Journal of Gerontological Nursing

Evidence-Based Practice Guideline Supplemental Data

Acute Pain Management in Older Adults

Randy Cornelius, DNP, CRNA; Keela A. Herr, PhD, RN, FAAN; Debra B. Gordon, RN, DNP, FAAN; Kikikipa Kretzer, PhD, CRNP

Abstract

Acute pain is a prevalent problem in a growing segment of the older adult population and is often ineffectively managed despite the accumulation of evidence to guide assessment and support interventions in managing pain. Improvements in acute pain management in older adults are needed to provide consistent and quality pain assessment techniques and treatment therapies consistent with patient and/or family preferences. The current article briefly discusses ways to improve the pain experience and outcomes for older patients and families. [Journal of Gerontological Nursing, 43(2), 18–27.]

Abstract

Acute pain is a prevalent problem in a growing segment of the older adult population and is often ineffectively managed despite the accumulation of evidence to guide assessment and support interventions in managing pain. Improvements in acute pain management in older adults are needed to provide consistent and quality pain assessment techniques and treatment therapies consistent with patient and/or family preferences. The current article briefly discusses ways to improve the pain experience and outcomes for older patients and families. [Journal of Gerontological Nursing, 43(2), 18–27.]

Pain is a prevalent problem in a growing segment of the population and is often ineffectively managed. The world population of older adults, defined herein as those 60 and older, is increasing. In 2009, individuals older than 60 accounted for 11% of the world population; by 2050, it will reach 22% (Coldrey, Upton, & Macintyre, 2011; Gibson & Lussier, 2012). Forty percent of independently living older adults and up to 83% of older adults living in health care facilities report having pain that impacts daily life activities (Gagliese, 2009; Hwang, Richardson, Harris, & Morrison, 2010), and 20% to 40% of older adults experience pain daily (Platts-Mills et al., 2012). Older adults also have the highest rates of surgery, hospitalization, injury, and disease, which increase the risk of pain (Gibson & Lussier, 2012). Despite the high incidence of pain in the older adult population, research has demonstrated they receive significantly less analgesic medication than younger adults who experience similar painful conditions or procedures, leading to inadequate pain relief. Patients older than 75 are 19% less likely to have pain medication prescribed for acute pain versus patients aged 35 to 54 (Platts-Mills et al., 2012). Undertreated acute pain correlates with poorer outcomes during hospital stays to include development of persistent pain, longer length of hospitalization, ineffective physical therapy sessions, delays in ambulation, and delirium (Hwang & Platts-Mills, 2013; Hwang et al., 2010; Platts-Mills et al., 2012).

Purpose

The purpose of the current evidence-based practice guideline is to help nurses and other health care providers in the management of acute pain in older adults through assessment and treatment strategies. It is designed for older adults who are at risk for acute pain, to include individuals experiencing medical procedures, surgery, or medical conditions associated with acute pain, such as hip fracture or trauma. Expected outcomes of effective acute pain management in older adults include the reduction in incidence and severity of acute pain, minimization of preventable complications associated with pain management, reduction in morbidities associated with poorly controlled pain, and improvement of function and enhancement of patient comfort and satisfaction.

This article is a condensed version of the evidence-based guideline, Acute Pain Management in Older Adults (Cornelius, Herr, Gordon, & Kretzer, 2016). The full guideline can be purchased and downloaded in an electronic format from the Csomay Center for Gerontologi-cal Excellence (access http://www.iowanursingguidelines.com).

Definitions of Pain

According to McCaffery (1968, p. 95), “pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” Merskey (1986, p. 210) defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” This definition has been endorsed by many organizations, including the International Association for the Study of Pain (IASP; Huijer, Miaskowski, Quinn, & Twycross, 2013), American Pain Society (APS; 2008), and North American Nursing Diagnosis Association (Herdman & Kamitsuru, 2014).

Acute pain has been defined as pain of recent onset and probable limited duration. It typically has an identifiable temporal and causal relationship to injury or disease. Chronic pain commonly persists beyond the time of healing of an injury and frequently there may not be any clearly identifiable cause (Hollenack, Cranmer, Zarowitz, & O'Shea, 2007; IASP, 2012; Macintyre, Scott, Schug, Visser, & Walker, 2010). Table A (available in the online version of this article) lists the types of pain older adults can experience.


