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Assessing and managing acute pain in older adults: a research base to guide practice.

Older adults frequently undergo medical and surgical treatments that result in acute pain. However, these patients often receive significantly less analgesic medication than younger patients experiencing similar painful conditions (Feldt, Ryden, & Miles 1998; Honari et al., 1997). Moreover, cognitively impaired older individuals receive significantly less analgesics than cognitively intact elders with similar painful events (Morrison & Siu, 2000), even though there is no empirical evidence that cognitive impairment is associated with decreased pain sensation (Feldt, Ryden et al., 1998). The tendency to undermedicate older adults may be related to several factors, including misguided beliefs, fears regarding complications, and a failure to assess and treat pain in confused older adults (Doucet et al., 1996; Feldt, Ryden, & Miles, 1998; Honari et al., 1997; Short, Burnett, Egbert, & Parks, 1990). The common practice of undertreating older adults with acute pain is particularly troublesome in light of research that demonstrates better patient outcomes, reduced length of stay, and reduced resource use as a result of effective pain management and mobility (Carli & Halliday, 1997; Hoenig, Rubenstein, Sloane, Horner, & Kahn, 1997; Kehlet, 1998; Liu, Carpenter, & Mackey, 1995; Pati, Perme, Trail, Henry, & Bryan, 1994).

As part of a study funded by the Agency for Healthcare Research and Quality on translating research into practice (Grant #R01 HS10482), researchers at the University of Iowa reviewed and critiqued existing literature on acute pain management in older adults. The result is an evidence-based guideline on "Acute Pain Management in the Elderly," developed with the intent of improving nurse and physician practices (Herr et al., 2000). The guideline addresses the following general areas of practice related to acute pain the elderly: (a) pain assessment, (b) pain assessment in confused eiders, (c) monitoring pain in older adults, (d) education of the patient and family, (e) pharmacologic management, and (f) non-pharmacologic management. Key recommendations from the guideline, with selected reference support, are summarized.

Pain Assessment

Ideally, a baseline pain assessment should be completed prior to a known painful event. However, for elders who present in acute pain of moderate to severe intensity, a rapid pain assessment should be conducted and pain should be treated prior to completing a comprehensive assessment. The rapid assessment should include self-reports of pain intensity, quality, location, and duration, if possible. A thorough assessment of the patient's pain includes, in addition to a self-report of pain, a physical examination, pain history, past pain experience and knowledge, and medication history.

A self-report of pain from the elder is the single most reliable indicator of the existence and intensity of pain (American Geriatrics Society [AGS], 1998). Since older adults may use a term other than pain, different questions may be needed, such as "Are you feeling hurt?.... Are you uncomfortable right now?" or "Do you hurt anywhere?" The patient's preferred term should be used throughout pain assessment and management (Duggleby & Lander, 1994; Feldt, Miles, & Ryden, 1998; Miller et al., 1996).

Most older adults can use some type of pain rating scale to report pain intensity. Even many cognitively impaired elders can report pain reliably using verbal descriptor scales, pain thermometers, and faces pain scales. Consistently using one tool that matches the patient's preferences and cognitive/functional abilities will yield the best results (AGS, 1998; Briggs & Class, 1999; Carey, Turpin, Smith, Whatley, & Haddox, 1997; Choiniere & Amsel, 1996; Feldt, Ryden, & Miles, 1998; Ferrell, Ferrell, & Rivera, 1995; Herr, Mobily, Kohout, & Wagenaar, 1998; Stuppy, 1998; Wynne, Ling, & Remsburg, 2000). Once a pain intensity scale is selected for use, ask the older adult to set an acceptable level of pain (McCaffery & Pasero, 1999a), explaining the detrimental effects of high levels of pain on immune response and coping ability.

It is important to compensate for auditory and visual impairments that the patient might have. Position your face in view of the patient, speak in a slow, normal tone of voice, reduce extraneous noises, and provide written instructions. Adapt assessment tools and other written materials to compensate for visual impairments (AGS, 1998). Use simple lettering, at least 14 point font size, adequate line spacing, and nonglare paper. Assure that the patient has eyeglasses, functional hearing aids, and adequate time to respond to questions.

The physical examination should focus on the reported location of pain and the existence of pathologic conditions (Kovach, Weissman, Griffie, Matson, & Muchka, 1999). The patient may experience autonomic responses typically associated with acute pain (for example, increased heart rate and blood pressure, increased or decreased respiratory rate, diaphoresis), but the absence of these responses does not necessarily indicate that pain is absent (Pasero, Reed, & McCaffery, 1999). The patient should be observed when engaged in activity, such as transfers, ambulation, and repositioning, as behavior at rest can be misleading (Feldt, Ryden, & Miles, 1998; Feldt, 2000).

