Journal of Gerontological Nursing

Age and Gender Differences in PAIN Management Following Coronary Artery Bypass Surgery

Barbara Celia, EdD, RN

Abstract

TABLE 1

SUBJECTS' DEMOGRAPHICS

TABLE 2

ANALYSIS OF VARIANCE TO COMPARE AMOUNT OF MEDICATION ADMINISTERED TO THREE AGE GROUPS (60 OR YOUNGER, 61 TO 69, 70 OR OLDER)

TABLE 3

MEANS AND STANDARD DEVIATIONS FOR THREE AGE GROUPS FOR AMOUNT OF PAIN MEDICATION ADMINISTERED DURING THE 3-DAY POSTOPERATIVE PERIOD

TABLE 4

t TESTS TO COMPARE AMOUNT OF MEDICATION ADMINISTERED BY GENDER

TABLE 5

ANALYSIS OF COVARIANCE FOR INTERACTION EFFECTS OF COMPLICATIONS AND NO COMPLICATIONS WITH REQUESTS FOR PAIN MEDICATION BY AMOUNT OF MEDICATION ADMINISTERED PER REQUEST

TABLE 6

t TEST TO COMPARE REQUESTS FOR MEDICATIONS BY PATIENTS WITH AND WITHOUT COMPLICATIONS…

Pain management is regarded as a major responsibility by practicing professional nurses. In fact, nurses spend more time with patients in pain than any other member of health care teams (Ferrell & Ferrell, 1992). Despite this strong belief within the profession, researchers have found that patients are consistently undermedicated for their pain, and recent research shows the elderly population may be a particularly vulnerable group at risk for this phenomenon (Kuperberg & Grubbs, 1997). The management of pain among elderly individuals is not adequate and is thought to be less effective than care provided for other age groups (Ferrell, Ferrell, & Osterweil, 1990; Herr & Mobily, 1991).

Undermedication for pain by nurses as well as underprescription for pain by physicians can ultimately be the cause of unfavorable outcomes. Unrelieved postoperative pain can retard post-surgical recovery leading to extended hospitalization and increased hospital costs (Dietrick-Gallagher, Palomano, & Carrick, 1994). The patient experiencing pain postoperatively often is unable to breathe deeply, thus predisposing the patient to pulmonary conditions such as atelectasis and pneumonia. In addition, the patient experiencing severe postoperative pain is reluctant to move or exercise, thereby increasing the potential for thrombosis. Post-surgery, elderly individuals are more at risk for experiencing confusion and delusions, which can mask the presence of pain (Memran et al., 1998).

Although pain may be perceived basically as a physiological phenomenon, cultural beliefs and attitudes may determine the meaning and responses to pain. Culture is an important variable in determining an individual's response to pain. People learn what is expected and accepted by their culture. This learning includes reactions to painful experiences. The definition of pain, similar to that of health and illness, is culturally determined (LudwigBeymer, 1989). Perception, expression, and management of pain are all embedded in a cultural context (Calvillo & Flaskerud, 1991). According to Meinhart and McCaffery (1983), cultural expectations may specify:

* Different reactions according to age, sex, and occupation.

* What treatment to seek.

* The intensity and duration of what should be tolerated.

* What response should be made.

* Whom to inform when pain occurs.

* What types require attention.

Nurses are in a position to make judgments about the severity of the patient's pain and whether or not the patient should receive pain medication. Often these judgments are influenced by cultural stereotypes. That is, nurses make their decisions based on their own impressions of what a person's pain threshold ought to be related to their own cultural values. Nurses must understand the phenomenon of pain and the role that culture plays in the perception and expression of pain. The purpose of this study was to determine if there are differences in age and gender and the amount of pain medication prescribed and administered following coronary artery bypass surgery (CABS).

THEORETICAL FRAMEWORK

Greipp's (1993) model of ethical decision-making can be used to assist nurses in analyzing the effects of culture, beliefs, and diversity on the caregiver and the care recipient within an ethical framework. In the management of patients' pain she makes evident the power of potential inhibitors to negatively affect decisions, often resulting in undermedication for pain. The model is based on four underlying assumptions:

* All patients experiencing pain share a need for pain relief.

