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Painful truths.

Treating chronic pain in residents can cure many industry ills

ONE OF THE MOST PERVASIVE AND COSTLY PROBLEMS IN long term care is also one of the most neglected. The vast majority of chronic pain remains untreated, overlooked, or mistakenly ascribed to dementia, depression, and normal aging. Surveyors and civil courts are scrutinizing chronic pain management, and providers should, too. Addressing chronic pain simultaneously treats other industry ills including staffing shortages, burnout, aggression, depression, costs, and poor quality of life.

Consequences of untreated pain include delayed healing and mobility, immune system depression, increased risk of falls, sleep disruptions, reduced appetite, behavioral outbursts, limited activity, decreased socialization, and unnecessary suffering.

Although pain is not a normal part of aging, an estimated 85 percent of people over 65 have at least one health problem that can cause pain; one fourth to half have significant pain.

"Surveys show that 50 to 80 percent of nursing home residents have pain, often chronic pain," says researcher June L. Dahl, PhD, professor of pharmacology at the University of Wisconsin Medical School, Madison. "Patients don't know they can get relief, staff members fall to assess all patients regularly and completely, both groups misunderstand the importance of managing pain, and facilities have many cost issues, particularly with expensive slow-release drugs. But pain itself is very expensive, and patients have the right to appropriate management."

Poor pain management (including failure to premedicate for pain and treatments, and inappropriate use of psychotropic drugs) has triggered survey citations for abuse, violation of patients' rights (per the self determination act), and substandard care. Consumers have followed suit, and several cases are now in court.

In 1999, the American Medical Directors Association released clinical practice guidelines on chronic pain management in the Long term Care setting. The 30-page, $8 guidelines cover assessment, treatment, monitoring, and action/decision flowcharts. (Call 800-876-2632 or visit [less than][greater than]). The American Geriatrics Society also offers chronic pain treatment guidelines for elders at [less than][greater than].

In 1999, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) revised its pain management standards for 2001 compliance scoring.

"Pain assessment and management have always been a standard for long term care, yet it's always been a high noncompliance area," says Susie McBeth, JCAHO's associate director of standards. "Facilities may have some things in place, but surveyors find many lack organization-wide consistency and documentation of pain policies, assessment, and interventions."

The revised standards (available at [less than][greater than]) address residents' right to appropriate pain assessment, management, and informed participation in decisions. Facilities must assess pain that interferes with optimal function and rehabilitation; teach residents and families about pain, risk factors, and the importance of pain management; and monitor appropriateness and effectiveness of pain management.

"How they do this is up to the individual facilities, but they may want to look at pain as the fifth vital sign," says McBeth.

That practice, and many other implementation examples, came from Brandywine Nursing Home, a 131-bed JCAHO-accredited SNF and subacute facility in Briarcliff Manor, N.Y. Vickie Logan, RN, describes life for a 50-year-old resident with chronic pain, lupus, Lyme disease, scoliosis, and an old car injury:

"It's horrible adjusting to a new place, particularly when depressed by pain so severe you can't sleep through the night, tolerate being up for more than a few hours a day, participate in activities, or provide any self-care. When pain is all encompassing, you're angry, miserable, and a different person. You isolate yourself. You're controlled by a disability that you can't see, hear, or touch, and it's screaming out in every cell of your body."

Logan is describing herself.

"It's a wonder I wasn't suicidal," she says. "What kept me from going crazy was knowing they were working on controlling the pain."

Brandywine, the only LTC facility recognized by JCAHO for best practices in pain management in 1999, was probably first in the country to implement a facility-wide pain control program. Thanks to a long-acting medication, Logan is finally pain free. "I have the same diseases, but I'm even rid of pain from old injuries," she says. "I'm amazed at my happiness. I can visit my brother, shop, go out to eat, or go out by myself in my wheelchair. I feel like a normal person. Life is not about pain anymore."

