discomfort is frequent in nursing homes, with 85% of residents reporting discomfort and over 60% expressing continuous pain. As a result, much study has been conducted to improve evaluation methods and methodologies for this group. However, far less research has been conducted to investigate how the course of pain in nursing home residents varies with time, according to the authors of a study published in the Journal of the American Geriatrics Society.¹
This multidisciplinary study team also looked at demographic and clinical correlations in an attempt to establish clinically relevant pain trajectories so that doctors may adopt a more educated approach to defining priorities and arranging therapy.
“Understanding and appreciating pain changes in the elderly can be tremendously important,” said Alan David Kaye, MD, PhD, a Tulane School of Medicine professor of anesthesiology and pharmacology. This is due, in part, to the fact that “many elderly patients are put on medications that cause central nervous system effects,” he explained. “The side effects of the drugs can create an even worse situation for the elderly than the intended benefits of the drugs.”
Design of the Study
The researchers conducted a longitudinal examination of data from patients who lived in 44 Indiana nursing homes from September 27, 2011, to December 16, 2019. They used information from the Minimum Data Set (MDS 3.0), a tool used for both assessing and supporting care management in nursing homes. The final analysis includes data from 4,864 nursing home residents. Residents with stays of less than 100 days were eliminated, as were those with fewer than three pain observation time points.
Females accounted for 63.9% of the sample population. The majority of the patients (87.3%) were white, with 11.6% black and 0.6% Hispanic. The age ranges (in years) were as follows:
< 60 — 8.8 %
60 to 69 — 11.9%
70 to 79 — 21.9%
80 to 89 — 37%
≥ 90 — 20.4%
For 38.8% of the residents studied, BMI was normal; 8.5% were underweight, 27.8% were overweight, and 24.9% were obese. The majority of the participants (76.7%) resided in a city.
Findings on Pain Pathways
The researchers discovered four pain pathways:
absence of chronic discomfort (48.9%)
decreasing-increasing pain presence: pain that first decreased, remained stable, and then rose with time (21.8%)
Presence of increasing-decreasing pain: defined as pain that first grew, remained stable, and then reduced with time (15.3%).
Pain is always present (14.0%).
45.6% of residents who died throughout the study period were in the increasing-decreasing category, whereas 41.3% were in the lack of constant pain category.
Hip fracture was linked to a five-fold increase in the incidence of chronic pain. Understanding the higher likelihood of chronic pain caused by a hip fracture “allows residents and clinicians to plan care and set priorities,” the authors said.¹ Living in a rural location was also linked to chronic pain. The authors believed that this may be related to less resources for recognising and treating pain outside of metropolitan regions.
Patients with Alzheimer’s disease or related dementias (ADRD) were less likely to have chronic discomfort. This conclusion is most likely due to pain under-estimation or under-reporting. “Pain assessment for residents who are unable to self-report pain relies on staff’s ability to infer pain from behaviours such as grimacing, yelling, or guarding a body part,” the authors explained. Nonetheless, they acknowledged that inferring pain is challenging. They proposed that alternative pain evaluations, such as movement-based pain assessments, might enhance quality of life and pain management for cognitively impaired individuals.
Important Takeaways
In terms of limitations, the research did not take into consideration comorbidities that vary over time or pain-relieving therapies.
Nonetheless, according to Dr. Kaye, “the study serves to clarify or better define a pain trajectory in any given patient, because trends have predictive value.” This can be particularly useful in assessing and selecting treatment strategies in specific subpopulations of patients who may have reduced cognitive performance or comorbidities associated with ageing.”
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