A pain history includes pain characteristics, intensity, location, aggravating and alleviating factors, and associated signs and symptoms (American Pain Society [APS], 1995; AGS, 1998). It is also important to assess the impact of pain on the patient's ability to perform activities of daily living, procedures, or treatments in the acute care setting (for example, coughing, deep breathing, turning) (AGS, 1998; McCaffery & Pasero, 1999a). Chronic disorders (such as osteoarthritis, peripheral vascular disease, neuropathies) may hinder the accurate assessment of acute pain (Dunajcik, 1999), and sociocultural variables may influence pain behavior and expression (Encandela, 1993; Neill, 1993).

Assessment of the patient's past pain experience and knowledge includes prior use of analgesics, their effectiveness, and their side effects (AGS, 1998), as well as nonpharmacologic methods previously used to relieve and cope with pain and their effectiveness (for example, folk/home remedies, heat, cold, massage, distraction, prayer, relaxation) (AGS, 1998; Ferrell, 1995; McDonald & Sterling, 1998). It is important to assess patient and family attitudes and beliefs. Expectations regarding pain, prior successes and failures with analgesics, and fears regarding addiction, tolerance, or analgesic side effects can affect willingness to use analgesics (Brockopp, Warden, Colclough, & Brockopp, 1996; Ferrell, Rhiner, & Ferrell, 1993; Ward, Carlson-Dakes, Hughes, Kwekkeboom, & Donovan, 1998; Ward et al., 1993; Yates, Dewar, & Fentiman, 1995). Finally, assessing the patient and family's current knowledge of pain management strategies that may be implemented during hospitalization can help direct teaching (McCaffery & Portenoy, 1999).

A medication history includes medication use for chronic conditions that may interact or interfere with analgesic use (AGS, 1998), allergies to analgesics (McCaffery & Portenoy, 1999), and alcohol consumption (Antai-Otong 1995; Pasero et al., 1999).

Assessment of Pain in Cognitively Impaired Patients

Noncommunicative, cognitively impaired patients can be observed for essential information on which to make a judgement regarding the presence of pain (Cariaga, Burgio, Flynn, & Martin, 1991; Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992). Behaviors that may indicate pain can be grouped into the four categories below, with the most common indicators of pain in noncommunicative patients in italics.

* Nonverbal cues/behaviors: restlessness, agitation, with-drawing, rapid blinking, rocking, rubbing, fidgeting, guarding or splinting operative or injured site, bracing, repositioning, tense body language, distorted posture, noisy breathing (Baker, Bowring, Brignell, & Kafford, 1996; Feldt, 2000; Feldt, Ryden et al., 1998; Hurley et al., 1992; Kovach et al., 1999; Raway, 1993; Weiner, Peterson, & Keefe, 1999).

* Vocalizations: groaning, moaning, crying, yelling, sighing, grunting, perseverant vocalizations, verbal outbursts, (Feldt, 2000; Feldt, Ryden. & Miles, 1998; Hurley et al., 1992; Kovach et al., 1999; Raway, 1993).

* Facial expressions of pain: brow lowering with jaw drop or mouth open; brow lowering with narrowing or closing eyes, clenched teeth, sad or distorted expression, frowning, grimacing, wincing, wrinkling of the forehead (Feldt, 2000; Hurley et al., 1992; Kovach et al., 1999; Prkachin, 1993; Raway, 1993).

* A change in usual activity or behavior: aggression, new onset of confusion, agitation/irritability, withdrawal, impaired mobility or change in activity, altered sleep, fatigue, anxiety, attention seeking, depression, change in appetite or refusal to eat, withdrawal, increased confusion, resistance to care (Baker et al., 1996; Feldt, 2000; Feldt, Warne, & Ryden, 1998).

Monitoring Acute Pain in Older Adults

Acute pain in older adults can only be managed effectively if pain is monitored regularly. Monitoring entails assessment of pain characteristics, intensity, duration, and effects using selected assessment tools at least every 2 to 4 hours around the clock (AHCPR, 1992). Once every 8 hours may be appropriate if pain is mild or well controlled. Pain and nonverbal pain-related behaviors should be assessed during transfers or patient care activities (Feldt, Ryden, & Miles, 1998). All patients can be observed for nonverbal cues of pain and behavioral changes, but there may be no such behaviors/cues present in the cognitively impaired (Baker et al., 1996; Hurley et al., 1992; Miller et al., 1996; Pasero et al., 1999; Prkachin, 1993; Simons & Malabar, 1995). It is also important to monitor postoperative older adults for the development of confusion, as well as for pain-related complications (including pulmonary function). A critical step in monitoring acute pain is documenting pain assessment and treatment information in a visible place that can be used by other health care professionals (APS, 1995; APS, 1999; Faries, Mills, Goldsmith, Phillips, & Orr, 1991; Voigt, Paice, & Pouliot, 1995).