Types of Pain, Examples, & Treatment

Table A.

Types of Pain, Examples, & Treatment

Clinical Decision Making

Systematic reviews and clinical guidelines are available to aid in clinical decision making. Selection of a guideline that is best aligned with patient (e.g., age, diagnosis) and setting characteristics is important. However, it is necessary to acknowledge that many guidelines exclude selected treatment options because of limited evidence available; thus, helpful approaches to treating pain may be abandoned. The clinician must consider individual patient circumstances and characteristics, as well as their established treatment goals, in determining the plan of care.

The most accurate and appropriate pain assessment method is self-report (American Geriatrics Society [AGS] Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009), which is a critical component of a comprehensive approach of acute pain management of older adults. The scope and nature of the pain assessment will depend on a variety of factors to include physiological stability of the individual, whether it is an emergency or planned situation (Macintyre et al., 2010).

If older adults present in moderate to severe acute pain (i.e., >4 on a 0 to 10 numeric rating scale), the first priority is to complete an initial, rapid pain assessment and treat the pain (Abdulla et al., 2013). Once the pain is alleviated, a comprehensive pain assessment can be completed. A comprehensive pain assessment should also be completed prior to a known painful event, such as surgery or diagnostic procedures. Older adults with cognitive impairment, such as delirium and severe dementia, may not be able to self-report pain and have special pain assessment needs. Based on the comprehensive assessment, an individual pain management plan is developed with the older adult and/or family. This plan should include multiple strategies to include patient education, pharmacological, and/or nonpharmacological interventions tailored to the individual's unique circumstances. Evaluation and scheduled systematic reassessment of the older adult's actual or potential pain is necessary to evaluate the effectiveness of the pain management plan. The plan is revised whenever necessary. Further, a discharge plan is developed to ensure continuity of pain care. The Figure represents a flow diagram for clinical decision making for acute pain in older adults.


Clinical decision-making process applied to pain assessment and management.

Figure.

Clinical decision-making process applied to pain assessment and management.

Description of the Practice Guideline

Assessment and management strategies are discussed in the guideline, along with key recommendations and evidence indicating strength of the recommendations. Assessment strategies include an initial rapid pain assessment and comprehensive pain assessment. Techniques are also included for pain assessment in older adults with cognitive impairment, non-verbal older adults, as well as screening tools for cognitive impairment. Management strategies include pharmacological interventions, nonpharmacological (i.e., physical and cognitive-behavioral) strategies, and education. Table B (available in the online version of this article) describes strategies for assessing pain in older adults with cognitive impairment.


Strategies for Obtaining Pain Intensity Report in Older Persons with Cognitive Impairment

Table B:

Strategies for Obtaining Pain Intensity Report in Older Persons with Cognitive Impairment

Assessment

A baseline pain assessment, using valid and reliable tools, is necessary prior to a known painful event, such as surgery or diagnostic procedures; pain is also reassessed after the procedure to ensure it is managed in a proactive manner. Components of an initial comprehensive assessment may include location, quality, intensity, onset, frequency, and duration of pain; aggravating and alleviating factors; and impact of pain on physical function, emotions, and sleep. However, in some situations, older patients present in moderate to severe acute pain (e.g., hip fracture) requiring a rapid pain assessment (e.g., level of consciousness, pain characteristics, vital signs) and prompt treatment prior to completing a more comprehensive pain assessment.

Most older adults can use pain scales, depending on individual cognitive, educational, psychomotor, and sensory factors. Various tools available for clinical use for assessing pain in older adults are included in the full guideline (access http://www.iowanursingguidelines.com). These assessment tools include the Numeric Rating Scales (NRS; Herr, Spratt, Garand, & Li, 2007); the Verbal Descriptor Scale (VDS), which appears to be the easiest and most preferred by older adults and easiest for those with cognitive impairment (Hallingbye, Martin, & Viscomi, 2011; Herr et al., 2007; Lukas, Niederecker, Gunther, & Nikolaus, 2013; Pesonen et al., 2009); Pain Thermometer, which combines a thermometer with a verbal descriptor (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011); and Revised Faces Pain Scale (FPS-R), an alternate tool often preferred by diverse older adults, such as Hispanic, Asian, and African American individuals (Ware, Epps, Herr, & Packard, 2006; Zhou, Petpichetchian, & Kitrungrote, 2011). Limited studies are available regarding validity and reliability of pain assessment tools for use with older adults of different racial/ethnic backgrounds.

