Identifying pain in Cognitively Impaired Residents in Long-Term Care

1. Identifying pain in Cognitively Impaired Residents in Long-Term Care Lisa R. Booth, R.N. Northeastern State University EBP Symposium April 23, 2010 Boteone@yahoo.com Good Afternoon everyone. I am glad to be here. I work in the LTC industry and truly enjoy working with our elderly population. I am also fortunate to travel which allows me the opportunity to experience a variety of cultures in North Eastern Oklahoma. Good Afternoon everyone. I am glad to be here. I work in the LTC industry and truly enjoy working with our elderly population. I am also fortunate to travel which allows me the opportunity to experience a variety of cultures in North Eastern Oklahoma.

2. Clinical Nursing Issue Many elders in long-term care (LTC) suffer from untreated and ineffective pain management. Estimated that 84% of LTC residents experience pain Pain is not a normal part of aging, yet there are many barriers to identifying pain in this population. The most vulnerable population are those with cognitive impairment. Up to 60% of LTC residents have dementia While there are many clinical issues facing LTC, maintaining a high standard quality of life for the residents cannot be ignored. Many elders in LTC experience untreated and ineffective pain management. According to Clark, Fink, Pennington, and Jones, 84% of LTC residents experience pain. The most vulnerable are those with cognitive impairment. Nevill, McCarthy, and Laurent found that 60% of LTC residents have dementia. In LTC one nurse may have 30 residents to care for during the day shift and up to 60 during the night shift. While the nurse has CNAs and CMAs assisting them, they are not able to address all the residents needs. It is the residents that cannot verbalize their pain that go untreated.While there are many clinical issues facing LTC, maintaining a high standard quality of life for the residents cannot be ignored. Many elders in LTC experience untreated and ineffective pain management. According to Clark, Fink, Pennington, and Jones, 84% of LTC residents experience pain. The most vulnerable are those with cognitive impairment. Nevill, McCarthy, and Laurent found that 60% of LTC residents have dementia. In LTC one nurse may have 30 residents to care for during the day shift and up to 60 during the night shift. While the nurse has CNAs and CMAs assisting them, they are not able to address all the residents needs. It is the residents that cannot verbalize their pain that go untreated.

3. Consequences of Untreated Pain Depression Decreased socialization Sleep disturbances Weight loss Increase risks for pressure ulcers Increase risks for falls Decreased quality of life Increased healthcare costs.

4. Clinical Question Among cognitively impaired LTC residents, will training non-licensed personnel (i.e. CNAs, housekeeping , and dietary) in identifying pain, as compared to only training LPNs and RNs, improve pain management? CNAs, CMAs, housekeeping, and dietary spend the most time with residents. They know the residents so you would think training all staff upon hire and updating all the staff several times a year on s/s of pain in the cognitively impaired would improve pain identification and management?CNAs, CMAs, housekeeping, and dietary spend the most time with residents. They know the residents so you would think training all staff upon hire and updating all the staff several times a year on s/s of pain in the cognitively impaired would improve pain identification and management?

5. Barriers Lack of staff education Staff turnover rates Staff to resident ratios Lack of staff continuity Pain assessment tools One common denominator in all the research I read was a Lack of staff education regarding pain management. Then you add the rest of the barriers found therefore leading to an increase in resident experiencing pain without effective identification or management.One common denominator in all the research I read was a Lack of staff education regarding pain management. Then you add the rest of the barriers found therefore leading to an increase in resident experiencing pain without effective identification or management.

6. Barriers Oklahoma LTC turnover rate: OK Health Care Authority 2008-2009 annual report I just wanted to show you these stats, with turnover rates like these what can we do?I just wanted to show you these stats, with turnover rates like these what can we do?

7. Barriers

8. Barriers

9. Benefits of Training Improved quality of life for all residents. Education empowers the staff. Increased autonomy Leads to an increased feeling of being a part of a team. Policy and Procedure already in place. Training tools are already there. Minimal financial cost Might be an increase payroll expenses for initial training. Biggest cost will be a concerted commitment by leaders.Might be an increase payroll expenses for initial training. Biggest cost will be a concerted commitment by leaders.