Patient and Family Education

Health care information, skills training, and psychosocial support can decrease postoperative pain, analgesic use, and health care resource use (Devine 1992; Devine & Cook, 1986; Ferrell, Ferrell, Ahn, & Tran, 1994; Ferrell et al., 1995). The timing and level of education provided should be based on the patient's current pain state. Pain relief must be a priority. Providing ongoing explanations of procedures or treatments can help the patient decrease pain (Devine 1992; McCaffery & Portenoy, 1999).

A comprehensive educational program for patients and families includes several components including: teaching about planned procedures and associated pain, explaining that pain can be managed and/or relieved, stressing the importance of reporting pain, the importance of preventing rather than "chasing" pain, and the benefit of pain control in the recovery process (APS, 1995; APS, 1999; Ferrell et al., 1994; McCaffery & Portenoy, 1999; Yates et al., 1995; Zalon, 1997). Pain assessment is more effective when the patient understands the pain assessment schedule, the method of pain assessment, and selected pain intensity assessment tool(s) (Ferrell et al., 1994). The patient should be coached in accurately reporting pain, with instructions repeated each time pain is assessed (Wilkie, Williams, Grevstad, & Mekwa, 1995).

Allaying common fears and misconceptions regarding opioid use, such as addiction, tolerance, and respiratory depression, can improve a patient's willingness to take opioids (Brockopp et al., 1996). Explaining both the common side effects of analgesics and planned interventions for any side effects experienced can also improve patient willingness to take analgesics (McCaffery & Portenoy, 1999).

It is important to describe nonpharmacologic interventions that can be used to manage pain, including cognitive-behavioral pain management options (for example, relaxation strategies, imagery) and cutaneous stimulation options (heat/cold, transcutaneous electrical nerve stimulation [TENS]) (McCaffery & Pasero, 1999b; Mobily, 1994). Finally, routine procedural and post-procedure activities and methods to decrease discomfort from these activities should be explained and demonstrated when practical (Pasero & McCaffery, 1999).

Pharmacologic Management

Older individuals generally receive a greater peak and longer duration of action from opioids than younger individuals (Giuffre, Asci, Amstein, & Wilkinson, 1991; Kaiko, Wallenstein, Rogers, Grabinski, & Houde, 1982). Thus, opioid therapy should be initiated at a 25% to 50% lower dose than that recommended for adults and slowly increased by 25% on an individual basis (AGS, 1998; APS, 1999; Pasero et al., 1999; Vigano, Bruera, & Suarez-Almazor, 1998). Increases of 25% to 50% should be administered until there is either a 50% reduction in the patient's pain rating, or the patient reports satisfactory pain relief (APS, 1999). A repeat dose can be safely administered at the time of the peak if the previous dose is ineffective and side effects are minimal (McCaffery & Portenoy, 1999).

When changing to a new opioid or a different route, use a standard equianalgesic conversion table for adults to estimate the new dose; then modify the estimate based on the clinical situation and specific drugs (APS, 1999; Forman, 1996).

Analgesics should be administered by means of the least invasive and safest route that can relieve pain. Oral administration is appropriate as soon as the elder can tolerate oral intake (Tramter et al., 1998; Pasero et al., 1999). Intravenous administration is the parenteral route of choice after major surgery (Pasero & McCaffery, 1996), and IV or epidural access is appropriate for postoperative management of severe pain (Burstal, Wegener, Hayes, & Lantry, 1998). Intramuscular administration should be avoided in older adults. Older adults have muscle wasting and less-fatty tissue compared to younger adults. Slowed intramuscular absorption of analgesics in elderly patients can result in delayed or prolonged effects, altered analgesic serum levels, and possible toxicity with repeated injections. If unable to tolerate oral medication, alternative routes such as rectal and sub-lingual administration can be used (Conner & Deane, 1995; Erstad, Meeks, Hsiao-Hui, Rappaport, & Levinson, 1997; Pasero et al., 1999; Segstro, Morely-Forster, & Lu, 1991; Tramter et al., 1998). Epidural anesthesia allows for smaller doses of opioids than those required by the parenteral route. This can benefit cognitive function, decrease the risk of postoperative cardiac and pulmonary complications, and improve function postoperatively (Ballantyne et al., 1998; Beattie, Buckley, & Forrest, 1993; Burstal et al., 1998; de Leon-Casasola, Parker, Lema, Harrison, & Massey, 1994; Kehlet, 1998; Liu, Carpenter, & Neal, 1995; Major, Greer, & Russell, 1996; Mann et al., 2000).