Completion of a comprehensive pain assessment follows an initial rapid assessment and provides information to guide treatment planning (Hadjistavropoulos et al., 2007). The patient and/or family is integral in this information gathering process. The following are important assessment aspects:

Assessment Strategies for Cognitively Impaired Older Adults

The cognitive status of the older adult will impact the approach to pain assessment, patient and family education, and treatment options. Obtaining a baseline assessment of cognitive status provides a basis for evaluating changes in cognitive status throughout the period of illness. Older adults are at risk for development of delirium post-trauma, such as a hip fracture, or postoperatively (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). Evidence suggests cognitive impairment does not alter the intensity of pain, but may affect its interpretation (Colel et al., 2011; Kunz, Mylius, Scharmann, Schepelman, & Lautenbacher, 2009).

Older adults with mild to moderate cognitive impairment are often able to rate pain using self-report instruments, and individual patient ability to do so should be assessed. Older adults with memory impairment may often be able to report the pain in the here and now, so it is important to ask about existing pain (Herr et al., 2011). They also can respond to simple questioning about presence of pain and may be able to use a simple rating scale, such as the VDS, pain thermometers, and FPS (Lukas et al., 2013).

It is important to observe for behavioral indicators of pain in individuals who are unable to provide self-report, such as grimacing, moaning, guarding, bracing, and posturing, as well as less common indicators such as agitation, aggression, restlessness, and resisting care (Ahn & Horgas, 2013; Sheu, Versloot, Nader, Kerr, & Craig, 2012). In addition, behavior should be observed when the older adult is engaged in activity (e.g., transfers, ambulation, repositioning), as observation at rest can be misleading (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; American Medical Directors Association, 2012). If the older adult is verbally unresponsive or noncommunicative, his/her usual pain behaviors (e.g., withdrawal, agitation, facial grimacing, guarding, moaning) should be elicited from the family or caregiver (Eritz & Hadjistavropoulos, 2011; Liu, 2014).

A pain assessment tool should be used to assess presence of pain based on behavioral pain indicators when severely cognitively impaired older adults are unable to self-report. Selected behavior pain scales validated for use in acute care with individuals who have dementia or other cognitive impairment and are unable to reliably communicate their pain include the Checklist of Nonverbal Pain Indicators (CNPI; Lints-Martindale, Hadjistavropoulos, Lix, & Thorpe, 2012; Neville & Ostini, 2014), Pain Assessment in Advanced Dementia (PAINAD; DeWaters et al., 2008), and in the critical care setting, the Critical-Care Observation Tool (CPOT; Ersek, Herr, Neradilek, Buck, & Black, 2010; Lints-Martindale et al., 2012; Neville & Ostini, 2014).

Pharmacological Pain Management Strategies

Analgesic agents are the cornerstone of acute pain management of older adults, although they should be used with nonpharmacological approaches for most benefit. Some general principles of pharmacological management relevant to older adults are noted below.

General Principles

  • Analgesic agent selection should be based on thorough medical history and consideration of coexisting morbidities and drug treatments that may interact or impact the effect of analgesic treatment and treatment goals (Abdulla et al., 2013; Chou et al., 2016).
  • An increased risk of side effects due to physiological changes in older adults results in the need to start low and go slow; therefore, analgesic agents should always be titrated to response (Abdulla et al., 2013; Liukas et al., 2008; Liukas et al., 2011).
  • Pain medication should be scheduled or offered around-the-clock when acute pain is predictable or continuous to help maintain a stable analgesic blood level and provide structure to the pain management plan. Analgesic agents should be administered on an as needed (prn) basis later in the course of treatment of the acute pain episode, as indicated by the patient's pain status (Fine, 2012).
  • Administering analgesia prior to activity may improve the older adult's ability to perform the activity and may reduce post-activity analgesic requirements (Abdulla et al., 2013).
  • Multimodal analgesia should be provided using combinations of analgesic agents with varying mechanisms of action (Chou et al., 2016; McDaid et al., 2009).
  • In addition to the multimodal analgesia approach, a preoperative dose of one or more nonopioid agents, such as gabapentin or pregabalin, acetaminophen, or local anesthetic injection, should be considered (Chou et al., 2016; Eipe et al., 2015; Mishriky, Waldron, & Habib, 2015).
  • High vigilance should be maintained for side effects and drug–drug, drug–disease interactions. Normal effects of aging on the pharmacokinetic and pharmacodynamic properties of medications as well as common comorbid diseases, such as coronary artery disease, congestive heart failure, hypertension and parkinsonism, amplify side effects and potential for drug interactions (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

