Feature Article
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Undertreatment of Pain in the Elderly: Causes and Prevention A high percentage of elderly people report experiencing acute or chronic pain. The incidence of pain increases substantially after age 60, including an increased incidence of pain due to cancer. Undertreatment of pain in the elderly is a significant problem in long-term care facilities. Successful pain management will require an analysis of the causes, a framework for understanding the pain, and a simple yet comprehensive protocol to assist health care professionals in assessing, documenting, and treating pain in the elderly.
(Annals of Long-Term Care 1999;7[5]:190-196)
A high prevalence of undertreatment of pain in the elderly has been documented in a variety of national and international clinical settings.1-7 Both acute pain and chronic pain are longstanding health problems in the elderly.1-3 Older adults are two times more likely to experience pain than younger adults. Twenty-five percent to 50% of elderly people in the community experience pain, and as many as 85% of the elderly in residential facilities report pain.4
An increased incidence of pain occurs after the age of 60, with 70% of nursing home patients experiencing pain and one-third of these patients reporting constant pain. The increased prevalence of cancer in older populations has led to an increased incidence of cancer pain.3 Forty percent to 50% of cancer patients described their pain as moderate, with 25% to 30% characterizing it as severe.5 Thus, there is no doubt that undertreatment of pain in the elderly is a critical problem in long-term care facilities.
Undertreatment of pain has led not only to increased suffering and personal distress, but also to such problems as immobility with accompanying complications; decreased functional ability; poor or interrupted sleep; increased anxiety and depression; decreased social activities; increased isolation; loss of appetite, which often results in malnutrition; and an increased number of falls.3,8,9 Uncontrolled pain impinges upon the health status of the elderly, affecting all aspects of their lives and negatively impacting their overall quality of life.8
Causes of Undertreatment of Pain
There may be several reasons for undertreatment of pain in the elderly, including patient beliefs and communication problems. The elderly are especially susceptible to undertreatment of pain because of their beliefs about aging and misconceptions about pain.3 If the elderly believe that pain is a natural part of the aging process, then they are less likely to report being in pain. When this belief is communicated to health care providers, providers are unlikely to treat the pain.
Additional problems related to undertreatment of pain in the elderly concern other commonly held beliefs.10 Patients may (1) view the admission of pain as a weakness; (2) fear that the pain signals disease progression; (3) fear taking medications because of possible side effects; or (4) fear that they are not being a "good patient" and that reporting pain is a bother to nurses and physicians.10,11 Communication problems associated with sensory and cognitive impairment also are causes of undertreatment related to the underreporting of pain in the elderly.3,10
Inadequate education in pain management for health care professionals is a major problem leading to undertreatment.10 Health care professionals are seldom trained in pain assessment and the use of nondrug therapies to manage pain. They may not realize the importance of pain management or recognize that a patient is in pain, and, therefore, they may not prescribe adequate amounts of opioid medications.11 The limited availability of scientific knowledge about pain in the elderly contributes to the widespread belief among health care professionals that the elderly have a high threshold and a high tolerance for pain,2,9,12-15 and that pain is a normal part of the aging process.10,16 Although it is generally accepted that aging causes physiologic changes that decrease the number of neurons and neurotransmitters in the central nervous system, there is still no definitive clinical evidence that pain perception thresholds are altered in the elderly in real-life situations.17
Physicians and nurses also may have limited ability to detect pain in nonverbal and cognitively compromised elderly patients.5,11 In a study by Sengstaken and King,7 doctors were able to detect pain in 43% of patients who were able to communicate, but in only 17% of those who were cognitively impaired and not able to communicate.
Other factors that may contribute to health care providers' undertreating of pain are sociocultural differences between the patient and the caregiver.18 Bernabei et al19 found that patients age 85 and older were less likely to receive either weak opiates or morphine than those age 65 to 74. More than 26% of the patients experiencing daily pain did not receive any analgesic agent. Other independent predictors of failing to receive an analgesic agent were related to racial background (eg, African-Americans) and low cognitive ability.19 Health care providers with more years of experience are more likely to undermedicate than those with fewer years of experience.20 Health care providers who have had a major personal pain experience are more likely to give more medication than those who have not.20 All of the above factors may contribute to physicians and nurses' underestimating pain intensity levels, leading to undertreatment of pain in their patients.7
Many of the problems associated with undertreating pain can be overcome by administrators, physicians, and other health care providers working together to provide adequate pain relief to patients and making sure that standards of care are implemented. Standards of care have been clearly delineated by the Agency for Health Care Policy and Research (AHCPR), the American Pain Society, and other professional organizations. Standards for improving pain management include implementing pain guidelines, protocols, and methodologies into clinical practice to systematically assess, document, and treat pain. Unfortunately, standards for pain management are not being systematically implemented in most hospitals, nursing homes, and other health care facilities today. Theoretical Basis for Understanding the Pain Experience
Although pain is a universally experienced phenomenon, reactions to pain vary widely among the elderly. Pain is defined as "an unpleasant subjective, sensory and emotional experience associated with tissue damage or described in terms of such damage."21 According to this definition, one has to rely on the individual's own perception as well as verbal and nonverbal expressions in assessing and evaluating the pain experience.