Around-the-clock scheduling of opioid and nonopioid pain medication is superior to prn dosing, because it helps maintain a stable analgesic blood level and gives structure to the pain management plan (APS, 1999). Patient-controlled analgesia (PCA) for intravenous analgesics can be used in cognitively intact elder patients, particularly during the immediate post-procedure period. Patients should be monitored closely and doses should be titrated cautiously due to an increased potential for toxicity (Egbert, 1996; Mann et al., 2000). It is important to screen for cognitive and physical ability to manage pain by PCA. Extra time should be allocated if necessary to teach the use of PCA preoperatively and to reinforce its correct use postoperatively. Unless a patient is awakened by pain during sleep, continuous basal infusion is not recommended because of increased risk of drug accumulation and toxicity (Parker, Holtmann, & White, 1991). Patient-controlled analgesia should not be used in confused patients, primarily because it may result in inadequate analgesia (Egbert, 1996).

Pharmacologic management for mild to moderate pain should begin, unless contraindicated, with a nonopioid (NSAID or acetaminophen). Moderate to severe pain should be treated initially with an opioid analgesic, with or without a nonopioid (McCaffery & Portenoy, 1999). The patient's hepatic and renal function should be evaluated to guide selection of analgesics for elders with concurrent medical conditions (Pasero et al., 1999).

Nonopioids include aceta-minophen, aspirin, and NSAIDs. Acetaminophen is an effective analgesic in older adults and does not produce gastric and bleeding complications (Bradley, Brandt, Katx, Kalasinski, & Ryan, 1991; Moore, Collins, Carroll, & McQuay, 1997). However, the total daily dose must not exceed 4 gm to avoid toxicity related to reduced hepatic metabolism. It is critical to monitor the amount of acetaminophen administered in combination drugs (such as Darvocet[R], Vicodin[R], and combination codeine preparations) (APS, 1999).

Aspirin is not a good choice for most elders. Age-associated physiologic changes result in increased toxicity with aspirin use (Baskin & Goldfarb, 1983). Gastric disturbances and bleeding are more common adverse effects (APS, 1999).

The analgesic effects of NSAIDs supplement the analgesic effects of opioids, thereby reducing the dose of opioid that is required for effective pain management. However, the risk for gastric and renal toxicity from NSAIDs is increased among older patients, and unusual drug reactions, including cognitive impairment, constipation, and headaches are also common (Camu, Lauwers, & Vanlersberghe, 1996; Karplus & Saag, 1998; Mallet & Kuyumjian, 1998; Perez-Gutthann, Garcia-Rodriguez, Duque-Oliart, & Varas-Lorenzo, 1999). Gastrointestinal bleeding is a common problem (Bjorkman, 1996; Henry et al., 1996; Perez-Gutthann et al., 1999; Piette, Teillet, Naudin, Boichut, & Capron, 1997). A meta-analysis of the variability and risk of gastroin-testinal complications of NSAIDs found that low-dose ibuprofen (under 1,600 mg/day) was associated with the lowest relative risk (Henry et al., 1996). Newer Cox-2 NSAIDs can be considered as a way to lessen the risk of gastroin-testinal bleeding and gastric/duodenal ulcers. Cox-2-selective inhibitors (Celecoxib[R], Rofecoxib) produce analgesia with less gastric mucosal damage and bleeding than older Cox-1 NSAIDs (Ehrich et al., 1999; Kaplan-Machlis & Klostermeyer, 1999; Langman et al., 1999; Simon et al., 1999). However, Cox-2 inhibitors do exhibit complications similar to other NSAIDs related to renal toxicity (Clemett & Goa, 2000). Generally, NSAIDs should be avoided for patients with a history of bleeding disorders or a concurrent use of anticoagulants (Roche & Forman, 1994).

The use of NSAIDs also should be avoided for patients with a history of renal impairment, congestive heart failure, concurrent volume depletion, or diuretic use (Camu et al., 1996; Murray & Brater, 1993). Patients on NSAIDs should be monitored for a new onset of confusion, and patients with dementia should be monitored for increased confusion during initial use. Long-term use has a protective effect on cognitive decline (Roth, 1989; Rozzini, Ferrucci, Losonczy, Havlik, & Guralnik, 1996).

