Management of Pain in the Long Term Care Setting

1. Management of Pain in the Long Term Care Setting Slide Notes: The “Management of Pain in the Long Term Care Setting” PowerPoint presentation was developed to aid in educating nursing home staff. This presentation attempts to merge best practice, facility practice, regulatory issues and the resident’s Quality of life into a realistic, user-friendly tool aiding in the application of Quality Improvement for your facility.

2. Objectives • Describe how pain management is different from reacting to pain • List barriers to pain management • Explain myths related to pain management Slide Notes: An understanding of the basics of pain management within the nursing home environment will be helpful to all staff including nurses, nursing assistants, dietary aids, Activity coordinators, maintenance and housekeeping. Teamwork in applying these basics is key to a successful program.

3. Understandingpain management instead ofreacting to a complaint ofpain. Image of Pill bottles lined up in a row Slide Notes: Do you want to know if your facility understands pain management or are they just reacting to a complaint of pain? Here are a few simple questions that will determine what is occurring in your facility. How many PRN pain medications are given? When are they given? Check how many PRN pain medications, instead of routinely scheduled pain medications on the medication administration record (MAR) are documented as being administered. Look for a pattern or trend in the administration of these PRN medications. This assessment may be a quick indicator showing whether Staff are proactive in treating pain by assessing and routinely treating for pain or only reacting to pain when a resident complains of pain. Another check can be done by observing if the same residents are getting PRN pain medications at the same time almost everyday. Does one nurse give out PRN pain medications while a different nurse gives no PRN pain medications for the same residents? This observation may show that nurses may not be consistent in their understanding of how to assess for pain, behaviors for pain, or appropriate reasons for using pain medications. Look to see how many PRN pain medications the evening charge nurse administers. When the nurse reacts to a complaint of pain while attempting to do other required nursing duties it interrupts the routine which causes a delay and increased work. Looking at trends or patterns with the PRN pain medications may help save extra work for the nurse and increase quality of life for the resident.

4. The goal The goal ofpain managementis the reduction of pain and suffering Slide Notes: The experiences of hospice nurses show that patients worry more about the possible unrelieved pain and suffering of their terminal illness than the experience of death. Many people can accept death but cannot accept pain. If you asked the resident “what’s the worse thing that can happen?” Would the answer be “I could die?” For most people the answer would be “ No, I could be in pain.” Pain is an important issue with residents and their families. But, unless the resident asks for a pain pill, we often don’t think about managing pain. Many nurses have stories of how effective pain management brought comfort and heartfelt thankfulness from the resident and their family members. Nurses need to hear these success stories in order to understand the importance of assisting their residents with pain management. Once success is achieved, it will help improve the life of the resident and help the nurse feel job satisfaction. Staff retention is not a problem in a facility where everyone feels that they are part of the success. With pain management the success is the reduction of pain and suffering.

5. Why focus on pain? • 45-80% of Nursing Home residents have chronic pain • Under recognized and under treated • Can impact every aspect of a resident’s life Slide Notes: Are we aware of the pain our residents are experiencing? If there are up to 80 out of every 100 residents in pain, are we addressing pain through care plans and staff education? Are we assessing pain in diagnoses that we know cause pain? Whether pain is managed in a hospital or a long term facility, research has shown that it is generally under-recognized and under-treated. Our elderly residents are particularly at risk due to their increased incidence of dementia and the myths of pain management shared both by staff and residents. Focusing on pain may lead us to interventions that not only reduce pain and suffering but directly affect the ability of a resident to walk, sleep, eat, think, socialize and many other aspects of their life. If we listen to the night staff list which residents could not sleep or the day staff list which residents inappropriately called out and exhibited behavior problems, we may find that pain has been the silent barrier for many of these residents trying to achieve a higher quality of life.

