Annals of Long Term Care

This article is the fourth in a series on palliative care in the LTC setting. Part I appeared in the April issue, Part II appeared in the May issue, and Part III appeared in the July issue of the Journal.

The high prevalence of painful conditions in residents in the LTC continuum can result in major losses in resident quality of life and dignity. Those with advanced life-threatening illness require timely, effective, and safe management of their total pain. The undertreatment of pain can result in decreased functionality, depression, and poor sleep. Effective pain management requires a thorough interdisciplinary assessment guided by excellent practitioner and nurse skills, a sound knowledge base, and a conducive attitude—all provided within the context of the federal and state regulatory environment in LTC and each practitioner’s scope of practice. Scheduled low-dose opioids are considered the foundation to the treatment of chronic persistent pain of moderate severity in LTC residents. Acetaminophen should be considered as initial treatment for musculoskeletal pain, while any nonsteroidal anti-inflammatory drug should be prescribed for only a brief period. Use of adjuvant analgesics as well as nonpharmacologic and complementary and alternative medicine treatments can further optimize the treatment of pain. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[9]:28-35)

The high prevalence of conditions that cause either acute and/or persistent pain in residents in the long-term care (LTC) setting challenges practitioners to effectively manage pain. Up to 80% of residents have a condition that is associated with either intermittent or constant pain.1

Successful pain management and palliation of nonpain symptoms in this patient population (whether on hospice or not) is challenging to practitioners and must be integrated into the treatment of multiple and complex interacting medical and psychosocial conditions in patients who also commonly have a high prevalence of cognitive impairment, functional dependency, and are receiving a high number of prescription medications. All of these factors require practitioners to become knowledgeable in pain management and the total care of all patients who reside in skilled nursing and residential/assisted living facilities, especially for those patients with advanced life-threatening illness or who are on hospice.

Effective pain management requires timely recognition, a comprehensive and interdisciplinary assessment, an appropriate treatment plan, and monitoring of treatment outcomes. The emergence of pain or a painful condition should be anticipated and, if possible, prevented. Treatment of pain should be consistent with the patient’s values, preferences, and goals of care, and provided within the context of healthcare ethics and state and federal law.

Pain and Associated Sequelae
The International Association for the Study of Pain has defined pain as an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”² All pain should be assessed as to the four components of total pain: physical, psychoemotional, social, and spiritual³; assessment also includes determining whether the pain is nociceptive, neuropathic, or inflammatory.