Recent estimates indicate more than half of residents in nursing homes suffer from chronic pain. Yet multiple studies over the years show it remains largely undertreated.
That's not suprising, given the challenges of pain management across the population generally. There's simply no clear way to measure pain. And identifying the source can be just as tricky.
In senior communities, particularly in nursing homes, there are additional complexities—from residents living with cognitive impairments and communication limitations to access to diagnostic and specialty services.
Making sure pain is being properly evaluated and treated requires a coordinated and personalized approach involving the residents' doctors, specialists, therapists, nursing center staff, and families.
Step 1: Identifying the Pain, Understanding the Individual
The first step is recognizing if a resident is experiencing pain, to what degree, and why.
Many seniors, especially in nursing homes, have trouble describing or communicating their pain. So it's important to really get to know patients. Sometimes the sign that someone's having pain is simply that they're more easily agitated or more aggressive.
Determining the level of pain is another challenge. You may have someone who barely bumps themselves and claims how much pain they are in. Then you could have someone who's had a major surgical procedure shrugging it off, saying, “I'm not too bad," even if they are in excruciating pain.
Step 2: Determining the Appropriate Treatment Plan
After pain is diagnosed, it's important to develop the right treatment plan. There is no one-size-fits-all approach. Options can involve a variety of things, from topical medications to therapeutic modalities like ice, heat, diathermy, and therapeutic exercises; splints; compression; oral or injectable medication; and therapeutic injections directly to the site of pain.
Choosing the best pain treatments for nursing home residents, however, can be complicated by the fact that many struggle with multiple chronic conditions.
Again, that is why it is so important to really understand the individual, their unique health challenges, and personal care goals—even getting down to the cultural basis that may influence how this individual sees their treatment and how they express their pain.
When medication is part of the plan, it's critical to carefully consider all the side effects and how any new medication may interact with the resident's other prescriptions to avoid any adverse interactions.
The Last, But Not Always a Bad Step: Opioids
The increased scrutiny on opioid prescriptions has increased hesitancy to prescribe these pain-blocking medications. It has also led to an unfortunate belief by some that all opioids are bad.
While opioids aren't the first, second, or even the third line of treatment, they can play an important role in pain management when symptoms can't otherwise be controlled.
Of course, there are risks, such as lethargy, confusion, falls—even respiratory depression and death. Understanding that balance of when it's important to use opioids can be challenging.
It's also important to discuss the resident's pain and potential benefits and risks of using opoids, all while staying up-to-date on how the drugs are regulated.
Teamwork Is Key to Effective, Personalized Pain Management
Unfortunately, chronic pain doesn't just go away. It needs to be constantly monitored and treatment options revisited when necessary to ensure the best possible quality of life for residents.
And that requires a team approach. For example, clinicians can work closely with on-site therapists, nurses, and nurses aides to help them decipher whether changes in patient behavior—from moaning to needing more support in a wheelchair to suddenly needing more assistance with transfers—is the result of a new condition or worsening pain.
Then all the caregivers work together to get the right care for the individual. Coordination and communication are at the heart of effective pain management programs.
Karl Dauphinais, MD, MSS, FACP, CMD, is the Connecticut and Rhode Island medical director for Optum's Complex Care Management division. He also serves as medical director at Autumn Lake Healthcare of New Britain, a 280-bed skilled nursing facility.