidence-Based Content - Updated July 2012

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Standard

All older adults will either be pain free, or their pain will be controlled to a level that is acceptable to the patient and allows the person to maintain the highest level of functioning possible.

Pain is a common experience for many older adults, and is associated with a number of chronic (e.g., osteoarthritis) and acute (e.g., cancer, surgery) conditions.

Back to top

Overview

Pain a common, subjective experience for many older adults, is associated with a number of chronic (e.g., osteoarthritis) and acute (e.g., cancer, surgery) conditions. Despite its prevalence, evidence suggests that pain is often poorly assessed and poorly managed, especially in older adults. Cognitive impairment due to dementia and/or delirium represents a particular challenge to pain management because older adults with these conditions may be unable to verbalize their pain. Nurses, an integral part of the interdisciplinary care team, need to understand myths associated with pain management, including addiction and belief that pain is a normal result of aging, to provide optimal care and to educate patients and families about managing pain. Nurses must also examine their personal biases about pain and its management.

Back to top

Background

A. Definitions

1. Pain is defined as "an unpleasant sensory and emotional experience" 1, 2 and also as "whatever the experiencing person says it is, existing whenever he says it does." 3 These definitions highlight the multidimensional and highly subjective nature of pain. Pain is usually characterized according to the duration of pain (e.g., acute versus persistent) and the cause of pain (e.g., nociceptive versus neuropathic). These definitions have implications for pain management strategies.

2. Acute pain defines pain that results from injury, surgery, or trauma. It may be associated with autonomic activity, such as tachycardia and diaphoresis. Acute pain is usually time-limited and subsides with healing.

3. Persistent pain defines pain that lasts for a prolonged period (usually more than 3--6 months) and is associated with chronic disease or injury (e.g., osteoarthritis) (Ref 2). Persistent pain is not always time dependent, however, and can be characterized as pain that lasts longer than the anticipated healing time. Autonomic activity is usually absent, but persistent pain is often associated with functional loss, mood disruptions, behavior changes, and reduced quality of life.

4. Nociceptive pain refers to pain caused by stimulation of specific peripheral or visceral pain receptors. This type of pain results from disease processes (e.g., osteoarthritis), soft-tissue injuries (e.g., falls), and medical treatment (e.g., surgery, venipuncture, and other procedures). It is usually localized and responsive to treatment.

5. Neuropathic pain refers to pain caused by damage to the peripheral or central nervous system. This type of pain is associated with diabetic neuropathies, post-herpetic and trigeminal neuralgias, stroke, and chemotherapy treatment for cancer. It is usually more diffuse and less responsive to analgesic medications.

B. Epidemiology

1. Approximately 50% of community-dwelling older adults and 85% of nursing home residents experience persistent pain.

2. More than one half of all inpatient hospital days are occupied by older adults, and more than 9 million surgeries are performed o older adults annually (Ref 4) Thus, pain is a common experience among older adults in the acute care setting (Ref 5).

C. Etiology

1. More than 80% of older adults have chronic medical conditions that are typically associated with pain, such as osteoarthritis and peripheral vascular disease.

2. Older adults often have multiple medical conditions, both chronic and/or acute, and may suffer from multiple types and sources of pain.

D. Significance

1. Pain has major implications for older adults’ health, functioning, and quality of life. If unrelieved, pain is associated with the following (Ref 6; 7):

a. Impaired immune function and healing
b. Impaired mobility
c. Postoperative complications related to immobility (e.g., thrombosis, embolis, pneumonia)d. Sleep disturbancese. Mental health symptoms (e.g., depression, anxiety)f. Withdrawal and decreased socialization
g. Functional loss and increased dependency
h. Exacerbation of cognitive impairment
i. Increased health care utilization and costs

2. Nurses have a key role in pain management. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain in late life to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary health care teams.

3. The Joint Commission requires regular and systematic assessment of pain in all hospitalized patients. Since older adults constitute a significant portion of the patient population in many acute care settings, nurses need to have the knowledge and skill to address specific pain needs of older adults.

Back to top

Assessment Parameters

A. Assumptions (Ref 1; 2; 6; 8)

1. Most hospitalized older patients suffer from both acute and persistent pain.

2. Older adults with cognitive impairment experience pain but are often unable to verbalize it.

3. Both patients and health care providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that (a) influence the pain management process, and (b) must be acknowledged before optimal pain relief can be achieved.

4. Pain assessment must be regular, systematic, and documented to accurately evaluate treatment effectiveness.

5. Self-report is the gold standard for pain assessment.

B. Strategies for Pain Assessment

1. Initial, quick pain assessment (Ref 9)

a. Assess older adults who who present with acute pain of moderate-to-severe intensity or who appear to be in distress.

b. Assess pain localization, intensity, duration, quality, and onset.

c. Assess vital signs. If changes in vital signs are absent, do not assume that pain is absent (Ref 8).