6. Five easy steps to better pain management 1. Screen for Pain 2. Conduct an Evaluation of Pain 3. Develop a Care Plan 4. Put the Plan into Action. Be Consistent. 5. Re-evaluate regularly Slide Notes: Doing an effective job managing pain is possible in every facility. Facilities that are successful do the five steps listed above CONSISTENTLY. When a facility uses Continuous Quality Improvement they are helping to ensure that their facility is aware of what it takes to keep the five steps moving toward better resident care instead of stumbling blocks that frustrate staff. Most facilities have an area on their admission sheet and periodic assessment sheets that screen for pain. Staff educated in pain management realize the importance of completing the Screen and are more likely to consistently do the screening. An EVALUATION of the pain will lead to a more effective pain treatment by allowing the nurse to communicate to the physician exactly what is going on with the resident. This is done by describing the pain and how it affects the resident. A CARE PLAN allows the sharing of specific details for managing pain to be passed on to all day, evening, night, weekend, and temporary staff for implementation. Since up to 80% of nursing home residents have chronic pain, the CONSISTENT use of these five steps for pain management is the hardest barrier most facilities face. Without regular RE-EVALUATION, a pain management program is unable to identify how the resident is actually being managed. Our assumptions that appropriate care is being given would only be based on guesses. Screen for PAIN. Conduct an EVALUATION OF PAIN. Develop aCARE PLAN. Put the plan into ACTION. Be CONSISTENT. RE-EVALUATE regularly.

7. Develop a tracking system You need data to check processes • Accurate assessments • Prompt and appropriate treatments • Repeat evaluations • High risk residents identified Pain Coordinator or Pain Committee Slide Notes: Quality Improvement continually strives to make systems and processes better. Sometimes a barrier occurs in a facility that stops the efficiency of one or more steps to success. A facility must be able to identify which piece of the process needs improvement in order to get back on the track to good care. A tracking system uses data to check processes to isolate problems and verify good care. The data can easily tell you whether the system is effective or just busy work for the staff. A Pain Coordinator or Pain Committee has been used by many facilities in coordinating their pain management program. The facility is able to continue other aspects of resident care while the Pain Coordinator or Pain Committee ensure that pain is properly addressed. Often times the Pain Coordinator will be called by other staff as a resource for a pain problem. The Pain Coordinator usually maintains a binder of pain information that also contains the facility’s policies and procedures for pain management.

8. FIVESystemic Barriers To Good Pain Management Slide Notes: There are some reoccurring common barriers to pain management that can influence how soon your facility succeeds in increasing the quality of care you give to your residents. We can learn from others in our field that have overcome these barriers. Their suggestions may help us learn without having to experience the negative outcome that we might have without this collaboration. We can made their successes our own.

9. First systemic barrier: Using inappropriate medications to treat pain in the elderly. Slide Notes: Our population of elderly residents require us to know how their bodies react to medications. At this stage of their life, drug absorption and the length of time the drug is effective will be different than when their bodies were younger. As part of an interdisciplinary team assigned to their care, if we see an inappropriate medication ordered, we cannot say “but that’s what the doctor ordered!” Communicating with the resident’s physician about the potential for side-effects from an inappropriate medication may give use the opportunity to establish a working relationship with the resident’s physician. By being specific and knowledgeable in our assessment of the pain information we present to the physician we can become a valuable partner in the resident’s care. If we have PRN pain medications routinely ordered for the resident we should be able to assess which PRN medication is most appropriate for the type of pain the resident is experiencing. We can practice “Best Practice” by following the World Health Organization’s (WHO) analgesic ladder that emphasizes the lowest dose of the least potent analgesic first. If pain control is not achieved then we can increase the dose or switch to a stronger analgesic until pain relief is achieved. A potential error may occur when the resident is admitted into the facility with medications prescribed while in the hospital before the resident’s primary physician at the nursing home has reviewed the orders. Inappropriate medications may be on that admission order. Another potential error may occur when the resident’s primary physician is unavailable. A physician on-call who is not familiar with the resident or may not have experience treating geriatric residents may be asked to write an order for a pain medication. Our residents are relying on us to be their advocates for appropriate care.