Ketorolac (Toradol[R]) IV may be used safely for many elders. However, ketorolac is contraindicated for frail elders with dehydration, pre-existing renal dysfunction, cirrhosis, or heart failure. The normal adult dose should be decreased by 50%, the total daily dose should not exceed 60 mg, and ketorolac should not be used for longer than 5 days (Pasero et al., 1999).

Morphine sulfate is the opioid analgesic of choice for most older adults (Ferrell, 1995). Hydromorphone is an acceptable alternative to morphine for older adults because of its short half-life and the absence of active metabolites (Dellasega & Keiser 1997; Popp & Portenoy, 1996). Oxycodone provides excellent pain relief with typical opioid side effects in elders. Controlled-release oxycodone (Oxycontin[R]) is an option for acute pain management, but immediate-release opioids should be available for break-through pain (Curtis et al., 1999; Pasero, Reed, & McCaffery, 1999; Reuben, Conelly, & Maciolek, 1999).

Fentanyl PCA is an option for elders because of a decreased incidence of both cognitive impairment and urinary retention (Herrick et al., 1996). However, intravenous fentanyl can result in late, prolonged sedation and respiratory depression (Marshall & Longnecker 1996; Mather & Denison, 1992; Willens & Myslinski, 1993).

Tramadol (Ultram[R]) causes less respiratory depression in older adults. However, caution must be exercised with patients who have hepatic or renal disorders. Due to a high incidence of nausea and vomiting, low dosing (25 to 50 mg per day) is recommended for the first 2 to 3 days. Moreover, dosing of tramadol should not exceed 300 mg per day for patients over 75 years of age (Katz, 1995; Pasero, Portenoy, & McCaffery, 1999).

Opioids to Avoid

Several opioids currently available are not recommended for older adults. Administration of meperidine can produce a high incidence of adverse symptoms, especially if the patient has coexisting CHF or renal impairment. Meperidine's metabolite, normeperidine, produces CNS excitability with tremors, seizures, mood alterations, and confusion (Francis, 1992; Kaiko et al., 1983; Marcantonio et al., 1994; Pasero et al., 1999; Szeto et al., 1977).

Propoxyphene (Darvon[R], Darvocet[R]) creates toxic metabolites that rely on renal clearance and contribute to increased CNS adverse effects. Moreover, propoxyphene is no more effective than aspirin or acetaminophen (Beers et al., 1991; Collins, Edwards, Moore, & McQuay, 1998; Forman, 1996; Willcox, Himmelstein, & Woolhandler, 1994).

Combined agonists/antagonists, including butorphanol (Stadol[R]), pentazocine (Talwin[R]), and buprenorphine (Buprenex[R]) are inappropriate because they antagonize the action of morphine-like agonists (such as morphine) and because their antagonist actions lessen analgesic effects seen at higher doses. In addition, butorphanol and pentazocine may produce psychomimetic effects and lead to confusion; pentazocine causes delirium and agitation in the elderly (APS, 1999; Ferrell, 1995). Transdermal fentanyl is not indicated for the management of acute pain (Ferrell & McCaffery, 1997), due to its extreme potency, its potential for delirium and respiratory depression, and the difficulties encountered in titrating dosages (Ferrell, 1995; Wakefield, Johnson, Kron-Chalupa, & Paulsen, 1998).

Benzodiazepines can diminish skeletal muscle spasm, reduce anxiety, and at high doses produce procedural amnesia. However, they do not provide analgesia for acute tissue injury. Long-acting benzodiazepines are not well tolerated by older adults, so short-acting agents such as alprazolam (Xanax[R]), lorazepam (Ativan[R]), and oxazepam (Serax[R]) are preferable (Marcantonio et al., 1994; Pasero et al., 1999; Ray, Griffin, & Downey, 1989).

The potential for side effects from analgesics is high in older adults, due to their altered ability to distribute and excrete drugs (Pasero et al., 1999). Common side effects of opioids include constipation, nausea and vomiting, confusion, decreased respiratory rate, sedation, pruritis, urinary retention, and hypotension (Ferrell, 1995; Nimmo, Heading, Wilson, Tothill, & Prescott, 1975). The best strategy for opioid-induced side effect management is decreasing the dose of the opioid by 25% to 50% if pain relief is satisfactory, depending on side-effect severity. For patients with side effects and unrelieved pain, adding a nonopi-old (acetaminophen or an NSAID) can be considered (Pasero et al., 1999a).