2. Comprehensive pain assessment (Ref 2; 6; 8)

a. Review medical history, physical exam, and laboratory and diagnostic tests in order to understand sequence of events contributing to pain.

b. Assess cognitive status (e.g., dementia, delirium), mental state (e.g., anxiety, agitation, depression), and functional status. If there is evidence of cognitive impairment, do not assume that the patient cannot provide a self-report of pain. Be prepared to augment self-report with observational measures and proxy report using the hierarchical approach.

c. Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors.

d. Assess pain history, including prior injuries, illnesses, and surgeries; pain experiences; and pain interference with daily activities.

e. Review medications, including current and previously used prescription drugs, over-the-counter drugs, and home remedies. Determine which pain control methods have previously been effective for the patient. Assess patient's attitudes and beliefs about use of analgesics, adjuvant drugs, and nonpharmacological treatments.

f. Use a standardized tool to assess self-reported pain. Choose from published measurement tools and recall that older adults may have difficulty using 10-point visual analog scales. Vertical verbal descriptor scales or faces scales may be more useful with older adults.

g. Assess pain regularly and frequently but at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness.

h. Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient's usual patterns.

i. Gather information from family members about the patient's pain experiences. Ask about the patient's verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.

j. When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume pain is unrelieved and treat accordingly.

C. Assessment Tools

Back to top

Nursing Care Strategies (Ref 2; 7; 8; 9; 10)

A. General Approach

1. Pain management requires an individualized approach.

2. Older adults with pain require comprehensive, individualized plans that incorporate personal goals, specify treatments, and address strategies to minimize the pain and its consequences on functioning, sleep, mood, and behavior.

B. Pain Prevention

1. Develop a written pain treatment plan upon admission to the hospital, or prior to surgery or treatments. Help the patient to set realistic pain treatment goals, and document the goals and plan.

2. Assess pain regularly and frequently to facilitate appropriate treatment.

3. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes prior to activities.

4. Educate patients, families, and other clinicians to use analgesic medications prophylactically prior to and after painful procedures.

5. Educate patients and families about pain medications and their side effects; adverse effects; and issues of addiction, dependence, and tolerance.

6. Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate.

7. Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and heat/cold.

C. Treatment Guidelines

1. Pharmacologic (Ref 2; 6)

a. Administer pain drugs on a regular basis to maintain therapeutic levels. Use PRN (as needed) medications for breakthrough pain.

b. Document treatment plan to maintain consistency across shifts and with other care providers.

c. Use equianalgesic dosing and the WHO three-step ladder to obtain optimal pain relief with fewer side effects. 10

 

d. For postoperative pain, choose the least invasive route. Intravenous analgesics are the first choice after major surgery. Avoid intramuscular injections. Transition from parenteral medications to oral analgesics when the patient has oral intake.

e. Choose the correct type of analgesic. Use opoids for treating moderate-to-severe pain and nonopoids for mild-to-moderate pain. Select the analgesic based on thorough medical history, comorbidities, other medications, and history of drug reactions.

f. Among nonopoid medications, acetaminophen is the preferred drug for treating mild-to-moderate pain. Guidelines recommend not exceeding 4 g per day (maximum 3 g/day in frail elders). The maximum dose should be reduced to 50%-75% in adults with reduced hepatic function or history of alcohol abuse.

g. The other major class of nonopoid medications, nonsteroidal anti-inflammatory drugs (NSAIDs), should be used with caution in older adults. Monitor for gastrointestinal (GI) bleeding and consider giving with a proton pump inhibitor to reduce gastric irritation. Also monitor for bleeding, nephrotoxicity, and delirium.

h. Older adults are at increased risk for adverse drug reactions due to age- and disease-related changes in pharmacokinetics and pharmacodynamics. Monitor medication effects closely to avoid overmedication  or undermedication and to detect adverse effects. Assess hepatic and renal functioning.

2. Nonpharmacologic (Ref 6; 7)

a. Investigate older patients' attitudes and beliefs about, preference for, and experience with nonpharmacological pain-treatment strategies.

b. Tailor nonpharmacologic techniques to the individual.

c. Cognitive-behavioral strategies focus on changing the person's perception of pain (e.g., relaxation therapy, education, and distraction) and may not be appropriate for cognitively impaired persons.

d. Physical pain relief strategies focus on promoting comfort and altering physiologic responses to pain (e.g., heat, cold, TENS units) and are generally safe and effective.

3. Combination approaches that include both pharmacological and nonpharmacological pain treatments are often the most effective.