Administration Guidance

  • When administering analgesics, the least invasive and safest route (e.g., oral) should be chosen first (Abdulla et al., 2013; Fine, 2012; Macintyre et al., 2010).
  • Intramuscular analgesic administration should be avoided in older adults due to muscle wasting and less fatty tissue, which slows and may result in delayed/prolonged effect, altered analgesic serum levels, and possible toxicity with repeated injections (Chou et al., 2016; Pasero & McCaffery, 2011b).
  • Intravenous (IV) administration should be used when rapid titration is needed for severe pain and IV patient-controlled analgesia (PCA) for times when prolonged parenteral administration is required (RNAO, 2013).
  • Due to an increased risk of drug accumulation and toxicity in older adults, the routine use of basal infusion with IV PCA is not recommended (Chou et al., 2016; George et al. 2010; Hudcova, McNicol, Quah, Lau, & Carr, 2009).
  • Local anesthetic-based regional anesthesia techniques should be promoted for surgical procedures of the extremities, abdomen, and thorax given in combination with systemic analgesic agents. Compared with opioid analgesia, continuous nerve block (regardless of catheter location) provides better postoperative analgesia and leads to reductions in opioid drug use as well as the incidence of nausea, vomiting, pruritus, and sedation (Macintyre et al., 2010).
  • Topical local anesthetic agents should be offered to reduce discomfort of procedural pain, including lidocaine topical 5% (Lidoderm®). Vapocoolant anesthetic sprays and lidocaine gel may be useful in older adults (Abdulla et al., 2013; AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

Analgesic Options

Analgesic options include nonopioid, opioid, and adjuvant medications. Determination of appropriate analgesic treatment is based on a careful risk-benefit analysis, considering the individual's unique characteristics, risk factors, comorbidities, and personal preferences. Nonopioid analgesic drugs are effective and appropriate for mild to moderate pain and as a coanalgesic with an opioid agent as part of a multimodal approach (Abdulla et al., 2013; AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

Key points of nonopioid analgesic use include:

  • Acetaminophen should be considered as preferred nonopioid agent for mild to moderate pain (Abdulla et al., 2013). Total daily dose must not exceed 4 g per day, with a maximum dose of 3 g in frail older adults. The amount of acetaminophen administered in combination drugs should be monitored (e.g., combination hydrocodone, oxycodone, or codeine preparations) (Abdulla et al., 2013).
  • Use of nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided if patients have a history of peptic ulcers (Barkin et al., 2010; Massó González, Patrignani, Tacconelli, & Rodríguez, 2010) and “platelet sparing” NSAIDs (e.g., nabumetone, sal-salate, choline magnesium trisalicy-late) or COX-2 selective NSAIDs (based on risk/benefit analysis) should be used to lessen the risk of gastrointestinal (GI) bleeding and gastric/duodenal ulcers (Chou et al., 2016).
  • All NSAIDs should be used with caution and within recommended maximum doses. The lowest effective NSAID dose for the shortest possible time should be administered postoperatively (i.e., depending on surgical procedure, consider discontinuing or lowering the dose of NSAID after 24 to 48 hours if pain is well controlled with other analgesic agents) (Barkin et al., 2010).
  • Older adults must be carefully monitored for NSAID complications. The risk for adverse effects from NSAIDs is increased among older adults, including unusual drug reactions, such as cognitive impairment, constipation, and headaches. Signs of GI bleeding, renal impairment, congestive heart failure, and cognitive impairment should be monitored (Abdulla et al., 2013; APS, 2008).