10. Drugs to avoid with elders Opioids that are generally contraindicated in the elderly: • Meperidine(e.g., Demerol confusion from metabolites, ceiling effect) • Propoxyphene(e.g., Darvocet, no better than acetaminophen, has CNS side-effects) • Mixed Opioid Antagonists(e.g., Talwin ceiling effect, delirium and hallucinations) Slide Notes: The organs of the body that process most medications are the kidneys and the liver. These organs do not process the medications as well when we are elderly. There are individual differences with medication effects at any age, but generally, as we age we need less of a medication and it takes longer for the medication to leave our body. Elder residents are usually taking more than one medication so they are also at risk for a drug interaction. As we progress in our facility pain management program we need to remain aware of these facts. If we work as a team we have excellent help through the scheduled monthly visit with our pharmacy consultant. If we have a designated Pain Coordinator we can use the resources that the Coordinator has collected. Certain routine medications are prescribed for geriatric residents that we should have information on in our pain resource binder. There is also a list of inappropriate medications for the geriatric population called the “Beer’s List” that we can reference. It is helpful to have information on these inappropriate medications available for physicians and family members to read. It is possible that the resident’s physician may want to prescribe a medication that is on the Beer’s List because he feels the benefits of the medication out-weigh the risks. It is then our responsibility to care plan the possible adverse effects so that staff will be aware of potential problems to watch out for with the resident. For example, if the medication makes the resident dizzy, then assistance with ambulation while on the medication may be necessary to add to the care plan.

11. Second systemic barrier: Not providing pain treatment or providing medications that do not fit the severity of the pain. Slide Notes: When a resident is in pain we may not be aware of the pain because the resident may not let us know. One of the more important parts of pain management is the screening and assessment of pain. The information gathered from the assessment of pain is essential to the treatment of pain. It may be unnecessary and inappropriate to treat a mild pain with a medication that has been ordered for the resident but is prescribed for a moderate to severe pain.

12. What drugs are used? The WHO analgesic ladder: • Step 1:Mild to moderate pain: Non-opioids (acetaminophen, aspirin, NSAIDs) • Step 2:Moderate pain unrelieved by Step 1: Opioids (codeine, dihydrocodeine, hydrocodone, oxycodone, tramadol, low dose morphine) • Step 3:Moderate to severe pain: Opioids such as morphine, oxycodone, hydromorphone, fentanyl Slide Notes: The Three Step WHO Analgesic Ladder is suggested for use based on the premise that health care professionals should learn to use a few pain relieving drugs well. One can move a step up the ladder if there is no relief obtained after a drug is used in the recommended dosage and frequency. Only one drug from each of the groups should be used at the same time. Should a drug cease to be effective, a switch should be made to one that is definitely stronger if it is available. The side effects of both the analgesic and the adjuvant should be kept in mind and where required, drugs to counteract these efforts should be prescribed. Acetaminophen –How much is too much. Ask this question to your nurses. Post a chart somewhere or everywhere. Max dosage is 4000mg/24hr. Dose every 4-6 hours. Can be toxic to liver. This drug is found in many different medications. Aspirin – What effects does aspirin have on the individual resident? Causes gastric bleeding and abnormal platelet function. NSAIDs – What are they? Ibuprofen (Advil, Motrin, Nuprin). Can cause gastric bleeding, renal impairment, abnormal platelet function, constipation, confusion, headaches in older residents. Tramadol – May precipitate seizures. May cause dizziness. Codeine – often combined with aspirin or acetaminophen. No pain relieve for 10% of population Hydrocodone – in Lorcet, Lortab, Vicodin Oxycodone – in Percocet, Percodan, Tyox, others

13. Third systemic barrier: Not assessing with the right tools at the right time. Slide Notes: Does your staff understand YOUR pain management policy? Is the right pain scale is used on the right resident at the right time? There are many different pain scales used to accommodate the different needs of the residents in you facility. Using the right scale instead of a “one size fits all” will ensure that the individual needs of your residents will be met. Not “fitting” the correct pain scale to your resident may result in the wrong type of medication or no medication being given for pain relief.

