Proper pain management is important for all, but especially for older adults with cognitive impairment. This population is vulnerable to unrelieved pain due to a decreased ability to articulate pain and because some healthcare providers have erroneous beliefs regarding pain (Kaasalainen et al., 2007). Lack of proper pain management can cause depression, anxiety, poor sleep, poor appetite, inability to carry out daily functions, social withdrawal, and worsening cognition (American Geriatrics Society [AGS], 2012). Unfortunately, between 25% and 50% of all older adults living at home and up to 85% of older adults living in nursing homes report serious pain (AGS).
Healthcare providers may hold certain beliefs that prevent adequate pain management such as: pain is a normal part of aging, aging causes reduced pain sensitivity, patients with dementia do not feel pain, and potential side effects of opioids in older adults make them too dangerous to use (Kaasalainen et al., 2007). Additionally, patients with cognitive impairment typically have fewer scheduled medications prescribed for pain and receive less pain medications than those without cognitive impairment (Kaasalainen et al.).
Pain in those with cognitive impairment typically involves disruptive behaviors rather than verbalization of pain (Ahn & Horgas, 2013). This occurs because, as the patient loses the ability to process information, they are not able to appropriately verbalize pain, so it manifests in other ways (Ahn & Horgas). Home care providers should assess for pain in cognitively impaired older adults by looking for disruptive behaviors such as aggression and agitation (Ahn & Horgas). Other behaviors that may indicate pain include restlessness, irritability, resistance, or guarding behaviors; vocalizations such as crying, moaning or groaning; limping, shifting positions; grimacing or other facial expressions; depression; less willingness to engage socially; refusing to eat; and disturbed sleep (AGS, 2012).
If a patient has mild or moderate cognitive impairment, first simply ask the patient if they are in pain and to rate their pain on the numeric rating scale, verbal descriptor scale, or pain thermometer (Geriatric Pain, 2015b). For more advanced dementia, the Pain Assessment in Advanced Dementia scale can be helpful in directly observing behaviors on a regular basis (the home healthcare clinician may need the help of a caregiver to accurately complete this assessment). These tools may be found online. Pain assessment upon movement (such as during a patient's activities of daily living) is a better indicator of persistent pain rather than observation of the patient at rest (Geriatric Pain, 2015b).
Effective treatments for pain management include medications and nonpharmacologic therapies. In addition to the analgesic medications (acetaminophen or nonsteroidal anti-inflammatory drugs such as ibuprofen or aspirin; as well as opioids for moderate-to-severe pain), there are adjuvant medications (topical lidocaine, antidepressants, anticonvulsants for nerve pain, and corticosteroids injected into joints, tendons, and muscles) (AGS, 2012). Nonpharmacologic therapies may include diversion (music, storytelling, television, pet therapy); hot or cold skin applications; relaxation techniques (meditation, deep breathing, yoga, massage); or exercise and physical therapy (AGS). Nonpharmacologic therapies should be used in addition to analgesics for those with moderate-to-severe pain. Monitoring for effectiveness of pain relief measures and side effects of medications is a critical part of the home healthcare provider's assessment. You will need to work with the primary care provider to develop a plan for proper pain management based on the patient's response and changing care needs.
Patients who exhibit disruptive behaviors may benefit from an analgesic trial to help determine if pain is the cause of their behaviors. If the use of analgesic medications reduces the indicated behavior, then the clinician should continue to treat the behaviors as if they are pain related (Geriatric Pain, 2015b). An analgesic trial and titration should use the following guidelines (Geriatric Pain, 2015a):
* For mild-to-moderate pain, a nonopioid may initially be given.
* If behaviors improve, assume the behavior was caused by pain and add appropriate nonpharmacologic interventions in addition to the analgesic.
* If behaviors continue, consider a single low-dose, short-acting opioid (hydrocodone, oxycodone, or morphine), and observe for effect.
* If no change in behavior occurs in 24 hours, titrate the dose up by 25% to 50% and observe effect.
* Continue to titrate opioid dose upward until a therapeutic effect is seen, bothersome side effects occur, or no benefit is determined.
* Explore other potential causes if behaviors continue after a reasonable analgesic trial (Geriatric Pain, 2015a).
Home healthcare clinicians should utilize nonpharmacologic and nonopioid pharmacologic treatments as a first line, with opioid use occurring only where these methods have not sufficiently controlled the patient's pain. When opioids are prescribed, other nonpharmacologic interventions should be used to assist with minimizing the opioid dosage (Lowes & Vega, 2016). Home healthcare clinicians need to discuss the goals of treatment and the balance of benefits and harm with patients and primary providers prior to the initiation of opioid use (Lowes & Vega). A few points regarding opioid use from the CDC (Lowes & Vega):
* Long-term pain is generally not well controlled with opioid use.
* Inform patients of the risk of respiratory depression, dependence, and the risk of adverse effects, such as constipation.
* Opioid therapy should begin with the smallest dose of opioid possible for effective therapy. Doses over 90 MME (morphine milligram equivalents) should be avoided without strong consideration to potential adverse effects.
* Patients who receive opioids for chronic pain should be evaluated every 1 to 4 weeks to reassess pain and function.
* When tapering opioids in long-term users, a decrease in 10% of the original dose of opioids per week is generally appropriate, but may need to change per patient.
* Avoid use of benzodiazepines and opioid concomitantly.
* Treatment of acute pain with opioids should be limited to less than 7 days (usually a 3-day course of opioids is sufficient).
Many older adults are in pain, and unnecessarily so. The home healthcare clinician has the responsibility to assess and manage pain appropriately for their patient, especially for those with cognitive impairment. Treatment should start with nonpharmacologic and nonopioid pharmacology, with opioids added with caution only as necessary. Even with opioid use, nonpharmaceutical therapies and nonopioid therapies should accompany opioid use.
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