It is important to remember that pain is a bio-psycho-social process. Pain is felt physically through a biological process in the central nervous system. A person’s mood and other psychological factors, as well as social support influence how pain is experienced. How the person is treated can help to make the pain better or worse. The perception of pain is a factor in the intensity and duration of the pain. No one can judge someone else’s pain. Prior pain history can sensitize the central nervous system, so that people are actually more vulnerable to feeling pain. Current pain conditions have a similar effect. Someone with arthritis is even more sensitive to pain from a fall, for example.
Due to the complexity of this bio-psycho-social experience the following are very significant things you can do to help:
Listen. Validate the emotions of what the person is saying. Acknowledge they are afraid, upset, or hurting. You are "hearing" them.
Have eye contact and stop what you are doing while you are listening.
Be compassionate. Gentle. Understanding.
Report all pain complaints.
Follow-up until the pain is stabilized.
Continue monitoring for pain and flare-ups.
Advocate for people who are suffering. Many older people, especially with dementia will not ask for PRN pain medications.
Offer non‐medicinal comforts: a cold or warm washcloth for a headache or on throbbing feet for neuropathy; extra blankets for chills or added comfort; adjust pillows for sore backs the right position can make a big difference.
Refer to social service. The social worker is trained to provide intervention or can make a referral. Psycho‐therapy is very beneficial.
According to the National Center for Complementary and Alternative Medicine (CAM), the following categories are considered CAM.
Art, music, and dance. These are excellent therapies that help with pain and can be modified for residents. Play music the person enjoys. Do not change the resident’s channel, CD, or volume unless asked. Soothing music can calm anxiety; uplifting music lifts the spirit and can help when feeling down. Earphones can be used if there is a roommate concern. Music can be played as much as the person enjoys it. Art and dance/movement can also be integrated into the person’s plan, depending on interests, functioning, etc.
Biologically based therapies. Some physicians prescribe vitamins and herbs. Aromatherapy can be helpful and is available in a variety of forms. Different scents have different effects. Aromatherapy can have a pharmacologic effect, so it’s important to check with the physician before using.
Mind-body interventions. Cognitive-behavioral therapy is very beneficial. Hypnosis, bio-feedback and support groups can also be helpful. These therapies are used so often, in so many traditional medical care facilities they are often not considered CAM. They are now main stream.
Manipulative and body based methods. Many people use manipulative and body based methods such as chiropractors. Alternative medical systems. These are systems built upon a complete system of their own theory and practice. Homeopathic and Chinese are examples of this. Some residents may have used these systems before coming in.
Energy therapies. Healing touch is an example and is often done by nurses and offered in many hospitals. This is a very gentle, relaxing technique using the person’s energy.
Other beneficial, non-medicinal interventions include: activities; physical and/or occupational therapies; social service; exercise; diet; and education. Remember the family too.
The following techniques/therapies/interventions have been used successfully to treat adults and children with persistent and intermittent pain. Do secure a medical diagnosis and follow through with physical therapy and diagnostic/treatment recommendations as you choose from these self help measures.
Core Body Weakness (back pain can be aggravated by excessive sitting) Intervention: Sit on a core strengthening ball chair, gradually increasing time. Seek exercises from a Physical Therapist. Maintain safety while on the ball chair.
Low Back Pain and Hips out of Alignment Intervention: Sit on a solid chair (no wheels). Tightly apply band/belt around thighs above both knees. Look straight ahead (not down). Stand up. Sit down. Stand up. Sit down. (Repeat sequence 10 times or as able.) May do slowly and support balance with hand on table if needed. Walk! Walking helps our body’s balance, alignment, and strength.
Muscle Spasms/Tightness/Cramps Interventions:
Relax with a warm 20 minute bath soak with 1-3 cups of Epsom Salt (Magnesium). Rinse body to prevent dry skin. Or, use a warming pillow or heating pad. (Do not use heating pad when not awake).
Seek massage: by self, family member, professional. A professional who is prepared to do myofascial release, cranial-sacral work is invaluable.
Recent research is showing a low Vitamin D level can lead to pain. Thus, have a blood test done to evaluate your levels and enjoy the sun. At the same time have your Calcium levels evaluated and take calcium supplements with Vitamin D as recommended for your age. For Calcium to be absorbed, it needs Vitamin D3 form.
Attend Yoga classes. They have been shown to assist with pain management.
Low Energy Interventions: Call a friend. Do activity with a friend. Walk barefoot in the grass. Feel the energy of the earth and the sun. Laugh and find joy in your life. Cut the cords of negativism from your life. Reset priorities. Pace yourself. BE HAPPY!