* Nurses act as "data analyst/ decision-maker" on a daily basis.

* All nurses practice within a code of ethics.

* Decision-making is a complex process subject to variations imposed by people, situations, and environments.

The model is used to examine primarily descriptive and normative ethics including the practitioner as caregiver, the client as care recipient, and those factors influencing the involved individuals, and ultimately, the decision outcome (Greipp, 1993). Emphasis within the model is given to learned potential inhibitors (e.g., personal experiences, professional experiences, personal/professional gain, belief system, culture) of the practitioner because these affect the outcome (i.e., decision of the interaction). The focus of the model is on the interactions between caregivers and recipients and the psychosocialcultural variables each possesses as part of self. The model requires nurses to recognize patients' culture and beliefs as well as their own culture and beliefs (Greipp, 1993).

LITERATURE REVIEW

In the last 20 years, advances in the understanding of pain and the management of pain have made pain control a priority in patient care. With improved pain management, one would expect fewer incidences of unrelieved pain. However, researchers continue to show that the majority of patients continue to experience moderate to severe pain (Abbot et al., 1992; Kuhn & Cooke, 1990). In 1973, Marks and Sachar found 73% of patients had moderate to severe pain. In 1990, Kuhn et al. found 87% of patients who had undergone abdominal surgery found the post-surgical pain experience moderately to very painful.

PROBLEMS IN ASSESSMENT OF PAIN

Nursing has a unique role in pain assessment and management (McCaffery & Beebe, 1989). The nurse, compared to other health care professionals, spends the most time with patients in pain, assesses the patient's pain level, and evaluates information based on assessments. The Agency for Health Care Policy and Research (AHCPR) (1992) has developed guidelines to assist nurses in assessing pain, and although the guidelines are relatively new, studies have shown assessment of pain are performed rarely, poorly, or inconsistently by nurses caring for patients in pain (Hamilton & Edgar, 1992).

Undermedication of pain appears to be the most common explanation for the frequency and severity of pain experienced by postoperative patients (McDonald, 1993). Carr (1990) found that preoperative expectation and postoperative experience of pain are significantly different in the surgical patient. The majority of patients underestimated the pain they would experience. In addition, severe postoperative pain on the first day is experienced by many patients, despite the availability of prescribed analgesia. Seers (1987) found that 77% of the time the nurses and patients did not agree about the intensity of pain; 54% of nurses rated the patient's pain at a lower level than the patient did.

ACE AND GENDER

McDonald (1994) investigated whether nurses provide different amounts of narcotic analgesics to male and female patients. The findings showed male patients received significantly larger initial doses than female patients. There were no gender differences in the total dose received postoperatively. MaxamMoore, Wilkie, and Woods (1994) reported gender and age effects in a study describing current practice with analgesics for cardiac surgery patients. A review of the medical records of 80 patients undergoing cardiac surgery in two hospitals showed women were prescribed smaller doses of intravenous morphine. Also, elderly individuals were prescribed and received less of acetaminophen with oxycodone. Calderone (1990) reported gender and age differences in a retrospective study that examined whether men received more pain medication than women after cardiac surgery.

The results showed male patients were administered pain medication significantly more frequently than female patients, and patients 61 years or younger received significantly more pain medication than patients 62 years or older. Bernabei et al. (1998) assessed a cohort of nursing home patients with cancer and found up to 38% had daily pain, but 26% of these patients received no analgesics. Older patients and those of nonwhite race were more likely to have untreated pain. Differences in genderweight also may have a bearing on amount of narcotic analgesic prescribed and administered, however the literature contains no findings related to this area.

STUDY DESIGN

This was a descriptive study using a retrospective review of 471 patients' medical records to determine amounts of pain medication prescribed and administered during a 3-day postoperative period following CABS. Equianalgesic doses for the narcotic analgesics were calculated so that all of the analgesics were comparable to morphine sulfate, the most commonly used postoperative analgesic. A major 554-bed, urban, university-affiliated medical center located in the northeast was the setting for the study. The method of convenience sampling was chosen to conduct this study. All patients undergoing CABS during a given year were included in the retrospective review. The following exclusions applied:

Table

TABLE 1SUBJECTS' DEMOGRAPHICS

TABLE 1

SUBJECTS' DEMOGRAPHICS

* Known history of drug addiction.