Constipation does not ease over time with opioid use. It is important to assess bowel function daily, initiate a bowel protocol as soon as opioid therapy is started, and continue through treatment. The incidence of constipation in elders is twice that of the general population (Levy, 1991).

Nausea and vomiting are less likely in older adults. Antiemetics for analgesic-induced nausea may result in problems in older patients due to increase sensitivity to their anticholinergic effects (bowel and bladder dysfunction, confusion, movement disorders). If needed, metoclopramide (Reglan[R]) has analgesic properties as well as antiemetic action and is more appropriate for older adults (Kandler & Lisander, 1993).

Short-term cognitive impairment may result when opioids are started, but acute confusion may be due to other factors, including electrolyte abnormalities, hypoxemia, dehydration, infection, other medications, sensory impairment, sleep disturbances, urinary elimination problems, slow mobilization, and changes in the patient's environment. Analgesics and adjuvants that may produce increased confusion levels in older patients include NSAIDs, meperidine, pentazocine, and anticholinergics (Duggleby & Lander, 1994; Ferrell, 1995; Foreman, Mion, Tryostad, Fletcher, & NICHE Faculty, 1999; Marcantonio et al., 1994; Morrison, Chassin, & Siu, 1998; Parikh & Chung, 1995; Popp & Portenoy, 1996; Rosenberg, Rosenberg-Adamsen, & Kehlet, 1995; Rozzini et al., 1996; Simpson, Lee, & Cameron, 1996; Williams et al., 1985).

Respiratory depression can occur, especially if rapid dose escalation is required because of severe pain and particularly in opioid-naive patients and in those with co-existing pulmonary conditions. Opioids should be withheld if the patient is sedated when awake or whenever the respiratory rate is < 8/min (APS, 1999; Pasero et al., 1999).

Nonpharmacologic Management

Multimodal treatments that include pharmacologic and non-pharmacologic interventions increase pain control, decrease analgesic use, increase activity and function, decrease depression and anxiety, and increase family involvement in care (Gibson, Farrell, Katz, & Helme, 1996; Good et al., 1999; Luskin et al., 2000). Patient preference is important in selecting and using nonpharmacologic treatments, and the patient's usual pain coping methods (such as prayer and meditation) should be supported (Ferrell, 1995). It also is important to evaluate physical and mental abilities necessary to use a nonpharmacologic pain treatment. Physical and mental fatigue may interfere with some techniques, such as distraction, relaxation, or imagery (McCaffery & Pasero, 1999b). Perhaps most importantly, nonpharmacologic strategies should be chosen to complement, not replace, analgesics (Mobily, 1994; Pasero et al., 1999).

Basic comfort measures can be implemented to improve comfort. The environment can be altered by decreasing lighting and noise, providing privacy, and limiting visitors as the patient wishes. Movement or repositioning, pressure-relieving devices, or rest and immobilization can reduce discomfort (Carr & Thomas, 1997; McDonald & Sterling, 1998). Eliminating stimulant foods and beverages at least 8 hours before retiring, providing a snack 1 to 2 hours before sleep, conforming to usual bedtime routines, and attention to environmental distracters can improve sleep patterns (Bowman, 1997).

Superficial massage may decrease pain in several ways. Improved circulation decreases the accumulation of irritants and inflammatory substances. Stimulation of large diameter sensory nerves inhibits pain transmission. Massage may stimulate release of endorphins and enkephalins. Touch through massage may improve a sense of well-being and diminish anxiety, thereby diminishing pain (Nixon, Teschendorff, Finney, & Karnilowicz, 1997; Richards, Gibson, & Overton-McCoy, 2000). The most common sites for massage include the back and shoulders, but hands and feet may be added. Use of a warm lubricant and long, slow strokes are recommended (Labyak & Metzger, 1997; Nixon et al., 1997; Richards et al., 2000).

Simple relaxation techniques can be used to complement analgesics. Use the Jacobson Jaw Relaxation technique during turning and activity to decrease pain and distress (see, Figure 1) (Good et al., 1999; Seers & Carroll, 1998). Guided imagery can be used to decrease pain, but should be avoided with patients who have severe cognitive impairment or psychosis (Seers & Carroll, 1998; Tusek, Church, & Fazio, 1997).