Key points of opioid analgesic use in older adults include:

  • Opioid analgesic drugs are effective as a coanalgesic drugs after establishment of a nonopioid foundation, and if not contraindicated, as part of a multimodal analgesia plan for moderate to severe pain associated with acute pain conditions (American Society of Anesthesiology, 2012; The Joint Commission, 2012).
  • Opioid therapy should be initiated with a 25% to 50% dose reduction and the dosage slowly titrated by 25% of the initial dose until there is either a 50% reduction in patient's pain rating, or the patient reports satisfactory pain relief (Pasero & McCaffery, 2011c).
  • Using more than one opioid drug at the same time should be avoided (Kosar et al., 2014; Robinson & Vollmer, 2010).
  • Older adults should be monitored closely for opioid drug adverse effects, including respiratory depression, sedation, constipation, nausea, vomiting, and urinary retention, and treated prophylactically when possible (e.g., constipation). Except for constipation, all opioid drug adverse effects are dose-related. The best side effect treatment is decreasing the dose of the opioid agent by 25% to 50% depending on severity of side effects (Chou et al., 2016; Macintyre et al., 2010).
  • An equinalgesic table should be used to estimate the new dose when changing to a new opioid agent or different route of administration (Pasero & McCaffery, 2011c).
  • It is important to understand the differences between addiction, physical dependence, and tolerance, and a plan for monitoring for risk of substance abuse or misuse should be established.
  • Provided in the Appendix of the full Acute Pain in Older Adult Evidence-Based Guideline (access http://www.iowanursingguidelines.com) are tools to assist in pharmacological management, including: a table of types of pain, examples, and treatment; selected nonopioid analgesics with older adult dosage and comparative efficacy to standards; opioid analgesics commonly used in older adults for management of mild to moderate and moderate to severe acute pain; risk factors for opioid drug–induced respiratory depression; and the Pasero Opioid-Induced Sedation Scale.

Nonpharmacological Pain Management Strategies

Clinicians should be aware that some evidence exists, although not yet conclusive, that nonpharmacological interventions may be effective in relieving acute pain in older adults. Multimodal approaches that combine select nonpharmacological strategies to complement analgesic agents may improve effects and pain control, decrease analgesic use, and increase activity (Lautenbacher et al., 2011; Wanich, Gelber, Rodeo, & Windsor, 2011). Nonpharmacological pain management strategies fall into two modalities: physical and cognitive. Physical therapeutic methods include application of heat/cold, vibration, rest or immobilization, transcutaneous electrical nerve stimulation (TENS), and auricular acupressure (Barker et al., 2006; Lang et al., 2007). Cognitive interventions help patients understand more about their pain and aid in its management. Pain must be relatively well controlled for older adults to participate in cognitive techniques (Chou et al., 2016). Cognitive techniques include relaxation techniques, such as Jacobson Jaw relaxation during turning and activity (Fakhar, Rafii, & Orak, 2013; Good et al., 1999). Another technique is superficial massage, which may decrease pain and increase comfort, mainly by relaxing muscles (Reid et al., 2008). Providers may also consider music, imagery, and distraction as other cognitive modalities.

Key aspects of nonpharmacological acute pain management include:

  • Implementing basic comfort measures as appropriate, such as altering the environment to provide comfort (e.g., decrease lighting and noise, provide privacy, limit visitors, position changes) (Gordon, Grimmer-Somers, & Trott, 2009; McCaffery & Locsin, 2006).
  • Considering older adults' preferences for alternative therapies, such as acupressure, music, tailored teaching, and distraction, which may support the treatment plan to decrease pain (Lautenbacher et al., 2011; McCaffrey & Locsin, 2006; Pellino et al., 2005; Tracy, 2010).
  • Facilitating the use of non-pharmacological strategies for specific procedures, conditions, and types of pain (Barker et al., 2006; Faigeles et al., 2013; Hodgson & Lafferty, 2012).
  • Supporting the older adult's usual pain coping methods. Older adults use diverse methods to cope with pain (e.g., prayer, meditation). Patient preference is important in selecting and using nondrug treatments (Delgado-Guay et al., 2011).
  • Evaluating physical and mental abilities necessary to use a non-pharmacological pain treatment. Physical and mental fatigue may interfere with some techniques, such as distraction, relaxation, or imagery (Abdulla et al., 2013).

Use of Physical Modalities

Health care providers should consider physical therapeutic methods to manage acute pain in older adults, such as application of heat/cold, vibration, rest or immobilization, TENS, and auricular acupressure (Barker et al., 2006; Lang et al., 2007). However, use of acupuncture, massage, or cold application as adjuncts to postoperative pain relief has limited evidence to recommend or discourage use for adults (Chou et al., 2016).

