Background    Approximately 25% of deaths in the United States occur in long-term care facilities – a care setting in which pain is common, and often poorly treated.   Reasons include inadequate pain education for nursing home staff, perceived regulatory barriers in the use of opioid analgesics, societal barriers regarding the nature of pain in the elderly (e.g. pain is part of normal aging and thus need not be treated), and high prevalence of resident cognitive impairment leading to inadequate pain assessment (see Fast Fact #126).  Physicians can help improve pain management of their nursing home residents by the way in which they prescribe analgesics.  This Fast Fact will review simple strategies for improving pain management outcomes.

How are medications distributed in nursing homes?

There is a critical shortage of licensed nurses in nursing homes; it is common for there to be only one nurse for 15-30 residents.  In most facilities, scheduled medications are distributed twice per 8 hour shift by a licensed vocational or practical nurse (LVN or LPN), who often have minimal pain education.  This system limits the opportunity for a skilled nurse to do frequent assessments of pain and monitoring the response to analgesics.  The large patient-nurse staffing ratio limits the utility of PRN medication orders, especially orders more frequent than every 4 hours, and also limits the ability of nurses to monitor pain in cognitively impaired residents, since these residents are typically unable to initiate a request for PRN medication.  Thus, specific instructions from the prescriber for how a medication is to be used are vital. 

Tips for improving pain management

Communicate your concerns regarding pain with a nursing supervisor.  Discuss how to maximize opportunities for a) pain assessment and b) provision of timely feedback to you for medication changes.  Review with the nursing supervisor the facility’s method of pain assessment documentation and standards for pain assessment and treatment.

• Write an order for a nurse to do a complete pain assessment on a regular basis.
• Whenever pain is constant, write an order for a scheduled medication, preferably a long-acting medication.
• Write orders for PRN medication at intervals of every four hours (e.g. morphine sulfate immediate release 15 mg q4h PRN pain).  If you know that the patient is likely to need frequent PRN medication, write the order as a scheduled order with “hold if no pain” or “patient may refuse.” 
• Do not write simultaneous PRN orders for multiple analgesics—only one opioid/non-opioid combination product (such as oxycodone with acetaminophen) should be prescribed at any one time.
• Plan ahead – it is common for nursing home residents to have increasing pain related to physical therapy, dressing changes, etc.  Write an analgesic order that anticipates painful activity (e.g. morphine elixir 10 mg PO 30 min prior to bath).
• Don’t forget to order a prophylactic bowel regimen for patients on opioids.
• Include options for non-pharmacological pain therapies (e.g. heat, music therapy, massage, PT).

The role of analgesics in reducing agitated pain behaviors in NH residents with dementia

A systematic review showed encouraging results for the use of scheduled acetaminophen (doses typically around 3000 mg/day) in reducing visual signs of discomfort and improving residents engagement in social activities among NH residents with dementia.  Likely, the most comprehensive study on the subject was done by Husebo et al in 2011.  In a controlled trial, patients randomized to an 8 week stepwise protocol of analgesic administration (which included first acetaminophen, then morphine, then the buprenorphine patch and/or pregabalin) that was individualized to the residents past pain treatment responses, significantly improved pain control and agitation based on validated scales. 

References:

1. Jones KR, Fink R, Pepper G, Hutt E, Vojir CP, Scott J, Clark L, Mellis K. Improving nursing home staff knowledge and attitudes about pain. Gerontologist. 2004; 44(4):469-78.
2. Winn PA, Dentino AN. Effective pain management in the long-term care setting. J Am Med Dir Assoc. 2004; 5(5):342-52.
3. Tarzian AJ, Hoffmann DE. Barriers to managing pain in the nursing home: findings from a statewide survey. J Am Med Dir Assoc. 2005; 6(3 Suppl):S13-9.
4.  Weissman DE, Griffie, J, Muchka S, Matson S.  Building an institutional commitment to pain management in long-term care facilities.  J Pain Symptom Manage. 2000; 20:35-43.
5. Stevenson KM, Dahl JL, Berry PH, Beck SL, Griffie J. Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations. J Pain Symptom Manage. 2006; 31(3):248-61.
6. Sandvik, Reidun Karin, et al. “Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: A cluster randomized trial.” European journal of pain 2014; 18: 1490-1500.
7. Pieper, Marjoleine JC, et al. “Interventions targeting pain or behaviour in dementia: A systematic review.” Ageing research reviews 12.4 (2013): 1042-1055.
8. Husebo, B.S., Ballard, C. and Aarsland, D. (2011), Pain treatment of agitation in patients with dementia: a systematic review. Int. J. Geriat. Psychiatry, 26: 1012–1018.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle and published October 2007; 3rd Edition June 2015. Current version re-copy-edited April 2009; then again by Sean Marks MD in June 2015 when references 7 and 8 were added as was the section on “the role of analgesics in reducing agitated pain behaviors.