1. http://careinaging.duke.edu/longterm care Presenter: Gwendolyn Buhr, MD long-term care Chronic Pain in the Nursing Home Resident

2. http://careinaging.duke.edu/longterm care Chronic Pain in the Nursing Home Resident Key Principles

3. long-term care network http://careinaging.duke.edu/longtermcare Pain Prevalence in the Nursing Home  Overall 45% to 80%  Nationwide, 14.7% of all nursing home residents were in persistent pain  In north Carolina in 1999, 40% of nursing home residents who were in pain at the first MDS assessment were still in pain at the next assessment 60 to 180 days later

4. long-term care network http://careinaging.duke.edu/longtermcare Pain Management in the Nursing Home  Data gathered from 1,492 nursing facilities in 5 states  Of 13,625 residents >65 years with cancer –24% - 38% reported daily pain –16% received non-opioid medications, adjuvants or both –26% received strong opioids (morphine) –26% did not receive any analgesic agent

5. long-term care network http://careinaging.duke.edu/longtermcare Legal Consequences of Poorly Managed Pain  1990: North Carolina, $15 million –Settled on appeal for undisclosed amount –Nursing home failed to treat cancer pain –Nurses did not give prescribed medications  1997: Virginia, $200 thousand –Hospital failed to treat cancer pain  2001: California, $1.5 million –Hospital settled (undisclosed)

6. long-term care network http://careinaging.duke.edu/longtermcare Morbidity of Poorly Managed Pain  Sleep disturbance  Malnutrition  Decline in social and recreational activities  Physical function decline: falls  Depression, anxiety, impaired cognition  Decreased quality of life  Increased health care utilization/costs

7. long-term care network http://careinaging.duke.edu/longtermcare Pain and Dementia  No evidence that pain transmission is impaired in dementia  Controversy about central nervous system changes that influence interpretation of pain transmission ASSUME PAIN PREVALENCE AND SEVERITY SAME AS IN COGNITIVELY INTACT ELDERS

8. long-term care network http://careinaging.duke.edu/longtermcare Pain and Dementia  Decreased verbal pain report  Decreased analgesic use  Significant untreated pain  Complaints of pain are reliable –83% able to quantify their pain with a scale  Noncommunicative dementia patients –Pain identified much less frequently

9. long-term care network http://careinaging.duke.edu/longtermcare AMDA Clinical Practice Guideline  Pain assessment –On admission –At each quarterly review –At any time that change in patient’s condition prompts a new MDS –Any time that pain is suspected

10. long-term care network http://careinaging.duke.edu/longtermcare Pain in the Cognitively Impaired  Do not assume that assessment is impossible  Ask simple yes/no questions –Are you uncomfortable? Do you feel pain? Hurt? Aching?  Use a scale if possible –Clear explanation, give time to grasp task  Ask about present pain

11. long-term care network http://careinaging.duke.edu/longtermcare Pain in Dementia  Learn a given patient’s baseline activities and behavior  Document changes  Could this be due to pain?  Screaming  Difficult behaviors  Attempt an analgesic trial

12. long-term care network http://careinaging.duke.edu/longtermcare WHO 3-step Ladder Opioid “around the clock” ± adjuvants Non-narcotic “around the clock” ± adjuvants Strong Opioid “around the clock” ± adjuvants 1 Mild 2 Moderate 3 Severe

13. long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Non-narcotic “around the clock” ± adjuvants 1 Mild Non-opioids Acetaminophen NSAIDS Ibuprofen naproxen COX-2

14. long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Non-narcotic “around the clock” ± adjuvants 1 Mild Adjuvants Calcitonin Corticosteroids Anticonvulsants Topical agents Antidepressants

15. long-term care network http://careinaging.duke.edu/longtermcare Different Types of Pain Require Different Treatments  Somatic — localized tissue destruction –Arthritis, bone pain, pain after surgery, trauma  Visceral — stretching internal organs –Bowel obstruction, angina, urinary retention, constipation  Neuropathic — injury to nerves –Diabetic foot pain, shingles, pinched nerves

16. long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Opioid “around the clock” ± adjuvants Non-narcotic “around the clock” ± adjuvants Strong Opioid “around the clock” ± adjuvants 1 Mild 2 Moderate 3 Severe Opioids Tramadol Tylenol #3 Tylenol #4 Vicodin Percocet Strong Opioids Morphine Dilaudid MSContin OxyContin Transdermal fentanyl

17. long-term care network http://careinaging.duke.edu/longtermcare Medications Not Recommended in the Nursing Home  NSAIDs: indomethacin (Indocin), piroxicam (Feldene), tolmetin (Tolectin), meclofenamate  Opioids: butorphanol (Stadol), propoxyphene (Darvoset), meperidine (Demerol), nalbuphine (Nubain), pentazocine (Talwin)

18. long-term care network http://careinaging.duke.edu/longtermcare Current Status of Treating Pain in the Nursing Home Characteristics of residents receiving at least one analgesic (n=2,065)  Pain type: chronic 77%, acute 20%  40.6% had no pain assessment  Most residents received no nonpharmacologic treatment: 69.4%  Most analgesics prescribed PRN: 63.2%  Propoxyphene was the most commonly prescribed opioid: 55.8%