Cherry Juice Intervention: Drink to determine if it helps your type of pain.
Topical Preparations Intervention: Seek over the counter products such as LMX to rub into the area of pain. Some are more costly than others.
Headaches and/or Congestion Intervention: Neurolymphatic Release: Place 2-3 fingers above your collarbone/clavicle on both sides. Gently pump toward middle/neck area. Do often to see if this lessens sinus or migraine headaches; Opens lymphatic drainage for the head.
Leg discomfort with swelling/fluid retention Intervention: Lie on back in bed. While exhaling, put chin to chest and have toes pointed up toward the trunk. While inhaling, extend head and toes. Hold briefly. Then repeat. This opens lymphatic drainage and helps decease swelling. Do 1-2 minutes.
Anti-inflammatory Intervention: Take Omega 3 (1000 mg) 3 times a day with meals. After two weeks, there will be improvement in inflammatory pain.
Give Forward Intervention: Sharing of ourselves with others, helping someone else, even with little things, distracting ourselves from the self with focus on the needs of others. All leads to less pain.
A physician who is devoted to evaluating and treating pain conditions
Board-certified pain management physicians have additional training and expertise in the field of neurological, orthopedic, connective-tissue, spinal, and other pain conditions
What is injection therapy?
Injection of local anesthetic and/or corticosteroid into a joint, muscle tissue, or spinal region to reduce irritation and inflammation and reduce pain
Who benefits from injection therapy?
People whose pain has not responded satisfactorily to medications such as non-steroidal anti-inflammatory drugs (NSAIDs) or pain medicines, or to physical therapy
People whose activity tolerance and social interaction is decreased because of pain People who are not sleeping or resting well due to pain
Some conditions that can be managed by injections are:
Cervical or Lumbar Spinal Stenosis
Degenerative Disk Disease, Arthritis or Bursitis, Sciatica
Neuropathy
How can neighbors and family help?
Do not ignore back or neck pain.
Notify the nurse, your primary care physician, or the facility physician if you notice that you do not tolerate activity due to pain.
Report loss of sleep or rest related to pain.
Give a complete report which includes:
What makes the pain better or worse? (Standing, sitting, walking, rest, heat, cold, sneezing, coughing, bowel movement, etc.)
What does the pain feel like? (Ache, dull, pressure, cramp, burning, numbness, tingling, sharp, shooting, electrical, hot, cold, twisting, etc.)
Does the pain radiate? (To the arm or hand, to the shoulder, to the knee, below the knee, to the feet, to the groin, etc.)
What is the severity or intensity of the symptoms? (Mild, moderate, severe; on a scale from 0 [no pain] to 10 [painful]. How do you rank your pain most of the time, and what is the highest level that you experience?)
How often does the pain occur and how long does it last? (Worse in the morning, worse at night, continuous or intermittent, lasts for a few minutes, lasts for several hours.)
Important physiological changes in the elderly that affect medications:
Less total body water
If the drug is water loving, the drug dissolves in less water; thus the concentration of the drug increases which could increase its effect and/or side effects.
More fat
If fat loving drugs are used, there is more fat for the drug to be distributed in and released slowly, which could result in a longer duration of action.
Less protein
Many drugs bind greatly to protein.
When there is less protein to bind to, there is more of the drug in the circulation; thus there is an increase in concentration of the free drug in the blood, which could result in toxicity.
Less cardiac output
Slower circulation time means it will take longer for the pain drug to reach its site of action; thus, it will take longer for the drug to work.
Less blood flow to the liver causes decreased breakdown of the drug, so more of it stays around longer, which could cause it to last longer.
Liver size decreases with age
This decreases the ability for the liver to breakdown drugs; which could result in toxicity.
A smaller liver also results in fewer enzymes that breakdown drugs; causing toxicity.
There is a reduced “first pass” extraction of drugs; potentially causing toxicity. (After giving a drug by mouth, it first goes to the liver where a lot of it is removed even BEFORE it goes into the blood stream.)
Decreased excretion of drugs by the kidney because of a loss of kidney cell
As a result of the above, generally speaking in elderly patients who receive pain medications, there is a higher effect of the drug (especially opioids) and a longer duration of action. Thus a good rule of thumb when adjusting pain medications in the elderly is to: START LOW AND GO SLOW. Start with a low dose and do not make changes in the drug regime too frequently.
