Background    Approximately 25% of deaths in the United States occur in long-term care facilities (LTFs) – a care setting in which approximately 60% report uncontrolled pain.  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 older adults (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). Clinicians can help improve pain management of their long-term care residents by the way in which they prescribe analgesics.  This Fast Fact reviews analgesic strategies for patients with serious illness who reside in LTFs.

How are medications distributed in LTFs? 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 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 and when an analgesic is to be used are vital. 

Tips for improving pain management

• Communicate concerns regarding pain with a nursing supervisor or director of nursing. Discuss how to maximize opportunities for a) pain assessment and b) provision of timely feedback to you for medication changes.
• Write an order for a nurse to do a complete pain assessment on a regular basis.
• Include non-pharmacological analgesic therapies. These can include ice, massage, music therapy, physical therapy, or occupational therapy. A systematic review found that non-pharmacological analgesic strategies such as exercise had a moderate to large effectiveness on lowering pain.
• 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 PRN opioid should be prescribed at any one time.
• Plan – 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).
• Whenever pain is constant, write an order for a scheduled, round-the-clock medication, such as acetaminophen, if appropriate.
• Don’t forget to order a prophylactic bowel regimen for patients on opioids.
• Consider physical medicine and rehab (PM&R), geriatrics, or palliative care consultation.

The role of analgesics in reducing agitated pain behaviors in LTF 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.  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 reviews4 (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.
9. Knopp-Sihota JA, MacGregor T, Reeves JTH, Kennedy M, Saleem A. Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2022 Sep;23(9):1507-1516.e0.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2^nd Edition was edited by Drew A Rosielle and published October 2007; 3^rd Edition June 2015;4^th Edition published February 2024 after being edited by Dr. Elizabeth Bukowy.
Conflicts of Interest: None to report.