Pain Management

While persistent pain may be common in older adults, it is not a normal part of the aging process. Most nursing home residents have at least one condition associated with pain, with pain prevalence estimated to be as high as 55 percent. Persistent pain, or insufficient treatment for pain, can lead to adverse outcomes including depression, sleep disturbances, changes in appetite, falls and an increase in functional impairment.

Successful pain management programs include processes for completing comprehensive pain assessments, along with re-evaluations to determine the treatment's effectiveness. Standardized, evidence-based assessment tools are an important component of any pain management program. A variety of valid and reliable assessment tools are available, including tools developed specifically for evaluating residents with dementia or other cognitive impairments. Each resident should have a comprehensive pain assessment completed on admission, quarterly thereafter and whenever there are changes in condition. The comprehensive pain assessment serves as the baseline from which care planning will be initiated and measurable goals established.

Care planning is an ongoing inter-disciplinary process that is initiated at the time of admission. Interventions should be based on identified factors from the pain assessment process, with measurable goals that address the resident’s preferences, expectations and needs. The effectiveness of the interventions should be evaluated periodically, and the care plan revised as necessary to reflect changes in the pain assessment. The goal for pain management and the best possible outcome is the relief and control of pain.

The toolkit below includes evidence-based resources that will assist facility staff in developing effective systems for pain management.

Resources Created by HHS

• Opioids: An Epidemic Crisis (PDF) was developed as a resource for prescribers, consultant pharmacists, and facility staff as they as they work to ensure the appropriate use of opioid medications in nursing home residents.
• Evidence-based Best Practice for Nursing Pain Management (PDF) summarizes the key elements of an effective nursing pain management program.
• Pain Management Guidance (PDF) is a resource to help identify and treat pain, with an emphasis on pharmacological and non-pharmacological treatment options.
• Pain Scale Determination Process [PDF] may be used to assist nursing staff in identifying the best pain scale to use based on the resident’s cognitive and verbal abilities.
• Best Practice System Summary/Technical Assistance Sheet for Pain Management (PDF) describes key elements of an effective system for pain management that facility staff can use to assess progress with implementing best practice for pain management.
• Understanding Pain Communication (PDF) identifies common painful conditions in older adults and offers suggestions for discussing pain with residents. The handout also outlines behavioral cues that could indicate the presence of pain in residents with cognitive impairments.
• Pain Management Care Plan Highlights (PDF) can assist facility staff in developing individualized care plans for pain management.
• Onset, Peak and Duration of Common Pain Medications identifies common medications used to manage pain and the onset of action, peak effect and duration of each of those medications.
• Using an Inter-disciplinary Team Process in the Management of Pain (PDF) outlines the role of the inter-disciplinary team in an effective pain management system.
• Pain, Pain Go Away! (PDF) includes an explanation of the three types of pain; a description of the negative outcomes associated with the use of antipsychotic medications to manage pain related behaviors in elderly persons with dementia; and three best practice pain management strategies for elderly persons with dementia.
• Peak Effect of Commonly Prescribed Pain Medications (PDF) identifies frequently prescribed pain medications (by trade and generic names) and the time of peak effect of each.

Resources from Other Organizations

• Analgesic Trial for Suspected Pain in Older Adults with Cognitive Impairment provides instructions for conducting analgesic trials, based on an assessment of the resident, when he or she is unable to self-report pain.
• Geriatric Pain website provides access to evidence-based resources for managing pain in older adults, including pain assessment tools. The website is organized by category, including pain assessment, pain management, education, quality improvement, guidelines and resources.
• 0-10 Numeric Rating Scale (PDF) is a validated pain scale, designed for use with residents who can point to or state the number that reflects their current level of pain.
• Iowa Pain Thermometer (PDF) is a verbal descriptor scale with a thermometer to assist resident in identifying the severity of their pain. The IPT descriptions may be assigned numerical values of 0 to 6, with zero being no pain.
• 0-10 Pain Thermometer (PDF) uses a vertical presentation with a thermometer to assist residents in identifying the severity of their pain. The instructions for use and interpretation of the results are the same as the numeric rating scale.
• Faces Pain Scale-Revised (PDF) has adult faces/expressions, including facial action units that are known to occur in humans when experiencing pain (raised brow, open mouth, nasal fold increases and tightened eyes). The FPS-R is not an observational tool, and is never to be used to measure facial grimacing by the nurse. Instructions for use and interpretation of the FPS-R should be reviewed prior to use.
• Pain Thermometer-VDS (PDF) is a verbal descriptor scale with a thermometer to assist residents in identifying the severity of their pain.
• Pain Assessment in Advanced Dementia (PDF) is a behavioral pain scale which may indicate pain is present. Residents should be assessed during movement/activity.
• Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PDF) is a behavioral assessment tool that can help caregivers identify pain in residents with dementia.
• Discomfort Scale for Dementia of the Alzheimer’s Type (PDF)is a behavioral pain scale which may indicate pain is present.
• Pain: Nursing Home Communication with Physician Pain Management Form (PDF) may be used by nursing staff to effectively communicate pain assessment findings or changes with the resident’s physician.
• Pain: Organizational Commitment to Pain Management in Your Facility (PDF) identifies the key steps to developing a successful pain management program, as well as the essential elements for each step.
• Side Effects of Opioid Medications and General Approaches to Management provides an overview of side effects that may occur with common pain medications and suggested treatment strategies for residents with chronic pain or at the end of life.
• Serial Trial Intervention is a proactive systemic process to assess and treat pain in residents with moderate to severe cognitive impairment. Use this documentation tool to help track the changes in assessment and effects of treatment for pain in these residents.

Clinical Practice Guidelines and Resources

• AMDA-The Society for Post-Acute and Long Term Care Medicine is a professional association of medical directors, attending physicians and others practicing in the long-term care continuum, dedicated to excellence in patient care.
• The American Society for Pain Management Nursing advances and promotes optimal nursing care for people affected by pain by promoting best nursing practice.
• The American Geriatrics Society is devoted to improving the health, independence and quality of life of all older people.
• The International Association for the Study of Pain brings together scientists, clinicians, health care providers and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide.
• The American Academy of Pain Medicine represents physicians practicing in the field of pain medicine.
• The American Academy of Pain Management educates clinicians about pain and its management through an integrative interdisciplinary approach.