Elders feel pain just as acutely and chronically as younger patients. They don’t have fewer pain nerves. Their response to pain is just like anyone. Depression may occur from unrelieved pain; however, the elderly do have more painful conditions than young people. For instance, osteoarthritis is a painful condition that usually occurs as one gets older. Elders may appear to “complain” of more pain, when in fact they actually have more painful conditions! By the way, they really are not complaining of pain when you assess them for pain, they are “stating,” “reporting,” or “telling” you of their pain.
Caregivers play a key role in the support and treatment of persons in pain. Assessing pain is the first step to helping. There are many tools that can be used by residents to rate pain. Ask what works best for each resident and use that same pain scale all of the time. Choices may include:
Numeric rating scale
Pain thermometer
Verbal descriptor scale
Wong-Baker faces scale
Some residents have problems thinking clearly and can not use scales. Staff may use facial or eye cues to detect pain and pain relief for these residents. There are also special pain tools for staff to use. These include:
PAINAD (Pain Assessment in Advanced Dementia)
PADE (Pain Assessment for the Dementing Elderly)
Working in a nursing home gives staff the chance to get to know their resident’s usual behavior and daily habits. Sometimes pain can be noticed by checking other things. Pain may cause:
Weight loss
Less movement
Falls
Decrease in ADLs
Trouble sleeping
Changes in mood or actions
Treatment tips for caregivers:
Ask for family input to help with detection of pain in their loved one. Relatives can provide past reasons for pain as well.
The best way to control persistent pain is for the resident to receive medication on a regular basis.
If you know that a certain activity causes pain, make sure the resident gets medication beforehand.
Use a variety of non-medication therapies such as:
Distraction
Music
Repositioning
Emotional support
Massage
Humor and laughter
Calming statements
Exercise
Story telling
Heat and/or cold therapy
You can make a difference in helping your residents have better pain control. Most importantly, pain relief will improve their quality of life.
References: Littlehale, S., Niemi, J., & Capitosti, S. (2007). Improving pain management. Provider, 33(10), 55-56, 59-60. Mentes, C., Teer, J., & Cadogan, M. (2004). The pain experience of cognitively impaired nursing home residents: Perceptions of family members and certified nursing assistants. Pain Management Nursing, 5(3), 118-125.
Adverse drug reactions (ADRs) occur frequently in nursing home residents and are often not recognized as preventable events. Many times the ADR is thought to be part of the patient’s disease progression or not noticed at all. A large portion of ADRs in the elderly are due to drug to drug interactions.
Drug to drug interactions can occur because of drug dose, the resident’s medical conditions, drug effects/actions, and the number of drugs prescribed. Some drug interactions occur more often and are more dangerous than others. Certain drugs frequently prescribed to nursing home residents have an increased chance for interactions.
The American Medical Directors Association together with the American Society of Consultant Pharmacists identified a top 10 list of drug to drug interactions in LTC patients. Five of the ten interactions dealt with warfarin (Coumadin), a medication that thins the blood.
Details of these interactions can be found at www.scoup.net/m3project/topten/. Pharmacists play a key role in monitoring drug therapy for these interactions. The LTC nursing staff also helps by identifying changes in a resident’s behavior, medical status, and medication profile. Drug to drug interactions vary in significance. Differences in a patient’s disease state, gender, age, or their medications determine the severity of the interaction. According to the Merck Manual, the average geriatric patient has up to 6 medical conditions! Knowing the number of drugs a typical LTC resident receives in one day, it is important to recognize that as the number of drugs increase for a patient, so do their chances for experiencing an ADR.
Occupational and physical therapy can have a positive impact on pain management with residents in long term care in many ways. After an evaluation by an occupational therapist or a physical therapist the evaluating therapist will develop an individualized treatment plan to meet the resident’s needs.
Depending on diagnosis and resident specific needs; this plan may include any combination of the following:
Learning to use adaptive equipment and new techniques for eating, dressing, bathing, toileting and leisure activities to avoid painful bending and trunk rotation.
Proper use of painful joints.
Hot and cold packs.
Paraffin for deep tissue and joint pain relief.
Tissue massage.
Therapeutic exercise and stretching.
Ultra sound and electrical stimulation are also popular modalities to use for pain relief.
Proper positioning to help the resident sit upright within midline to relieve discomfort. This positioning may include pressure relief cushions for wheel chair or bed to reduce the risk of compromising skin integrity with pressure sores.
Often times the therapist provides the therapeutic use of touch which helps to sooth the body and soul.
The therapist is also valuable in training caregivers how to best handle individuals with pain.
These are just a few things that an occupational therapist and/or physical therapist can do to address the pain that your long term care residents are experiencing. Check with your therapy department to see what they can do to help manage your residents with chronic pain.
