Pain Management and the Impact of Pain on Quality of Life in Nursing Home Residents

1. Henrietta Szold Hadassah Hebrew University School of Nursing, Jerusalem Pain Management and the Impact of Pain on Quality of Life in Nursing Home Residents 1 University of Maryland, School of Nursing, 2 Hadassah Medical organization, school of Nursing, 3 University of Maryland, School of medicine Efrat Adler, RN, MS, FNP, Doctoral Student 1,2 Ann L. Gruber-Baldini, PhD 3 Elizabeth Galik, PhD, CRNP1 Carolyn Yocom, RN, PhD, FAAN1 Marianne Shaughnessy, RN, PhD, CRNP1 Barbara Resnick, PhD, CRNP, FAAN, FAANP1

2. Background Management of pain and optimal quality of life are two of the most important goals of the Advancing Excellence in America’s Nursing Homes Campaign (“Advancing Excellence”, 2006; AGS, 2009; Ferrell, 1995; 2004)

3. Important information • There is a high prevalence (49%-84%) of persistent pain in NH residents • Typical nursing home (NH) residents are at increased risk of experiencing pain, and therefore may experience decreased Quality of Life (QOL) • Underestimated and undertreated pain is no longer acceptable in NH settings McSpadden et al. 2010; Tenoet al. 2008; Torvik et al. 2010)

4. Focus of Study • Despite the focus on pain little is known about the details of pain in these sites, management, and impact on residents quality of life (QOL)

5. Hypotheses • More than 50% of the participants will be found to suffer from pain while less than 75% will be treated by pharmacological therapy • Residents with severe pain will receive stronger pain medications (e.g., tramal and opioid analgesics) compare to residents with mild/discomfort pain • Residents who are younger, female, or white will report more of pain and receive more pain medication than those who are older, male, or non white

6. Hypotheses(Cont.) • Controlling for cognitive status, those with pain will have lower QOL scores across all five components of the Dementia Quality of Life (DQOL) (positive affect, negative affect, self-esteem, loneliness, and esthetics) and lower overall QOL compared to those with no pain • Residents complaining of musculoskeletal pain will have lower QOL scores across all five components of the DQOL and lower overall QOL than residents reporting other locations of pain (AMDA, 2009; Ferrell, 1995; 2004; Marinho et al., 2010; Stein, 2001; Weiner, & Hanlon, 2001).

7. Methods Design • secondary data analysis using baseline data obtained as part of the Res-Care Intervention Study Sample (Facilities) • 12 NHs in the greater Baltimore area (> 200 residents/facility) • two were independent facilities, the remaining were from three different facility chains • eight for-profit, four not-for-profit • facilities were matched based on ownership (Resnick et al. 2009)

8. Methods (Cont.) Sample residents, N=391 • 65 years of age or older • MMSE score of 12 or greater • life expectancy greater than 6 months • not receiving skilled rehabilitation services • participants completed their own consent or signed an assent to participate. In case they were not able to sign, there proxy was contacted to provide consent (Folstein, Folstein, & McHugh, 1975; Resnick, et al., 2009)

9. Measures QOL • DQOL instrument (fair support of internal consistency and validity in NHs) Pain • point prevalence, self-report (yes/no) • point to the location • short form of the McGill Pain Questionnaire (SF-MPQ) for pain intensity Demographics and pain medications • chart abstracting (Pain medications: acetaminophen, NSAIDS, opioid analgesics, tramadol, adjuvant) (Adler & Resnick, in press; Brod et al., 1999 ;Sloane et al., 2005; Melzack & Katz, 2001 )

10. Results

11. Table 1 Descriptive statistics of the sample

12. Figure 1 - Prevalence of drugs used in no pain and pain reported groups Note: of those who reported “no pain”, 96.1% were receiving pain medication, of those reported pain, 97.2 were receiving pain medication.

13. Figure 1.2 - DEA scheduled drugs in no pain and pain reported groups Note: the overall prevalence of the use of opioid analgesics =28.0% and within the pain reported group=39.6%

14. Results (Cont.) • With regard to the relationship between race, gender and age, there were no statistically significant differences on the presence of pain, severity, and location of pain Pain and QOL • of the five DQOL subscales, pain was correlated with overall QOL and negative affect

15. Results (Cont.) • those who reported pain in the head, face, and neck had lower overall QOL and those who reported of abdominal pain had higher negative affect • those who reported of severe pain were more likely to get tramadol or opioids than those with less severe pain • there were no significant differences between the drug group used to treat pain and QOL

16. Table 2 Effects of the presence of pain, severity, location, and treatment on QOL

17. Discussion • The prevalence of reported pain (28%), was much less than reported in the literature (49% -84%). Only 2.8% of residents reporting pain did not receive pain medications • The hypothesis suggesting that there would be age, gender or racial differences in resident reports of pain and how these individuals were managed was not supported • Hypothesis four (pain and QOL) was partially supported, hypothesis five (location) was not supported (AGS Panel, 2009; AMDA, 2009;Ferrell.2004; Helme & Gibson, 2001; Teno et al. 2008; Won et al.1999; 2004)

18. Limitations • Secondary data analysis • External validity – generalizibility • Measurement challenge: • the DQOL measure was originally developed for community dwelling older adults with mild to moderate dementia • Exclusion criteria (no hospice and rehabilitation patients) • No data on nonpharmacological pain treatments • Variations across states AMDA, 2009; AGS, 2009; Teno et al., 2001 US Census Bureau, 2010

19. Clinical Implications • Pain may be well assessed and controlled in some NH environments • Our findings show that there was no negative impact on QOL for pain management using pharmaceutical interventions • Our findings provide guidance for future work related to consideration of pain location specifically on QOL and highlight areas to be particularly diligent about assessing (e.g, head, neck and abdomen)

20. Clinical Implications (Cont.) • Management is imperative: • assessment strategies • nonpharmacological therapies • adequate medication prescription • staff, patient, and family education • cultural competence (McLennon, 2007)