* Long-standing chronic pain conditions (e.g., arthritis, cancer).

* Participating in patient-controlled analgesia. Collection of data was conducted during a 3-month period.

Frequencies were generated to obtain means and standard deviations for the total equianalgesic narcotic doses for postoperative days 1 to 3. Analysis of covariance (ANCOVA) was used to test for amount of pain medication administered to patients without complications and to patients with complications as per their requests for pain medication. T tests were used to test for postoperative differences between men and women and between ethnic majority and minority patients. Analysis of variance (ANOVA) tested for differences among three different age groups. Alpha was set at the .05 level.

FINDINGS

A total of 471 patients underwent CABS during this year in this institution. Of this total, 382 patients' medical records met the criteria for inclusion in this study. Eighty-nine patients were excluded because of existing chronic pain conditions or because of documented prior known drug addiction. None of the patients in this sample participated in patientcontrolled analgesia. More men (n = 279) than women (« = 103) had CABS, and 99.2% understood and spoke the English language. Postoperative complications occurred for 23.3% and mean length of stay was 9.9 days. Patient age was distributed among three age groups: 60 years or younger (n = 122), 61 years to 69 years (n - 133), and 70 years or older (n = 122), with a mean patient age of 63.9 years (Table 1).

Means and standard deviations derived from frequencies for prescribed amounts of medications for groups by age, gender, race, and complications showed no significant differences in amount of pain medication prescribed by physicians. This finding may be attributable to the collaborative practice guidelines used in this institution, which consist of protocols that are standard for all postoperative CABS patients. Generally, 2 mg of morphine sulfate was prescribed intravenously every hour as required for pain. Frequencies generated for statistical analysis of pain medication administration showed that, overall, very little of what was prescribed was administered (mean = 9.5084, SD = 6.3422).

Table

TABLE 2ANALYSIS OF VARIANCE TO COMPARE AMOUNT OF MEDICATION ADMINISTERED TO THREE AGE GROUPS (60 OR YOUNGER, 61 TO 69, 70 OR OLDER)

TABLE 2

ANALYSIS OF VARIANCE TO COMPARE AMOUNT OF MEDICATION ADMINISTERED TO THREE AGE GROUPS (60 OR YOUNGER, 61 TO 69, 70 OR OLDER)

Analysis of variance indicated significant differences in age groups for the amount of narcotic analgesic administered during the 3-day postoperative period (Table 2). Means and standard deviations for the three different age groups are presented in Table 3. Patients age 60 or younger received significandy more pain medication than older patients. Also, there were significant differences in amount of pain medication administered to men and women. T test results showed men received significantly more pain medication than women (Table 4).

Patients' requests for pain medication were analyzed using t tests to compare means for gender, race, and complications. There were no significant differences found for race; however, men and patients without complications received significantly more pain medication. Patients with complications received less pain medication overall than patients without complications (Table 6). However, when ANCOVA was applied to control for requests, (i.e., amount of pain medication administered per request), patients with complications received more pain medication per request than patients without complications (Table 5).

STUDY LIMITATIONS

The results of this study are limited because the sample consisted of CABS patients from only one institua tion, and the sample was unevenly distributed for race and gender. Eighty-five percent of the sample were White and 73% were men. Furthermore, patients' self-evaluations of pain and their responses to pain were not evaluated.

DISCUSSION

Study findings suggest that nurses may have undermedicated patients' pain overall during the 3-day postoperative period following CABS even though sufficient pain medication was prescribed. Ninety-nine percent of patients received less than 28% of what was prescribed. However, the omission of a pain rating scale to assess patients' pain precludes a definitive finding in this area. Patients 61 years and older received less pain medication than younger patients, and men received more pain medication than women. The findings are congruent with many earlier studies reporting undermedication for pain (Abbott et al., 1992; Calderone, 1990; MaxamMoore et al., 1994; McDonald, 1993).