14. Validated pain scales for the cognitively intact residents • Wong-Baker Face Scale • Numeric Rating Scale • Visual Analog Scale • Pain Map • Memorial Pain Assessment Card • McGill Pain Inventory • Brief Pain Inventory • Multidimensional Pain Inventory • Wisconsin Brief Pain Questionnaire Slide Notes: What is a validated pain scale? Validated can be defined as a pain scale that has data from at least one study to prove that it does what it is suppose to do. If you use a pain scale that is a combination of several pain scales or a pain scale that you have put together with the help of you staff, you can not be ASSURED that it will give you the correct information you need from your assessment. A good example of this point can be found when using the Wong-Baker Face Scale on cognitively impaired residents. Studies using the scale on cognitively impaired residents have found that as the cognition declines, the resident will pick the “happiest” face on the scale whether the resident has pain or not.

15. Validated pain scales for the cognitively impaired residents • Pain Assessment in Advanced Dementia (PAINAD) • Abby Pain Scale • Doloplus Scale • Discomfort Scale for Dementia of the Alzheimer’s type • Checklist of Nonverbal Pain Indicators • Non-Communicative Patients Pain Assessment Instrument (NOPPAIN) Slide Notes: All of these pain scales have been validated and are used to make assessments on the residents you have that may not be able to verbally express their pain.

16. Cognitively Impaired Residents • At higher risk for under treatment • Often able to report feeling pain • Assessment tools suited to the resident should be used “Even in cognitively impaired individuals, self reports of pain should be considered reliable” Slide Notes: Ask yourself and those in your facility who assess pain, if these statements are true or false. This slide can be used as a quick assessment of whether your cognitively impaired residents are accurately being assessed for pain. If any of these statements are believed by staff to be false, then the measure for pain management used in your facility may be falsely low. Pain may not be recognized in residents that can not respond to the pain scale you are using. ALL THE STATEMENTS ON THIS SLIDE ARE TRUE.

17. Reassessment Times • Done at the time of peak pain relieving effect. This time depends on the medication half-life, based on its form and route of delivery. • At the mid-point between doses • Immediately before a scheduled dose Slide Notes: An assessment for pain relief done at a time that is inappropriate will alert you to the problem of treating pain control in residents by reacting to pain versus having a pain management program. Knowing when to expect pain relief will allow staff to plan reassessment times. The decision to continue the pain medication as ordered or to alert the physician that the resident is not receiving pain relief can only be obtained if reassessment is timed to reflect the pain medications real effect on the resident. Making an assessment before the medication has had a chance to work with the resident’s body does not give an assessment of the medication. Nursing staff in services can contain the information needed for pain management. A periodic check of reassessment times in the nurse’s notes or in the medication administration record is a good way to monitor if more in services are needed.

18. Fourth systemic barrier: Not communicating the findings of the reassessment to the physician so the treatment can be revised and goals met. Slide Notes: Many physicians who prescribe a treatment plan for their nursing home resident’s pain rely solely on the information the nurse provides in the pain assessment or telephone conversation. If an inaccurate pain assessment is done then an inaccurate treatment for pain may be done.

19. Effectiveness of pain treatment • Function • Mood • Activity Level Does the pain treatment meet the resident’s acceptable level of discomfort? Slide Notes: An important question to ask the resident who has pain is “what level of pain is acceptable to you?.” There may be a different answer to this question from each resident. Nurses need to be aware of each individual answer to have an effective pain management program. Goals set for the resident should be contained in the care plan for pain. Using the information from the care plan will help ensure that the NEEDS OF THE RESIDENT ARE BEING MET. FUNCTION – Has the resident’s physical or cognitive function improved since the initiation of pain medication? MOOD – Has the resident’s mood or behavior improved? ACTIVITY LEVEL – Has the resident’s physical activity level increased? Improved ADL’s?