D. Follow-up Assessment

1. Monitor treatment effects within 1 hour of administration and at least every 4 hours.

2. Evaluate patient for pain relief and side effects of treatment.

3. Document patient's response to treatment effects.

4. Document treatment regimen in patient care plan to facilitate consistent implementation.

Back to top

Expected Outcomes

A. Patient:

1. Will be either pain free or pain will be at a level that the patient judges as acceptable.

2. Maintains highest level of self care, functional ability, and activity level possible.

3. Experiences no iatrogenic complications, such as falls, GI upset/bleeding, or altered cognitive status.

B. Nurse:

1. Will demonstrate evidence of ongoing and comprehensive pain assessment.

2. Will document evidence of prompt and effective pain management interventions.

3. Will document systematic evaluation of treatment effectiveness.

4. Will demonstrate knowledge of pain management in older patients, including assessment strategies, pain medications, nonpharmacological interventions, and patient and family education.

C. Institution (Ref 11)

1. Facilities/institutions will maintain strong institutional commitment and leadership to improve pain management. Evidence of institutional commitment include:

a. Providing adequate resources (including compensation for staff education and time; necessary materials)

b. Clear communication of how better pain management is congruent with organizational goals

c. Establishment of policies and standard operating procedures for the organization

d. Requiring clear accountability for outcomes

2. Facilities/institutions will establish an internal pain team of committed and knowledgeable staff who can lead quality improvement efforts to improve pain management practices.

3. Facilities/institutions will require evidence of documentation of pain assessment, intervention, and evaluation of treatment effectiveness. This includes adding pain assessment and reassessment questions to flow sheets and electronic forms.

4. Facilities/institutions will provide evidence of using a multispecialty approach to pain management. This includes referral to specialists for specific therapies (e.g., psychiatry, psychology, physical therapy, interdisciplinary pain treatment specialists). Clinical pathways and decision support tools will be developed to improve referrals and multispecialty consultation.

5. Facilities/institutions will provide evidence of pain management resources for staff (e.g., educational opportunites; print materals; access to web-based guidelines and information).

Back to top

For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Horgas, A. L., Yoon, S. L., & Grall, M. (2012). Pain management in Older Adults. In M. Boltz, E. Capezuti, T. Fulmer, & D. Zwicker,   (Eds.) Evidence-based geriatric nursing protocols for best practice (4th ed.) (pp. 258-263). New York: Springer Publishing Company, LLC.

References

1. American Geriatrics Society Panel on Persistent Pain in Older Persons. (2002). The management of persistent pain in older persons. Journal of the American Geriatrics Society, 50, S205–S224. Evidence Level VI: Expert Opinion.

2. American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons. (2009). Pharmacological management of persistent pain in older persons. Journal of the American Geriatrics Society, 57(8), 1331-1346. Evidence Level I.

3. McCaffery, M. (1968). Nursing practice theories related to cognition, bodily pain, and man–environment interaction. Los Angeles: UCLA Students Store.

4. Rosenthal, R.A., & Kavic, S.M. (2004). Assessment and management of the geriatric patient. Critical Care Medicine, 32(4 Suppl), S92-S105. Evidence Level V.

5. Herr, K. (2010). Pain in the older adult: An imperative across all health care settings. Pain Management Nursing, 11(2 Suppl), S1-S10. Evidence Level VI.

6. Pasero, C., & McCaffery, M. (2011). Pain assessment and pharmacologic management. St. Louis, MO: Mosby Elsevier. Evidence Level VI. 

7. Wells, N., Pasero, C., & McCaffery, M. (2008). Improving the quality of care through pain assessment and management. In R.G. Hughes (Ed), Patient safety and quality: An evidence-based handbook for nurses (Vol. 1, pp. 469-489). Rockville, MD: Agency for Healthcare Research and Quality.

8. Herr, K., Coyne, P. J., Key, T., Manworren, R., McCaffery, M., Merkel, S., et al. (2006). Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Management Nursing, 7(2), 44–52. Evidence Level VI: Expert Opinion.

9. Herr, K., Bjoro, K., Steffensmeier, J.J., & Rakel, B. (2006). Acute pain management in older adults. Iowa City, IA: Univeristy of Iowa Gerontological Nursing Interventions Research Center, Research Translation and Dissemination Core. Evidence Level I.

10. Hadjistavropoulos, T., Herr, K., Turk, D.C., Fine, P.G., Dworkin, R.H., Helme, R.,...Williams, J. (2007). An interdisciplinary expert consensus statement on assessment of pain in older persons. The Clinical Journal of Pain, 23(Supple 1): S1-S43. Evidence Level I.

11. Dirks, F. (2010). A national framework for geriatric home care excellence. American Journal of Nursing, 110(8), 64. Evidence Level VI.

Last updated - July 2012

Back to top