  • Measures to prevent burns or tissue injury should be implemented when using heat and cold in older adults by wrapping the cold or heat pack and/or protecting the skin with a towel. Individuals at risk include older adults with cognitive impairment or impaired sensation in the area of application.
  • Cold is preferred to heat for pain relief in the presence of acute trauma, bleeding, inflammation, and swelling, but should be avoided in patients with peripheral vascular disease, such as Raynaud's disease. Although cold may be more effective than heat, older patients may prefer heat and be reluctant to use cold (Adams & Arminio, 2008).
  • Exercise using passive and active range-of-motion exercises as appropriate to the patient's situation is recommended. Range-of-motion exercises decrease pain and support maintenance of independent movement. These activities are contraindicated whenever motion to a limb would be disruptive to the healing process (Hochberg et al., 2012).
  • The use of TENS should be considered to reduce postoperative pain and improve physical function in older adults (Chou et al., 2016). TENS has been used successfully in older adults (Adams & Arminio, 2008; RNAO, 2013; Vance, Dailey, Rakel, & Sluka, 2014).
  • Acupuncture and other physical therapies can be used to reduce postoperative pain, opioid analgesic consumption, and improve physical function in older adults (Macintyre et al., 2010; Wanich et al., 2011; Yeh, Chung, Chen, & Chen, 2011).

Use of Cognitive Modalities

Cognitive-behavioral interventions that promote relaxation (e.g., relaxation alone or with guided imagery, self-selected therapy or hypnosis, music, intraoperative suggestions) provide a moderate to large beneficial effect on pain (Chou et al., 2016; RNAO, 2013). Research evidence provided for the individual types of cognitive-behavioral interventions below demonstrates increasing support for use of these pain management approaches in older adults in conjunction with analgesic agents, not as a substitute:

  • Simple relaxation strategies can be used to complement analgesic agents, yet evidence for benefit from relaxation techniques in treating acute pain is weak and inconsistent (Macintyre et al., 2010; Park, Oh, & Kim, 2013).
  • Guided imagery can be used to decrease pain (Baird, Murawski, & Wu, 2010).
  • Distraction techniques, or directing attention away from pain, to decrease pain intensity and distress can be used. Distraction strategies include talking with others, listening to music, watching a video or television, or more active approaches, such as singing, praying, positive self-talk, or tapping a rhythm (Macintyre et al., 2010; RNAO, 2013).
  • Music can be used to decrease pain intensity during ambulation and rest and enhance sleep and comfort. Patient preference regarding music should be solicited. Listening to music produces a small reduction in postoperative pain and opioid drug requirement (Good et al., 2010; Skingley & Vella-Burrows, 2010).

Education

Appropriate education about pain assessment and treatment with the older adult and/or family to promote positive outcomes can decrease postoperative pain, decrease analgesic agent use, and decrease health care use (Cousins, 2009; RNAO, 2013). Topics in a comprehensive educational pain program comprise general information about pain to include the fact that pain can be managed and/or relieved, the importance of reporting pain and establishing comfort function goals, and the importance of preventing rather than “chasing” pain (RNAO, 2013). It is important to allay fears and misconceptions regarding opioid drug use, such as addiction, tolerance, and respiratory depression (Greer, Dalton, Carlson, & Youngblood, 2001; RNAO, 2013). Regarding nonpharmacological methods, it is important to explain that they complement pharmacological interventions, not replace them (RNAO, 2013).

Evaluation

Evaluating the effectiveness of acute pain management interventions is essential. The evaluation should include pain relief achieved from the plan, whether the comfort function goal is being achieved (e.g., pain <4 on a 0 to 10 scale to cough and deep breathe), duration of pain relief, impact of pain on the patient's ability to perform functional requirements necessary for recovery, and the patient's satisfaction with pain relief (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Chou et al., 2016; RNAO, 2013).

Key points in evaluation include:

Conclusion

Despite the accumulation of evidence to guide assessment and support interventions for managing pain in older adults, acute pain management in older adults remains a problem. Improvements in acute pain management are needed in systematizing consistent and appropriate pain assessment techniques, use of pharmacological and nonpharmacological therapies consistent with goals of treatment, and patient preferences, along with patient and/or family education. The complete Acute Pain in Older Adults Evidence-Based Guideline (Cornelius et al., 2016) provides detailed guidance and evidence for clinicians and systems for improving the pain experience and outcomes for older patients and families. Attention to this vulnerable population is essential to address disparities in health care and ensure that all older adults receive evidence-based pain management appropriate for this unique segment of the population.