Distraction strategies direct attention away from pain by focusing attention on other stimuli. Distraction strategies may include talking with others, listening to music, and watching video or TV, or more active approaches such as singing, praying, or tapping a rhythm. Distraction is most appropriately used for pain of mild or moderate intensity and for brief periods of time up to an hour. Basic principles to keep in mind when selecting a distraction technique include:

* The patient is given an opportunity to select from several distraction strategies.

* The distraction is of interest to the patient.

* The technique selected is congruent with the patient's energy level and ability to concentrate.

* The technique engages several sensory processes, such as listening, movement, vision, smell, and touch.

* The stimuli used in the technique can be increased or decreased as the pain changes.

* Techniques requiring more concentration are more likely to divert attention away from the pain and thus be more effective.

Unfortunately, patients distracted from their pain may not "look" like they are in pain, thus leading to an incorrect judgement about pain severity. Moreover, after the distraction is over, the pain may be increased, and pain-relief measures may be needed (Good et al., 1999; Heitz, Symreng, & Scamman, 1992).

Superficial heat or cold can be applied to the site of pain, or to a site other than the pain site (proximal, distal, or contralateral to the pain). Use heat and cold with caution in older adults, especially those with cognitive impairment or impaired sensation in the area of application. Wrap the cold or heat pack and/or protect the skin with a towel to prevent burns or tissue injury. Although cold may be more effective than heat, older patients may prefer heat and be reluctant to use cold. If cold is indicated, explain its benefits; provide a gradual onset with layering; choose a cold pack that is soft, lightweight, and conforming to body contours; and protect the patient from generalized chilling with blankets or additional clothing. Alternating heat and cold can also be effective in relieving pain, with the interval between heat and cold applications ranging from as short as 5 to 10 seconds up to 1 to 3 minutes (Creamer, Hunt, & Dieppe, 1996; Lehmann & Strain, 1985; McCaffery & Pasero, 1999b; Rhiner, Ferrell, Ferrell, & Grant, 1993; Sherer, Clelland, O'Sullivan, Doleys, & Canan, 1986; Yarnitsky, Kunin, Brik, & Sprecher, 1997).

Applied with moderate pressure, vibration may relieve pain by causing paresthesia and/or anesthesia of the area stimulated, and change sharp pain to a dull sensation (Yarnitsky et al., 1997). Pain relief may last for several hours when moderate pressure vibration continues for 30 minutes or longer. Vibration can be helpful for acute muscle pain or spasm, itching, neuropathic pain, phantom limb pain, oro-facial pain, and acute tendonitis, and can be used as a substitute for TENS. Many vibrating devices are available commercially. High-frequency vibrations of 100 to 200 Hz provide finer movements and tend to be more effective than coarser movements of 10 to 50 Hz. Vibrations of 20 to 30 minutes, 2 to 3 times per day, are suggested. Moreover, use of heat with vibration can be more effective than use of heat or vibration alone.

TENS has been used successfully in older adults to reduce pain and improve physical function. However, evidence is mixed regarding its effectiveness in acute pain (Hargreaves & Lander, 1989; Neary, 1981; Reeve, Menon, & Corabian, 1996). Meta-analyses estimating the clinical effect of TENS as a treatment for postoperative pain suggest that TENS has an effect beyond what is achieved with narcotics alone (Rakel & Schmidt, in review). However, its effect has a large placebo component, and the amount of variance due to factors other than sampling error suggests that other variables influence its effectiveness (Rakel & Schmidt, in review).

Immobilization or positioning includes splinting, traction, turning, and positioning techniques, and involves maintaining anatomically correct positioning in a manner that enhances comfort and minimizes pain or further injury to the patient (Nelson, Taylor, Adams, & Parker, 1990; Parker & Handoll, 2000). Mobilization involves passive and active range of motion activities appropriate to the patient's situation to decrease pain and to encourage maintenance of independent movement. These activities are contraindicated whenever motion to a limb would be disruptive to the healing process (McCaffery & Wolff, 1992).

Conclusion

Evidence is available and continually increasing to direct the management of acute pain in older adults. Assessment of pain every 4 hours using a selected pain-intensity scale is a prerequisite for adequately managing pain. Several opioid and nonopioid analgesics can be used effectively to manage acute pain in older adults. Nonpharmacologic interventions can be used to complement pharmacologic interventions. The effectiveness of pain management interventions should be monitored regularly. Pain relief from pharmacologic interventions (30 minutes after parenteral, 60 minutes after oral) and nonpharmacologic interventions should be assessed using patient-based feed-back through one of the pain-intensity scales described earlier (APS 1999).