20. Fifth systemic barrier: Not addressing pain myths in residents, family or staff. Slide Notes: We assume we all know the facts about pain management. In reality we all have different levels of knowledge. Pain myths can stop residents from letting Staff know if a resident has pain. Pain myths can stop nurses from screening and assessing for pain so that pain is not recognized or addressed.

21. Common myths about chronic pain • It is a signal of weakness to acknowledge pain • Pain is an inevitable part of aging • Pain is a punishment for past actions • Pain means death is near • Pain meds should only be taken for severe pain Slide Notes: Myths are not questioned by those residents or staff that believe they are true. It is hard to know if a myth is the problem leading to no pain complaints or lack of pain assessments. You will know if myths are a problem in your facility only if you discuss the myth with residents and staff.

22. Common myths about chronic pain • Acknowledging pain means undergoing painful tests • The elderly have a higher tolerance for pain • Cognitively impaired residents can’t feel pain • Residents complain about pain just to get attention • Taking pain medication leads to addiction Slide Notes: The greatest solution to the problem of myths being a barrier to pain management is to just TALK about pain.

23. Administrator Medical director Director of nursing Attending physician Consultant pharmacist Therapists (PT, OT) Social Workers Resident and family Nursing staff Environmental Services Dietary staff Activities staff Slide Notes: Reacting to pain is usually the solitary duty of the resident’s charge nurse. Pain Management is the duty of all the staff in the facility who care for the resident. Pain management:interdisciplinary team effort

24. Frontline caregivers play a vital role Ask the resident • Are you having pain right now? • Is your backside sore? • Does your arm hurt? • Are you uncomfortable? Give staff permission to….. Observe for signs of discomfort Slide Notes: Some residents will not acknowledge their pain by telling staff that they have pain. But, listening to the resident may reveal that the resident is “not up to par, or a little under the weather or just not comfortable.” Many other phases may tell staff that the resident is in pain. There are some residents who have a closer relationship with the nursing assistant, maintenance person or housekeeping person than their charge nurse. The resident may be more willing to say how they feel to them. If the nursing staff responds to information about the resident from other staff, a team approach to managing pain can help improve the care of the resident.

25. What is pain? • An unpleasant sensory and emotional experience • Highly subjective with no objective biological markers • Chronic pain is an abnormal condition • Pain is what the resident says it is. Slide Notes: Pain is not meant by the body to be tolerated. The body uses pain to let us know something is not right and needs our attention.

26. Causes of chronic pain in elders • DJD • Rheumatoid arthritis • Low back disorders • Osteoporosis with compression fractures • Diabetic neuropathy • Headaches • Oral or dental pathology • PVD • Improper positioning, use of restraints • Pressure Ulcers • Immobility, contractures

27. How do I know when a resident has pain?

28. Signs and symptoms suggestive of pain • Frowning, grimacing, fearful facial expressions, grinding of teeth, calling out • Bracing, guarding, rubbing, rocking • Fidgeting, increasing or recurring restlessness • Striking out, increasing or recurring agitation • Eating or sleeping poorly • Decreasing activity level • Loss of function

29. Pain may impact other issues • Mobility (gait disturbances, falls)

30. Pain may impact other issues • Sleep (increased, decreased)

31. Pain may impact other issues • Appetite (malnutrition)

32. Pain may impact other issues • Bowel / Bladder

33. Pain may impact other issues • Cognition (confusion, depression, anxiety)

34. Pain may impact other issues • Socialization (decreased)

35. Pain may impact other issues • Multiple Med Use(psychotropic misuse)

36. Staff play a vital role • Use the same pain assessment tools • Appoint a pain coordinator • Education program for all staff Communication –information must be conveyed to and acted on by the appropriate staff.