Nurses are aware that as individuals age, the ability to clear drugs from the system via the kidneys decreases, thereby creating the potential for drug accumulation and overdosing. Fear of narcotic overdosing, which may lead to respiratory depression, can be a factor in nurses' decisionmaking to administer less pain medication to elderly individuals. In addition, common misconceptions about aging can also complicate postoperative pain management (McCaffery & Beebe, 1989). These include believing either that pain perception decreases with age or that pain is an inevitable consequence of aging and should be expected after surgery. However, no physiologic changes in pain perception in older adults have been demonstrated (Kwentus, Harkins, & Lignon, 1985). In fact, older adults may experience more pain than younger individuals (Corran, Gibson, Farrell, & Helme, 1994).

The possibility of gender stereotyping by nurses in this study may exist because men received more pain medication than women. Calderone (1990) expresses the belief that men tend to receive more pain medication, while women tend to receive more sedatives. Health professionals may view women as being more emotionally expressive and more prone to dramatize and exaggerate pain complaints. The United States Census Bureau (1994) reports that women live longer than men. This has clear implications for future pain management practices as the elderly population continues to grow. Greipp (1993) contends:

There is an overwhelming need to educate further all health care professionals on narcotics, other analgesics... and their use in providing safe and effective pain relief for clients of all ages, from all cultures, who are experiencing pain (p. 129).

There were assessment problems in this study because nurses did not use a pain rating scale to assess patients' pain. A pain rating scale is considered to be a sensitive and reliable method of measuring pain intensity (Syrjala & Chapman, 1984). The omission of using a pain rating scale can have a direct relationship to the amount of pain medication administered. Without the benefit of a pain rating scale, nurses are unable to accurately assess their patients' pain. The pain rating scale is a tool that allows patients to assess the pain they are feeling, and that assessment is valuable input to the nurses' decision to administer pain medication. Lack of patient assessment of pain can cause the nurse to rely on preconceived cultural beliefs and attitudes about older adults and influence the pain management decision negatively.

NURSING IMPLICATIONS

The United States Census Bureau (1994) predicts that by the year 2020, people age 65 and older will comprise 16% of the population. The fastest growing group in this population is people age 85 and older. These demographics are a clear indicator for nurses to increase their clinical interventions for elderly individuals, particularly in the area of pain management.

The results of this study are congruent with the findings of many previous studies regarding undermedication for pain. A major contributing factor appears to be inadequate assessment of pain. Ongoing continuing education programs are an essential initial step to increasing nurses' awareness of assessment methods, including the use of a pain rating scale.

Continuing nursing education programs also must address the misconceptions that persist regarding pain management in older adults. The relationship between the patient who is in pain and the nurse who is assessing the pain is an important example of how a cultural discrepancy can occur.

Table

TABLE 3MEANS AND STANDARD DEVIATIONS FOR THREE AGE GROUPS FOR AMOUNT OF PAIN MEDICATION ADMINISTERED DURING THE 3-DAY POSTOPERATIVE PERIOD

TABLE 3

MEANS AND STANDARD DEVIATIONS FOR THREE AGE GROUPS FOR AMOUNT OF PAIN MEDICATION ADMINISTERED DURING THE 3-DAY POSTOPERATIVE PERIOD

Table

TABLE 4t TESTS TO COMPARE AMOUNT OF MEDICATION ADMINISTERED BY GENDER

TABLE 4

t TESTS TO COMPARE AMOUNT OF MEDICATION ADMINISTERED BY GENDER

Brockopp, Warden, Colclough, & Brockopp (1996) found deficits in nurses' knowledge of basic pain management practices and attitudes that were not facilitative of good care. Barriers such as cultural stereotypes may lead to misconceptions about pain management in older adults. While it is true elderly individuals need special considerations in the use of narcotic analgesic, Pasero and McCaffery (1996) assert that:

Table

TABLE 5ANALYSIS OF COVARIANCE FOR INTERACTION EFFECTS OF COMPLICATIONS AND NO COMPLICATIONS WITH REQUESTS FOR PAIN MEDICATION BY AMOUNT OF MEDICATION ADMINISTERED PER REQUEST