Every Brandywine admission, family, and new employee is educated about pain management and communication, with repeated updates at resident and family councils, patients' rights inservices, and ongoing training. "Otherwise, residents either think pain is part of normal aging, assume we know they have pain, don't want to 'bother' us, or think there's no help available," explains program originator Jill Loeb, RN, BSN, pain management specialist and QA coordinator. "It's lack of teaching, not caring, that makes pain under-reported. Housekeeping and maintenance can recognize and report it. Nursing can start strategies that are more than meds. We can't forget the importance of touch, time, and personal care."

Strategies range from caregiver-assisted guided imagery to hand massage, aromatherapy, and comfort foods including soup, chocolate, and wine.

Pain is assessed on admission, then quarterly and with every physical or behavioral status change, and screened every shift until well controlled. Pain management is assessed in every care plan and interdisciplinary care plan review, and reported at QA and morning management meetings. "Interventions more than pay for themselves," says Loeb.

Since chronic pain makes life miserable for patients and providers, why isn't more done elsewhere?

Patients and providers must understand there are multiple types of pain, all very real, although some are poorly understood, says neurologist Bradley Galer, MD, director of the Beth Israel Medical Center Pain Program and associate neurology professor, Albert Einstein College of Medicine (New York). "For example, damaging any part of the nervous system creates 'short circuits' that can send pain signals in the absence of injury," he explains.

Providers who don't understand or ask about pain don't seek adequate tests, treatments, or consultations with neurologists and knowledgeable specialists who can diagnose and provide appropriate relief measures.

"Elders, particularly the cognitively impaired, are at greatest risk for poor pain management," says pain researcher Patricia Starck, DSN, RN, professor and nursing dean, University of Texas Health Center, Houston. "Encourage self-reports of pain, relief, and satisfaction, which are definitive measures. Even dementia patients can communicate pain levels if you try scales such as visual analogs."

Contrary to expectations that elders complain frequently, researchers find they often under-report pain, either because they consider pain part of normal aging, fear testing or the diagnosis, think they must be stoic, or believe relief is impossible.

Elders respond as well or better than younger patients to pain management programs, says psychologist John Hodgson, Mayo Clinic Comprehensive Pain Rehabilitation Center, Rochester, Minn. Walking, stretching, and strengthening are critical because they provide distraction and socialization while reversing deconditioning. The Center teaches patients to schedule and moderate activities; promotes recreation; and provides trainers, scripts, and tapes for relaxation, breathing, and imagery.

Kaiser Permanente's Chronic Pain Management Program, San Diego, covers self-hypnosis, cognitive restructuring, yoga, tai chi, massage, dance, acupuncture, and herbs in sessions for patients and caregivers. "Premedication is often necessary to control moderate pain sufficiently for patients to learn alternative techniques well enough so they flow naturally when needed," says medical director Bill McCarberg, MD. "Residents are starved for attention and love something novel." Including caregivers allows nurses to be more than pill pushers and gives families ways to help.

Medications are often the most effective management and diagnostic tool, yet providers withhold them because they don't understand titration and confuse tolerance with addiction, says pain specialist Bev Moline, MS, RN, Poudre Valley Hospital, Fort Collins, Colo. "People in chronic pain tolerate and need

far larger doses of medication to get relief, yet the actual incidence of addiction for pain control is under 1 percent," she notes.

"You have an ethical duty to relieve pain," says consultant Elise NeeDell Babcock, author of, When Life Becomes Precious (Bantam, 1997). When physicians don't prescribe adequate medication, she advises staff to request consults diplomatically, find interdisciplinary team advocates, and chart requests.

"Being able to recognize pain and do something about it makes a big difference in how we see residents and ourselves," says Brandywine rehabilitation aide Jackie Rittie, CNA. "We can often distinguish pain from depression or dementia. One man hit frequently, but I realized it was pain, not aggression. I addressed the pain, and he's like a new person. If you premedicate patients before therapy, instead of walking 25 feet in pain, they'll walk 100 feet and recuperate faster."

Fort Collins, Colo.-based Wendy L. Bonifazi, RN, APR, is a contributing writer to Contemporary Long Term Care.
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Publication:Contemporary Long Term Care
Date:Aug 1, 2000
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