Assessment of pain in the elderly, especially when they have dementia, are nonverbal or have problems communicating can be difficult but the necessity of identifying and relieving the distress of pain makes it necessary and desirable. Fortunately, experience has given us various steps to overcome communication difficulty. The American Society for Pain Management Nurses (ASPMN) has issued guidelines for assessing pain in nonverbal residents with advanced dementia.
Step 1: Ask the Resident About Pain
Many elderly, like normal residents can report pain, especially if you use words like "hurt," "ache," and "feel OK." If the resident uses specific words to describe discomfort, document and use these words to reassess pain and comfort level.
Know the resident’s primary diagnosis and medical history. Ask hip fracture residents about the affected hip and leg, but don't stop there. Touch or point to the body part of concern while asking about pain to focus attention and clarify where any pain is located. Commonly used tools include the Numeric Rating Scale ("Is your pain 0 [none] to 10 [worst pain ever] or the Visual Analog Scale where the resident indicates their pain on a straight line from 0 to 10). These can be used both with residents who are cognitively intact and for some residents who are impaired. Although these tools have not been validated for use with elders with dementia, it is worth trying to use a pain assessment tool because only the resident can rate his or her level of pain. Several tools including the facial expression test where the resident is shown faces from smiling to frowning to assess pain in residents who are unable to reliably report their pain have been developed and validated, but each tool has limitations and none of these tools rates pain severity.
The painAD scale is available at http://www.adma.com/caring/may2004/painad.htm. It consists of 4 parameters: breathing independent of vocalization, negative vocalization, facial expression, body language and consolability. The scores are tallied on a 1-2 scale and added.
Step 2: Search for Potential Causes of Pain
Ask doctors, nurses and other caregivers about chronic conditions, especially musculoskeletal disorders and neuropathies. When a resident has limited mobility, consider the need for repositioning. Look for sources of discomfort in addition to pain -- for example, new skin irritation, constipation, recent falls, environmental conditions (too cold, too warm, too much glare, too noisy).
Step 3: Observe Behaviors
In the absence of self-report, observation of behavior is a valid approach to assess pain. However, behaviors do not always accurately reflect pain intensity, and in some cases, the observed behavior indicates another source of distress. Behaviors that are likely to be signs of pain include guarding a body part, reluctance to move or be moved, decreased mobility, and crying out or wincing when touched, with movement, or during procedures. Nonspecific distress behaviors that may or may not be caused by pain include restlessness, vocalizations, irritability, and decreased appetite. In a setting where longer contact fosters familiarity, the care giver may be better able to identify a resident’s unique pain behaviors.
Step 4: Seek Surrogate Reports of Pain
In the absence of a resident’s self-report of pain or comfort, family, friends, and other caregivers can function as surrogates to assist in identifying a resident’s pain. Family members are often able to describe lifelong or recent patterns associated with pain such as changes in effect, mood, appetite, or activity.
Pain is a significant health problem that is often unrecognized or under treated with residents in long term care. Among the institutionalized elderly, up to 83% report at least one pain problem. Left untreated, pain can lead to substantial health and social problems, including: cognitive changes with impaired memory/thinking; behavioral problems; appetite changes (frequently decreased); mood disorders (depression, anxiety); disrupted sleep; increased fatigue; trouble breathing deeply and decreased walking/functioning , increasing the risk for falls. Pain can cause slower rehabilitation and it weakens the immune system, increasing risk for colds/flu. Pain can destroy relationships, creating more stress and difficulties with family and staff. Pain decreases a person’s overall quality of life.
Pain is a complex process, it’s not just the physical cause (sometimes this can’t be determined), but also the person’s prior pain history, different biological factors, psychological status and how people are interacting with them. Pain is unique to each person; you can’t judge someone’s pain.
The elderly as a group do not report pain, you have to ask. Pain is not a natural part of aging. Everyone deserves treatment, whatever age or functional status. There are many different types of pain management options. Pain responds best when treated early and promptly. Addiction is misunderstood and rarely occurs with this population. It’s important for everyone working with residents to take a close look at your own beliefs, are they correct?
Determine how pain monitoring is done in the home by sharing this newsletter and discussing methods with your nursing staff.
Encourage staff to report changes that might suggest a resident is having an issue with pain.
Discuss the level of difficulty CNAs experience in reporting residents’ pain and help determine ways to make it easier and timely.
If you are not signed up for the Advancing Excellence Campaign, go to www.nhqualitycampaign.org to join. Already a member? Visit the website to update your goals and locate tools.
January 2010
February 8, 2010
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