Epidemiology Of Pain In The Nursing Home

Pain is a frequent complaint of older patients and a common problem in the nursing home. Most cross-sectional studies have demonstrated that the overall prevalence of pain rises with advancing age, although this increase does not appear to continue beyond the seventh decade (9). Why is there greater prevalence of pain in older patients? Researchers have investigated whether there may be changes in pain perception and altered pain reporting in older patients, and the data are inconclusive (10). "Pathological load" is probably the primary factor behind the increase in pain complaints with advancing age (9).

Although the prevalence of pain in community-dwelling older patients is about 25-50%, the documented prevalence of pain in nursing homes is as high as 45-80% (4,5,9,11-15). The prevalence variability across studies is multifactorial and cannot be explained entirely by data review. Potential influences include number of subjects in each group, assessment tools, questions asked, and patients' cognitive status (9). Nursing home patients tend to have multiple medical problems and medications. A study of 217 subjects from 10 nursing facilities found an average of eight active medical problems and nine medications per patient (7).

Knowledge of the type and source of pain is necessary for effective pain assessment and management. In a study of 97 subjects from a large long-term care facility, 71% of the patients had at least one pain complaint, with 34% in continuous pain and 66% experiencing intermittent pain (5). Of those with intermittent pain, 51% reported daily symptoms. Table 1 lists the most common sources of pain, which are musculoskel-etal, including lower back pain, arthritis, and previous fracture sites; followed by neuropathic pain syndromes and malignancies (5,7). Other less common but significant causes of persistent pain are claudication, headache, and leg cramps (4).

Pain affects quality of life. In one study, pain in nursing home residents was associated with impaired ambulation and reduced ability to enjoy recreational activities (5). Other research showed a strong correlation, even after controlling for functional status and physical health, between pain and depression in nursing home residents (6). Clearly, pain has an impact on the physical and psychological functioning of nursing home patients.

Table 1

Sources of Pain

Source

Frequency (N = 65)

Low back pain

26 (40%)

Previous fractures

9 (14%)

Neuropathies

7 (11%)

Leg cramps

6 (9%)

Knee, arthritic

6 (9%)

Claudication

5 (8%)

Shoulder, arthritic

5 (8%)

Foot

5 (8%)

Hip, arthritic

4 (6%)

Neck

4 (6%)

Headache

4 (6%)

Generalized pain

3 (5%)

Neoplasm

2 (3%)

Angina

2 (3%)

Eye

1 (2%)

Source: From ref. 5, with permission. Note: Numbers total more than 100% because some subjects had more than one source of pain.

Source: From ref. 5, with permission. Note: Numbers total more than 100% because some subjects had more than one source of pain.

Knowledge of the epidemiology of pain may be influenced by how pain has been measured. Typically, pain is assessed by either patient self-report or nursing assessment. Several studies used the Minimum Data Set (MDS), which collects multiple data points, including those on patients' pain as recorded by the nursing home staff. These studies showed a lower prevalence of pain among nursing home patients, range from 24 to 41% (14,16).

It has been generally felt and recently documented that MDS documentation underestimates the frequency and intensity of pain when compared with patients' reports (14,17). Nursing aides, who typically work closely with a group of patients, appear to be more accurate at assessing pain intensity than licensed practical nurses (17). Physicians have also underestimated nursing home resident pain (12). In a study by Sengstaken and King, 66% of communicative patients were described as having chronic pain; treating physicians did not detect this problem in one-third of these residents (12).

Epidemiological data suggest that pain management strategies in the nursing home are often limited in scope and only partially successful in controlling pain (7). In a large, cross-sectional study of nursing home patients with cancer, more than one-quarter of patients in daily pain did not receive any analgesia (16). This same study found that age older than 85 years, minority race, cognitive impairment, and number of other medications received were independent predictors of failure to receive analgesia (16). Other research showed that many patients receiving pain medication still complain of pain and suggested that the effectiveness of pain management must be assessed frequently (12).

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