Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
long-term care Chronic Pain in the Nursing Home Resident Presenter: Gwendolyn Buhr, MD http://careinaging.duke.edu/longterm care Chronic Pain in the Nursing Home Resident Key Principles http://careinaging.duke.edu/longterm care 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 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 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) 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 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 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 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 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 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 long-term care network http://careinaging.duke.edu/longtermcare WHO 3-step Ladder 3 Severe 2 Moderate Strong Opioid Opioid 1 Mild “around the Non-narcotic “around the clock” clock” “around the ± adjuvants ± adjuvants clock” ± adjuvants long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Non-opioids •Acetaminophen •NSAIDS •Ibuprofen •naproxen •COX-2 1 Mild Non-narcotic “around the clock” ± adjuvants long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Adjuvants •Calcitonin •Corticosteroids •Anticonvulsants •Topical agents •Antidepressants 1 Mild Non-narcotic “around the clock” ± adjuvants 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 long-term care network http://careinaging.duke.edu/longtermcare Step Approach to Pain Management Opioids •Tramadol •Tylenol #3 •Tylenol #4 •Vicodin •Percocet Strong Opioids •Morphine •Dilaudid •MSContin •OxyContin •Transdermal fentanyl 3 Severe 2 Moderate Strong Opioid Opioid 1 Mild “around the “around the Non-narcotic clock” clock” “around the ± adjuvants ± adjuvants clock” ± adjuvants 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) 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% long-term care network http://careinaging.duke.edu/longtermcare