Care of the Elderly at the
End-of-Life (Long Term Care)

Olga Wells, RN, BSN, Assistant Administrator, River Garden Hebrew Home
&  John Giannini, M.D., Medical Director, River Garden Hebrew Home, Jacksonville, FL
 

The popular and professional literature has had an increased focus over the past several years on our aging population. The number of elders in our country is growing rapidly and as that number increases so will the problems society must come to grips with that are associated with aging. A number of diseases that are common in the elderly, such as diabetes, coronary artery disease, arthritis and peripheral vascular disease, are also pain related diagnoses.

Although most elders continue to live in the community, nursing homes are increasingly utilized. The number of elders who will use the nursing home for rehabilitation or recuperation following a hospital stay will continue to increase as will the number of individuals who will use it as a place to live out their lives.¹ The National Center for Health Statistics reports that in 1993, 1 in 5 deaths in the U.S. occurred in a nursing home, twice the number reported in 1978. End-of-life care or palliative care will be a growing part of nursing home care.

The Problem of Chronic Pain

Chronic pain is a serious elder care issue. Among nursing home elders, chronic non-cancer pain is common. The literature reports anywhere from 26% to 55% of these individuals have daily pain and that a significant number of these elders receive no analgesic pain medication. In a 1995 study of pain prevalence in Oregon nursing homes, 44% of the 461 residents sampled had pain management needs but those needs were being inadequately met. Most had no orders for analgesic medication. Those who did received them infrequently. The authors concluded that lack of pain assessment was a major factor in the under-treatment of pain in that population.² A review of the pain literature of the past five years continues to demonstrate that pain in elders, and particularly in nursing home dwelling elders, is both inadequately assessed and inadequately treated.

Daily pain affects quality of life and quality of care for nursing home residents. It is a factor in increased dependence in activities of daily living, decreased or impaired mobility, increased falls and other injuries, decreased appetite, weight loss, insomnia and depression. As we continue to deal with an aging population, the need to address chronic pain will become more and more important.

Barriers and Myths Related to Pain Management

The Resident

The primary barrier to pain management in the long-term care setting initially revolves around poor communication between the resident and his or her caregivers. Residents often possess a diminished ability to perceive, express, localize, or describe the intensity of their pain. Decreasing cognitive function related to dementia or delirium, combined with the impaired sensory processes of hearing, vision and motors skills further complicates the assessment and treatment of pain.

The most reliable indicator of pain is self-reporting but even that has pitfalls from a resident's perspective. Many are reluctant to report their pain as a way to avoid any testing or because they don't want to bother anyone. Elders frequently believe that pain is a normal part of aging and so they fail to report pain. Pain may represent an indication that the end is getting near and denial may prohibit the admission of discomfort. Repeatedly asking for pain medication often results in a sense of frustration for the resident who may then fear being isolated from caregivers for complaining. Patients may not wish to be perceived as weak. Certain religious denominations believe that pain is punishment for sin or a requirement for cleansing. And finally, residents may feel that nothing else can be done.

The Caregiver

The overwhelming belief among health care providers is that they know when their patients are in pain. The reality is just the opposite. In a comparison study of nurses perceptions of pain in elderly patients and the patient's own perceptions, using the same rating scale, the nurses consistently under-estimated severe pain and over-estimated mild pain.³ However, even if adequately assessed and reported, nurses and physicians frequently have the misconception that pain is an unavoidable consequence of aging and that pain management has limited effectiveness in the older population.

Caregivers may believe that with declining mental function and multiple medical conditions, pain sensation is altered, and that little or no medication is needed. Although some studies have shown that individuals with severe cognitive impairment have decreased awareness of pain, most studies continue to show that even impaired elders experience pain but may be unable to express it. Some caregivers still view requests for medication as "drug seeking behavior" rather than a legitimate need for pain relief. Interestingly enough, what caregivers consider the chronic pain personality is often the result of years of frustration due to failure of relief and confrontational isolation.

Physicians may avoid prescribing certain medications or order inadequate dosages in an effort to minimize side effects or to account for a lowered drug tolerance in the elderly patient. Avoiding side effects through lower dosing, although commendable caution, should not impede the appropriate titration of adequate medication to alleviate suffering and improve quality of life. Unfortunately, government monitoring and regulation of physician prescribing practices in the long-term care setting continues to result in guarded narcotic use of doses sufficient to provide adequate pain relief and even wary use of other analgesics in this setting. Physician education regarding the laws governing medication prescribing and administration in long-term care is a key component to effective pain control and management in the elderly.

The System

Systems barriers in long-term care exist in the form of high turnover rates of direct caregivers coupled with inadequate education in the assessment, monitoring and treatment of pain. This in turn contributes to the overall environment of poor pain management. Pain assessment and pain management have historically been "afterthoughts" in medical and nursing education. ⁴ Institutional leadership may have an insufficient commitment to pain management with minimal team approach and a poorly organized effort in this area of patient care. The long-term care facility medical director and administration must believe that controlling pain in their elderly residents is important and that these elders have a right to be pain free. The new JCAHO requirement of pain assessment and management as the "Fifth Vital Sign" in health care and HCFA's interest in pain as a quality indicator for long-term care settings, will no doubt result in improvement in this area.

Pain Assessment

Most nursing home residents, even those with mild to moderate cognitive impairment can use a pain assessment tool. A number of visual analog scales are available. They can help to evaluate the intensity of pain as well as the effectiveness of the analgesic or other measure used in pain relief. Sometimes, more than one tool must be used. Combining a visual analog scale with words that describe pain is frequently the most effective way to assess pain in the elderly.