37. Screen for the presence of pain

38. Screeningschedule • On admission • Quarterly MDS review • On “significant change” in condition • During annual MDS • During routine daily care • Any time pain is suspected DRIP, DRIP, DRIP, DRIP Data Rich – Information Poor (DRIP)

39. Tools for Pain Management • Nurses use MAR’s to manage pain. • QI/QM Reports generated from MDS data can be used to monitor pain program Slide Notes: These tools provide us with data to manage the process.

40. How to do a pain evaluation How does the pain affect the resident? 1. Locationof pain (where) 2. Time of onset (first started) 3. Frequencyof pain (how often am/pm) 4. Quality of pain (description) • Intensity of pain (validated pain scale) Slide Notes: Does your facility’s policy and procedures cover these important areas in a pain evaluation?

41. Assessing Pain:Quality • Nociceptive pain (somatic) – aching, deep, dull, gnawing, throbbing, sharp • Nociceptive pain (visceral) – cramping, squeezing, pressure • Neuropathic pain – burning, numb, radiating, shooting, stabbing, tingling Slide Notes: This information is important for the nurse to convey to the physician as a result of the pain evaluation.

42. Conduct an in-depth evaluation • Review diagnoses contributing to the pain. • Note all current treatments • Note dosage and frequency of all pain med • Ask about frequency and location of pain • How is pain affecting mood, activities, sleep, etc • Review effectiveness of drugs and txused in past Slide Notes: • Diagnoses or conditions that may be causing or contributing to the pain. • Treatments • Dosage and frequency of all pain medications • Frequency and location of pain and words used to describe pain. What makes pain better or worse? • Pain affecting mood, activities, sleep, etc • Effectiveness of drugs and treatment used in past

43. Review the resident’s med record • With each change in pain medication • With a sudden change in status of the resident • With the Consultant Pharmacist • Any med changes if recently admitted • Any recently discontinued pain meds • Drugs poorly tolerated OR giving less than optimal control • Any increase in pain related to worsening disease • When drug toxicity could be a problem

44. Repeat evaluation with each new complaint of pain Don’t assume a change in the nature of a resident’s pain, or a new pain, is related to the original underlying cause. Sometimes it is caused by an acute condition requiring immediate attention!

45. How do we select individualized care plan interventions?

46. Identify preferences for treatment Ask aboutpreferencesandexpectations Slide Notes: Preferences and expectations individualizes the resident’s PLAN OF CARE and facilitates adherence to treatment regimen and achievement of therapeutic goals.

47. Comfort measures • Environment • Positioning • Backrubs / Massage • Reassuring words and touch • Topical analgesic • Chaplain or counselor • Education Slide Notes: Environment – temperature and noise…move resident to a quieter part of the facility Positioning – restraints and wheelchairs can increase the feeling of discomfort if left in place Backrubs/Massage – try a foot massage Topical analgesic – like aspercreme or something they had successfully used at home Chaplain or counselor should be invited to visit. Can help with some of the “myths of pain” Education of staff, residents and family members can be very beneficial without additional medications or cost

48. Relaxation and diversion techniques • Books on tape • Conversation • Activity • Visitors • Pet Therapy • Music • Aromatherapy

49. Non pharmacological Physical/Occupational Therapy • Hot packs or ice, Transcutaneous Electrical Nerve Stimulation (TENS) unit, or Ultrasound treatments, evaluate for positioning, high-backed wheelchair, soft neck collar, wedge, braces, walking program, stretching exercises

50. Non pharmacological • Psychiatry • Psychology or Social Work • Chaplain consult Slide Notes: Psychiatry – for depression, anxiety, behavior management Psychology or Social Work – support and counseling for coping through difficult situations Chaplain consult – for concerns about suffering, finding meaning, end-of-life concerns, prayer