All pain assessments and pharmacologic and nonpharmacologic pain interventions should be documented on a pain flowsheet (Faries et al. 1991; Pasero et al., 1999; Voigt et al., 1995). Each patient's pain record or flowsheet should be monitored for patterns in order to identify the efficacy of the pain intervention activities chosen and to determine a need for revision in the pain plan (Pasero, Gordon, McCaffery, & Ferrell, 1999). If pain management is not adequate, the plan should be revised based on consultation among the patient's physician, nursing staff, and the pharmacy department (McCaffery & Portenoy, 1999). When pain is assessed frequently, pharmacologic and nonpharmacologic interventions are administered on a regular basis, and the effectiveness of those interventions is monitored regularly, health care providers can expect older adults to attain relief and positive outcomes when dealing with acute pain problems.

Figure 1.

Jacobson Jaw Relaxation Technique

Describe the following steps to the patient in a slow, comforting voice:

1. Let your lower jaw drop slightly, as though you were starting a small yawn.

2. Keep your tongue still and resting in the bottom of your mouth.

3. Let your lips get soft.

4. Breathe slowly and rhythmically with a three-rhythm pattern of "inhale," "exhale," and "rest."

5. Stop forming words; do not even think about words.

Have the patient practice this technique during turning and activity.

Note: This paper was supported by the Agency for Healthcare Research and Quality (Grant # R01 HS10482). A copy of the guideline may be obtained by contacting the Research Dissemination Core of the Gerontological Nursing Interventions Research Center, 4118 Westlawn, University of Iowa, Iowa City, IA 52242, at (319) 384-4429 (phone), 319-353-5843 (fax), or research-dissemination-core@uiowa.edu.
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Assessing and Managing Pain in Older Adults: A Research Base to Guide
Practice

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learned by completing this activity. --

2. How will you apply the information from this learning activity to
your practice?

a. Patient education.

b. Staff education.

c. Improve my patient care.

d. In my educational course work.

e. Other: Please describe. --

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The offering met the stated objectives.

1. Describe the key features of           1   2   3   4   5
a baseline pain assessment.

2. List types of pharmacologic and        1   2   3   4   5
nonpharmacologic therapies used in
pain management.

3. Discuss education of the patient       1   2   3   4   5
and family.

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Objectives

This educational activity is designed for nurses and other health care professionals who care for and educate patients regarding acute pain in older adults. The evaluation that follows is designed to test your achievement of the following educational objectives. After reading this article, you will be able to:

1. Describe the key features of a baseline pain assessment.

2. List types of pharmacologic and nonpharmacologic therapies used in pain management.

3. Discuss education of the patient and family.

Posttest Instructions

1. To receive continuing education credit for individual study after reading the article, complete the answer/evaluation form to the left.

2. Detach and send the answer/evaluation form along with a check or money order payable to Jannetti Publications/MEDSURG Nursing to MEDSURG Nursing, CE Series, East Holly Avenue Box 56, Pitman, NJ 08071-0056.

4. Test returns must be postmarked by February 28, 2005. Upon completion of the answer/evaluation form, a certificate for 2.6 contact hour(s) will be awarded and sent to you.

This independent study activity is provided by Anthony J. Jannetti, Inc., which is accredited as a provider and approver of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation (ANCC-COA).

This article was reviewed and formatted for contact hour credit by Dottle Roberts, MSN, RN,BC, ONC, MEDSURG Nursing Editor; and Sally S. Russell, MN, RN,C, AMSN Education Director.

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Gail Ardery, PhD, RN, is Project Director, Evidence-Based Practice Research Study on Acute Pain Management in the Elderly, University of Iowa College of Nursing, Iowa City, IA.

Keela A. Herr, PhD, RN, is a Professor, University of Iowa College of Nursing, Iowa City, IA, and Co-Principal Investigator of this study.

Marita G. Titler, PhD, RN, FAAN, is Director of Nursing Research, Quality and Outcomes, Department of Nursing and Patient Services, University of Iowa Hospitals and Clinics, Iowa City, IA, and Principal Investigator of this study.

Bernard A. Sorofman, PhD, is a Professor and Associate Dean for Academic Affairs, the College of Pharmacy, University of Iowa, Iowa City, IA, and an Investigator of this study.

Mary B. Schmitt, BSN, RN, is a Clinical Nurse, Surgical Intensive Care Unit, University of Iowa Hospitals and Clinics, Iowa City, IA, and a Research Assistant on this study.
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Author:Ardery, Gail; Herr, Keela A.; Titler, Marita G.; Sorofman, Bernard A.; Schmitt, Mary B.
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Feb 1, 2003
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