The Pain Experience
The pain experience can be seen as a dynamic process that includes the perception of pain, the evaluation of pain, and responses to pain.22 This theoretical framework is one aspect of the symptom management model developed by Larson et al22 in 1994 at the University of California, San Francisco.
Perception of Pain. This part of the process refers to whether an individual notices a change from the way he or she usually feels or behaves. The perception of pain depends on the complex interaction between nociceptive and nonnociceptive impulses in ascending pathways in relation to the activation of descending pain-inhibiting systems in the nervous system.11
According to Larson et al,22 there are several factors that influence a person's perception of pain, such as attitudes, beliefs, coping ability, age, gender, cognitive capacity, ethnocultural factors, religion, health status, and disease. This framework provides the basis for a comprehensive, multimodal approach to the assessment and treatment of pain--which corresponds with the observation made in clinical settings that there is no single approach to successful pain management.
Evaluation of Pain. This part of the process includes assessment of pain intensity, sensory and emotional components of pain, quality, location, and duration.5,11,17,22 The systematic evaluation of pain is best achieved by utilizing a simple, valid, and reliable pain tool that meets the patient's needs and also provides a comprehensive pain assessment.5,11 The pain tool should enable patients to quantify multiple dimensions of the pain experience and should assist caregivers in choosing appropriate drug and nondrug treatment strategies to prevent, eliminate, or reduce pain.
Assessment of pain in the elderly may at times be difficult because of decreased cognitive capacity, disease, illness, and disability.22 A decreased cognitive capacity may prevent the use of a pain assessment tool, leaving observation of the patient's biobehavioral responses--a less accurate method of assessing pain--as the only procedure available for estimating pain intensity.
Biobehavioral Responses. These responses are physiologic (eg, heart palpitations, change in respiratory rate and blood pressure); psychological (such mood changes as irritability and nervousness); and behavioral. Behavioral responses are the objective expressions of pain and can include verbal and social communication, such as crying and yelling, medication intake, social withdrawal, alteration in sleep patterns, and changes in role performance.22
Although biobehavioral responses are sometimes used as a method to assess pain intensity and as a means for recognizing the presence of pain, they should not be the primary methodology. Biobehavioral responses can be used as a complement to the patient's self-report of pain and can provide important information that is helpful in determining the type and dose of pain medication. Neither behavior, psychological state, nor vital signs should be substituted for a self-report of pain that is obtained by the use of a valid and reliable pain assessment tool. Patients using laughter as a coping mechanism may even experience excruciating pain while smiling. Biobehavioral responses may be used to assess pain when patients are unable to communicate their pain due to decreased cognitive capacity.
Pain Guidelines
To combat the problems of inadequate pain assessment and undertreatment, the AHCPR5,11 and the American Pain Society23,24 have developed and disseminated pain guidelines. The AHCPR guidelines appear in Table I. The pain guidelines are considered by many professional groups and legal experts to be the standard of care for pain management; the guidelines selected are critical to the prevention of undertreatment of pain in the elderly.
The guidelines can be easily implemented by requiring that a simple yet comprehensive pain protocol be introduced into practice. Implementation of the pain protocol would require health care providers caring for elderly patients to select and systematically use a pain tool to routinely assess pain, and to document the pain experience, treatment strategies used to prevent or relieve pain, and other pertinent data, on a pain flow sheet.
Implementation of a Simple Pain Protocol
An important pain protocol available is the Painometer™ pain protocol (Figure), along with the Painometer™ pain flow sheet (Table II).
Painometer™ Pain Protocol
The Painometer™ pain protocol25 is one example that demonstrates how a specific pain protocol can be used to prevent undertreatment of pain and to hold staff accountable for pain relief. The Painometer™ protocol is based on a comprehensive and multimodal approach to the assessment and treatment of pain. This protocol calls for the implementation of the Painometer™ and the Painometer™ pain flow sheet or a similar protocol into geriatric practice settings.
The Painometer™ provides a multidimensional assessment of pain that includes pain intensity, sensory and emotional components of pain, and pain quality, location, and duration. The Painometer™ has demonstrated validity and reliability17 and has been tested with a variety of ethnic/cultural, national, and international groups, including the elderly.26-31
Two methods for assessing pain intensity are located on the Painometer.™ The first method is a 10-cm visual analogue scale with a movable marker that patients use to rate their pain intensity on a scale ranging from 0 cm to 10 cm (Figure). The second method is a list of sensory and affective word descriptors located on the back of the tool. Each word descriptor is assigned an intensity value ranging from 1 to 5. Among the words chosen, the sensory word and the emotional word with the highest intensity value provide a quick method for comparing the intensity of these two components of pain. The words also are used to describe the quality of pain and provide valuable clues to the etiology and treatment of pain. In addition, word descriptors can be particularly effective in assessing pain in the elderly. Elderly patients may deny feeling pain but may still choose words such as "burning," "agonizing," or "tiring" to describe their pain.3
The Painometer™ contains a pullout body chart showing 79 locations on a human body. Patients who have difficulty describing the location of their pain may find it easier to point it out on the body chart or on their own body. The body chart is particularly useful for the elderly since they often experience pain in many different locations.32 The Painometer™ also assesses the duration of pain by asking its user whether the pain comes and goes or is continuous.