10. What Does The Research Say? Common denominator in most of the research is lack of staff education regarding pain and pain management in cognitively impaired residents. Staff beliefs that pain is a normal part of aging and residents with cognitive impairment cannot feel pain. Staff beliefs that Alzheimer�s or dementia causes behaviors instead of pain. IN A 2007 STUDY by (Kaasalainen, Coker, Dolovich, Papaioannou, Hadjistavropoulos, Emili, and Ploeg,) found that staff beliefs that pain in a normal part of aging and that residents with cognitive impairment cannot feel pain. In the same study they found that nurses felt, �Well the resident is in bed, they are resting, they are comfortable.� In LTC you have to look for pain. Just because there is an absence of a pain report does not mean there is an absence of pain. In a literature review by McAuliffe, Nay, O�Donnell, & Fetherstonhaugh they found that the staffs beliefs that behaviors were from the dx and not pain.IN A 2007 STUDY by (Kaasalainen, Coker, Dolovich, Papaioannou, Hadjistavropoulos, Emili, and Ploeg,) found that staff beliefs that pain in a normal part of aging and that residents with cognitive impairment cannot feel pain. In the same study they found that nurses felt, �Well the resident is in bed, they are resting, they are comfortable.� In LTC you have to look for pain. Just because there is an absence of a pain report does not mean there is an absence of pain. In a literature review by McAuliffe, Nay, O�Donnell, & Fetherstonhaugh they found that the staffs beliefs that behaviors were from the dx and not pain.

11. What Does The Research Say? Pain medication use was lower in residents with cognitive impairment. Staff afraid to use morphine calling it a �safety risk� and associating its use with hospice residents. 78% of residents with chronic pain diagnosis were not prescribed opioid medications. CNA ratings of pain were more accurate than nurse r/t knowledge of residents. Nygaard & Jarland while examining the differences in LTC on pain tx. Found that pain medication use was lower in residents with cognitive impairment. I also found this to be the case at the facility I was doing my preceptorship. I also found that residents with a dx of chronic pain were not prescribed opiod medicationNygaard & Jarland while examining the differences in LTC on pain tx. Found that pain medication use was lower in residents with cognitive impairment. I also found this to be the case at the facility I was doing my preceptorship. I also found that residents with a dx of chronic pain were not prescribed opiod medication

12. What Does The Research Say? CNAs felt they had to �nag� nurses to intervene on pain management issues for the residents. Only 44% of LTC facilities provided training to nurses and only 34% for CNAs. Input from family members, CNAs, therapists, social workers, and housekeepers lead to better pain management outcome.

13. What Does The Research Say? In elders with dementia , lack of recognition of pain, lack of education/training are main barriers. Improvements in in-service education in the area of pain recognition and management for all staff are a priority. CNAs gained satisfaction from seeing residents relieved of pain.

14. Strategize Approaches To The Problem In-service all current employees. Implement the training protocol for all newly hired employees. Establish a pain committee comprised of a representative from all departments to meet monthly. Evaluate goals and outcomes quarterly.

15. Getting Started Review company policy and procedures on pain. Decide on date to implement program. In-service Consider inviting a nurse from hospice to discuss pain. Consider inviting family members of residents. Make it interesting, informative, and fun! Encourage staff and family participation and feedback. Food is always a winner. Appoint nurse to do newly hired employee training.

16. Pain Committee Include a staff member from all departments. Include therapists and consultant pharmacist and medical director. Meet monthly or more frequently to discuss new issues or problems. Discuss non-pharmacological interventions used. Review medication administration records (MARs), physician orders, and focused pain assessments.

17. Leadership Support As nursing leaders, when problems are identified, interventions and goals must be put into place. Director of Nursing (DON) will do the initial general training of all staff. Separate training for licensed staff. The administrator will be included in the training. The administrators� support and leadership is vital to the success of the program.

18. Remember! The power of communication! It could prevent a resident from suffering pain.

19. Evaluation Quarterly reevaluate progress, measure outcomes, and identify changes that need to be made. Review Minimum Data Sets (MDS), comprehensive pain assessments and the quality indicator reports. Query staff regarding their beliefs in the value of this education program and the benefits to the residents.

20. Questions??