TABLE 5

ANALYSIS OF COVARIANCE FOR INTERACTION EFFECTS OF COMPLICATIONS AND NO COMPLICATIONS WITH REQUESTS FOR PAIN MEDICATION BY AMOUNT OF MEDICATION ADMINISTERED PER REQUEST

Table

TABLE 6t TEST TO COMPARE REQUESTS FOR MEDICATIONS BY PATIENTS WITH AND WITHOUT COMPLICATIONS

TABLE 6

t TEST TO COMPARE REQUESTS FOR MEDICATIONS BY PATIENTS WITH AND WITHOUT COMPLICATIONS

Measures such as reducing the initial dose, titrating doses slowly, using combined regimens with nonopioid analgesics, and closely monitoring patient response can ensure safe and effective opioid administration (p. 39).

Another difficulty nurses may encounter is differentiating pain from anxiety. Nurses may have difficulty interpreting patients' physiological indicators when these conflict with their behavioral cues. In these cases, the use of analgesics and sedatives may serve to lessen both the pain and the anxiety.

Elderly patients present special challenges for acute postoperative pain management. Some elderly patients may believe their nurses know that surgery has caused pain and that everything possible is being done to relieve the pain. Elderly individuals also fear opioid addiction. Elderly patients and their families need to be educated about the effects of pain medications and the minimal risk of addiction. A patient's pain is a subjective experience; therefore, nurses must respond by first believing the patient's report of pain and by treating the pain with a collaborative approach.

Recent guidelines for treating pain in older adults recommend starting with lower doses of pain medication and slowly increasing the dosage while continuously assessing and monitoring the patient's response. Adequate treatment of postoperative pain is critical to avoiding complications such as atelectasis, pneumonia, deep vein thrombosis, confusion, and delirium which can prolong recuperation and length of stay for the vulnerable elderly patient.

There are a number of questions that remain to be answered through research. What are the elderly patient's perceptions and concerns regarding pain management? Which areas of education regarding pain management need to be addressed for elderly individuals and their families? Are there cultural differences or stereotypical thinking that may impact nurses' decision-making in pain management with elderly individuals. Are nurses perpetuating gender differences with their pain management decisions? As the elderly segment of the population continues to grow, nurses must position themselves to be responsive and proactive to the particular needs of this population. Research-based clinical interventions will ensure elderly individuals receive the care and comfort they deserve and expect from the health care team. The growing emphasis on beneficial clinical outcomes serves as an impetus to nurses to define their cultural beliefs and attitudes regarding older adults and how these may impact their clinical pain management practices.

CONCLUSION

Poor pain management can lead to unfavorable outcomes for patients including extended post-surgical recovery and increased hospital costs. Pain assessment by nurses has been found to be problematic mainly because nurses do not use a pain rating scale to assess patients' pain. Without benefit of patients' selfassessment of pain, nurses may rely on their own preconceived cultural beliefs in their pain management decisions. Ongoing continuing education programs are an essential initial step to increasing nurses' awareness of assessment methods including the use of a pain rating scale and also differences in cultural responses to pain.

REFERENCES

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TABLE 1

SUBJECTS' DEMOGRAPHICS

TABLE 2

ANALYSIS OF VARIANCE TO COMPARE AMOUNT OF MEDICATION ADMINISTERED TO THREE AGE GROUPS (60 OR YOUNGER, 61 TO 69, 70 OR OLDER)

TABLE 3

MEANS AND STANDARD DEVIATIONS FOR THREE AGE GROUPS FOR AMOUNT OF PAIN MEDICATION ADMINISTERED DURING THE 3-DAY POSTOPERATIVE PERIOD

TABLE 4

t TESTS TO COMPARE AMOUNT OF MEDICATION ADMINISTERED BY GENDER

TABLE 5

ANALYSIS OF COVARIANCE FOR INTERACTION EFFECTS OF COMPLICATIONS AND NO COMPLICATIONS WITH REQUESTS FOR PAIN MEDICATION BY AMOUNT OF MEDICATION ADMINISTERED PER REQUEST

TABLE 6

t TEST TO COMPARE REQUESTS FOR MEDICATIONS BY PATIENTS WITH AND WITHOUT COMPLICATIONS

10.3928/0098-9134-20000501-07

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