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Types of Pain, Examples, & Treatment

Types of Pain & ExamplesSource of PainTypical DescriptionEffective Drug Classes & Nonpharmacologic Treatments
Nociceptive:somatic
Arthritis, acute postoperative, fracture, bone metastasisTissue injury (eg, bones, soft tissue, joints, musclesWell localized, constant; aching, stabbing, gnawing, throbbingAPAP, opioid, NSAIDS; PT and CBT
Nociceptive:visceral
Renal colic, constipationVisceraDiffuse, poorly localized, referred to other sites, intermittent paroxysmal; dull, colicky, squeezing, deep, cramping; often accompanied by nausea, vomiting, diaphoresisTx of underlying cause, APAP, opioids, PT and CBT
Neuropathic
Cervical or lumbar radiculopathy, post-herpetic neuralgia, diabetic neuropathy, post-stroke syndrome, herniated intervertebral disc, drug toxicitiesPNS or CNSProlonged, usually constant, but can have paroxysms; sharp, burning, pricking, tingling, electric shock-like; associated with other sensory disturbances eg paresthesias and dysesthesias; allodynia, hyperalgesia, impaired motor function, atrophy, or abnormal deep tendon reflexesTCAs, SNRIs, anticonvulsants, opioids, topical anesthetics, PT and CBT
Undetermined or Mixed
Myofascial pain syndrome, somatoform pain disorders, fibromyalgiaPoorly understoodNo identifiable pathologic processes or symptoms out of proportion to identifiable organic pathothology; widespread musculoskeletal pain, stiffness, and weaknessAntidepressants, antianxiety agents, PT, CBT, and psychological tx

Strategies for Obtaining Pain Intensity Report in Older Persons with Cognitive Impairment

Solicit self-report in all older persons, including those with mild to moderate pain severity. If the patient denies pain, use other descriptors such as discomfort, aching, or soreness. Assess pain during movement.

Use pain scales that are valid and reliable in older persons, including a numeric rating scale, verbal descriptor scale, and/or faces pain scale.

In a given patient, use same pain scale with each assessment and document assessment.

Assure that approaches to pain assessment address any sensory impairments including vision and hearing losses.

Hearing aids in place

Glasses in place

Enlarged tools (a minimum of 14 pt font) and bold drawings

Written and oral instructions

Assure adequate lighting

Determine reliability of the patient's self report in using a pain intensity scale if this is in question.

Consider using the Pain Screen Test (PST)1

Step 1: Ask patient to select a word describing pain

Ask patient to identify 3 numbers.

Step 2: Distract patient with conversation for 1 minute.

Step 3: Ask patient to recall the word and the 3 numbers.

Step 4: Score 1 point for each initial and ½ for each recalled word and number.

Step 5: Score of 3 is considered reliable reporter.

Ask patient to use selected pain scale and identify where a very bad pain would be located on the scale and where a mild pain would be located on the scale. Evaluate appropriate placement based on severity of pain.

Use a visual of the pain scales, rather than a verbal request of pain report.

Repeat clear simple instructions for use of a pain intensity scale each time the tool is used.

Provide sufficient time for the older adult to process the task and respond to the tool.

Ask about pain in the present, i.e. right now

Use a figure drawing to identify pain location.

Authors

Dr. Cornelius is Certified RN Anesthetist, Iowa Anesthesia L.C., Manchester, Iowa; Dr. Herr is Professor, College of Nursing, The University of Iowa, Iowa City, Iowa; Dr. Gordon is Co-Director Harborview Integrated Pain Care Program, Anesthesiology & Pain Medicine, University of Washington, Seattle; and Dr. Kretzer is Director of Staff Development, Montgomery Hospice, Rockville, Maryland.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Copyright © 2017 Csomay Center for Gerontological Excellence

Address correspondence to Randy Cornelius, DNP, CRNA, Certified Registered Nurse Anesthetist, Graduate of the College of Nursing, The University of Iowa, 306 CNB, Iowa City, IA 52242; e-mail: randy-cornelius@hotmail.com.

10.3928/00989134-20170111-08

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