Residents with cognitive impairments present a special challenge for pain assessment and management. When specifically asked, residents who are still verbal but with a dementia diagnosis can usually express pain and identify the pain area on their own bodies. Those who are unable to communicate pain may exhibit pain behaviors. These behaviors are often mistaken for the agitated behaviors associated with dementia resulting in no intervention or perhaps the inappropriate use of psychoactive medication when an analgesic is really needed. Teaching nursing home staff about pain behaviors is key to an effective pain management program for this population.

A number of excellent resources for pain assessment are available on the Internet. One that is particularly "user friendly" is Partners Against Pain and can be accessed at: http://www.partnersagainstpain.com. This site includes sections for professionals as well as patients. Various assessment tools, the World Health Organization (WHO) pain ladder, reports of the latest studies regarding chronic pain in elders, as well as treatment of cancer pain are described and availabe for download and use by clinicians. Of particular interest to those facilities with a culturally diverse population are the pain scales available in 18 languages.

Pain Treatment in the Long-Term Care Setting - Guiding Principles

Care, comfort, function and well-being of the individual resident are the foundation for the effective management of pain in the long-term care setting. Each resident's plan of care should be tailored to meet his or her needs without the constraints of resource or social bias toward medications (narcotics). Despite mounting scientific research supporting opioid analgesic use to adequately relieve pain and suffering, especially in the long-term setting, these medications continue to be underused for this purpose. Physician reluctance to prescribe and resident and family reluctance to accept these medications, is unwarranted not only from the low addiction profile but also because it serves to make these medications unavailable for adequate relief of significant pain.

Once the presence of pain has been established through appropriate and adequate pain assessment tools, there are a variety of ways to proceed in providing adequate pain relief. It is efficient to divide pain disorders into mild, moderate and severe, for the sake of classifying the appropriate medications used to treat the degree of the pain. An example of this is the WHO "Step Ladder" which provides one pharmacologic paradigm for the treatment of chronic pain. (Table 1).

Non-pharmacologic agents can be useful adjuncts or alternative pain treatments. These include physical therapy, massage, cognitive therapy, biofeedback relaxation techniques, prayer, hypnosis, ultrasound and electrotherapy. When a pharmacologic approach is necessary, it should proceed in a stepwise fashion and include the process of evaluation and assessment of response to treatment so that the drug can be titrated appropriately.

The fundamental principle of analgesic treatment for chronic pain is regular, not PRN (as needed), administration of medication. The dosage should be adjusted to meet the goals of decreased pain, improved function, mood and sleep, and should be limited only by side effects and potential toxicity. Those with neuropathic pain may also benefit from appropriate adjuncts, such as tricyclic antidepressants or anticonvulsants (gabapentin).

In the event that acetaminophen fails to provide adequate pain relief, NSAID's can be considered. However, despite their efficacy, they are not without significant risks including GI bleeding and renal complications. The newer COX2 inhibitors may be a welcome addition to the pain relief arsenal but there is insufficient longterm experience in the frail elderly in order for them to be fully endorsed. Tramadol, a central acting analgesic may be the next agent added, either alone or in combination with NSAID's, when residents or their advocates wish to avoid opiates.

The use of opioid analgesics used for non-cancer pain continues to gain wider acceptance as an important option in the treatment of chronic pain in the longterm care setting. It has been shown that longterm use of opioids presents no risk to physiologic systems like NSAID's do. While sedation may occur at the initiation of these medications, tolerance to this side effect develops rapidly, quickly becoming a non-issue. Also, fear of respiratory depression should not be regarded as a legitimate reason to withhold adequate pain relief. It is reasonable to start with an immediate release opioid and, once dosage is established, change to the sustained release form. Physicians and institutions can expect fewer regulatory obstacles prescribing opioids as governmental agencies and boards become further educated regarding their use and benefits in the care and comfort of elderly nursing home residents.

Summary

Pain assessment and management in elders can be difficult. Nursing home staff must be aware of pain related diagnoses in their residents. A good educational program for nursing home staff is critical. It should include when to assess, which residents need regular assessment, instruction on the use of the agreed upon pain measurement tool, discussion of pain behaviors and when to assess for them, and appropriate documentation.Pain management in the elderly and views surrounding this issue, have undergone a transformation in recent years. Longterm care policy makers, resident, families, and healthcare workers, have rallied to address the issue of pain in the frail elderly with great strides. We all face the challenge and commitment to address chronic pain assessment and treatment in our aging population and to insure the best quality of life we can offer in their waning years. Institutionally and personally, by dispelling barriers and myths and shedding our own prejudices, we can embrace the systematic approach in the relief of pain and serve our patients in a manner that would honor Hippocrates himself.

Appendix A

Appendix B

 

References

1. Teno J, Bird C, Mor V. The prevalence and treatment of pain in US nursing homes. A monograph prepared for the Center for Gerontology and Health Care Research at Brown University; 2000.
2. Wagner AM, Goodwin m, Campbell b, Eskro S, French SW, Shepherd PS, Wade M. Pain prevalence and pain treatments for residents in Oregon nursing homes. Geriatr Nsg 1997, 18 (6): 268-72.
3. Berg I, Sjostrom B. A comparative study of nurses and elderly patients' ratings of pain and pain tolerance. J Geron Nsg 1999, 25 (5): 30-6.
4. Warner RT. Pain management. Brown University LTC Qual Adv 1999, 11 (11): 1-6.

Jacksonville Medicine / May, 2001

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