Painometer™ Pain Flow Sheet
The Painometer™ pain flow sheet (Table II) includes information that is grounded in pain theory,6,21,25,33 in the pain experience, and in pain guidelines.5,11 It was designed so that health care providers are prompted to collect, document, and evaluate pain data related to the perception, evaluation, biobehavioral responses, and treatment of pain in elderly patients.
The front of the flow sheet is divided into the following sections: (1) evaluation of the pain experience, which includes provisions for assessing and documenting pain intensity and sensory and emotional components of pain, and pain quality, location, and duration; (2) information that should be given to all patients experiencing pain; (3) pain perception, which includes an evaluation of the person's cognitive capacity and alertness; (4) biobehavioral responses to pain; (5) pain therapy, which includes space for documentation of both drug and nondrug therapies; and (6) other observations that staff members might find helpful to document.
Side 2 of the flow sheet provides specific information needed by the health care provider to complete side 1. Side 2 also provides an educational section that includes a simple relaxation exercise, information that should be given to patients experiencing pain, and examples of positive coping strategies. Space is provided for the signature and title of the health care provider delivering care to the patient, along with space for additional observations. The design of the flow sheet permits one to get a comprehensive picture of the pain experience and the effectiveness of pain treatment strategies. The design of the flow sheet makes it possible for caregivers to easily evaluate the care they provide and to continuously improve it.
Implementing a pain protocol in clinical practice can help prevent the undertreatment of pain in the elderly. The Painometer™ and the flow sheet have been used in a variety of health care settings, including geriatric hospitals in the United States and Sweden.
Information produced by the Painometer™ or other comparable pain protocol can be of value in characterizing the pain experience and in determining the severity and etiology of the patient's condition, the diagnosis, and the type of treatment strategy to be implemented. Most important, the protocol provides a standardized methodology for systematically assessing and treating pain in the elderly, and for evaluating the outcomes of treatment so as to prevent undertreatment of pain.
Implications for Clinical Settings: Caring for Geriatric Patients
Unfortunately, there has been little collaboration and coordination among health care professionals working in nursing homes and geriatric facilities in efforts to prevent pain and to improve the quality of care across institutions. One reason may be that pain has not been a priority in the health care system. Because of this lack of collaboration and indecisiveness in the area of pain assessment, significant pressure has been placed on health care providers to create their own individualized methodologies for assessing pain, which are often inconsistent and confusing for patients.34 For example, staff members on the same service may use four different methods to assess pain in the same patient. One staff member may use the invalid and unreliable method of asking patients to assess pain "in their heads" on a scale of 1 to 10; another staff member may use the Painometer™'s 0-to-10 visual analogue scale, a 1-to-5 scale, or a 0-to-100 scale to assess pain in the same patient. Because a valid and reliable assessment of pain is the first step toward adequately treating pain, it is highly unlikely that the patient who is dealing with a variety of staff methods of pain assessment will understand how to accurately report pain or receive adequate pain relief.
The time has now come for leadership teams and caregivers in geriatric facilities to select and implement one standardized, multidimensional and multimodal treatment pain protocol--at least within the same institution.34 This action will make it possible for staff members to produce new and useful knowledge that will help them systematically assess pain, address pain management problems, select and evaluate treatment strategies, and improve the quality of care provided to the elderly.
Additional value may be realized from introducing a simple pain protocol into practice. A well-designed and theoretically sound pain flow sheet with a valid and reliable pain assessment tool adds credibility to data collected to determine outcomes measures for performance improvement purposes. Data could be collected routinely, documented on a standardized pain flow sheet, and evaluated on a regular basis during medical rounds, with appropriate treatment strategies initiated immediately. The data also could be computerized, evaluated, and compared within and across geriatric institutions. A large database could be assembled over time, from which relevant outcomes measures could be selected, evaluated, and used as local, national, and international benchmark indicators of quality care. Such an innovation also could make a major impact on the science of pain management in geriatric patients. Using a pain tool and a pain flow sheet could minimize patient and staff confusion, promote consistency in evaluation, and improve communication between patients and caregivers and among caregivers themselves.34
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From the Johns Hopkins University School of Nursing and Dola Health Systems, Baltimore, MD. Address for correspondence: Dr. Fannie Gaston-Johansson, Director, International and Extramural Programs, Johns Hopkins University School of Nursing, Anne M Annals of Long-Term Care - ISSN: 1524-7929 - Volume 7 - Issue 05 - May 1999 |