Pain and pharmacologic pain management in long-stay nursing home residents

Abstract

Prior studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set (MDS) 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after these important initiatives of: 1) prevalence and correlates of persistent pain; and 2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in United States NHs between 2011–2012 with 2 MDS assessments 90 days apart. Pain was categorized as persistent (pain on both assessments), intermittent (pain on either assessment), or none. Pharmacologic pain management was classified as untreated pain (no scheduled or as needed medications received) or potentially undertreated (no scheduled received). Modified Poisson models adjusting for resident clustering within NHs provided adjusted prevalence ratios estimates (APR) and 95% confidence intervals (CI). The prevalence of persistent and intermittent pain was 19.5% and 19.2% respectively but varied substantially by age, gender, race/ethnicity, cognitive impairment, and cancer. Of residents in persistent pain, 6.4% and 32.0% were untreated or undertreated. Racial/ethnic minorities (non-Hispanic blacks vs. whites, APR=1.19, 95% CI: 1.13–1.25) and severely cognitively impaired residents (severe vs. no/mild APR=1.51, 95% CI: 1.44–1.57) had an increased prevalence of untreated and undertreated pain. One in five NH residents has persistent pain. Although this estimate is greatly improved, many residents may be undertreated. The disturbing disparities in untreated and undertreated pain need to be addressed.

Long‐acting opioid initiation in US nursing homes

“…When examining resident correlates of newly initiating long‐acting opioids, our results are largely consistent with a prior study despite different treatment contrasts . Our prior work on the pharmacological management of nonmalignant pain suggests that non‐White residents are less likely to receive scheduled analgesics and be prescribed opioids long‐term in comparison with White residents . We are uncertain if similar mechanisms are driving the differences observed in this study because initiating long‐acting opioids is contraindicated, whereas scheduled analgesics and long‐term opioid use may be necessary for residents experiencing moderate to severe chronic pain…”

“…Resident characteristics were derived from the most recent MDS 3.0 assessment prior to opioid initiation and included age (50‐64, 65‐74, 75‐84, 85‐94, and ≥95 years), gender, race/ethnicity (non‐Hispanic White, non‐Hispanic Black, Hispanic/Latino, Asian, and other), cognitive impairment, physical limitations, and pain. We exclusively focused on these characteristics because they have been strongly associated with pain and analgesic prescribing in prior studies . Cognitive impairment was defined by using Centers for Medicare and Medicaid Services (CMS) definitions based on the Brief Interview for Mental Status (BIMS; range 0‐15) when the resident was able to self‐report and the Cognitive Performance Scale (CPS; range 0‐6) otherwise as none/mild (CPS: 0‐2, BIMS: 13‐15), moderate (CPS: 3‐4, BIMS: 8‐12), and severe impairment (CPS: 5‐6; BIMS: 0‐7) .…”

Prevalence of Long‐Term Opioid Use in Long‐Stay Nursing Home Residents

“…Cognitive impairment was classified using CMS definitions . We also evaluated persistent (pain lasting ≥3 months), and intermittent pain . We considered resident characteristics that might be potential confounders, including length of NH stay (<1, 1–2, 2–3, ≥3 years), marital status (married vs other), comorbidities known to cause pain (e.g., arthritis, fractures), and total comorbidity burden (based on MDS 3.0 Section I; categorized into quartiles).…”

“…Adjusted analyses included state of NH residence and all resident characteristics. We conducted analyses restricted to residents in persistent pain to provide further information on this vulnerable subgroup and to compare our results with those of prior studies …”

Pain Management in Nursing Home Residents: Findings from a Pilot Effectiveness‐Implementation Study

“…Pain is a prevalent symptom in nursing home (NH) residents. Affecting 40% to 85% of residents internationally and roughly 60% in Switzerland, it has a serious impact on quality of life . Among other outcomes, under‐ or untreated pain interacts with depressive symptoms and limits functional capabilities, leading to increased care demands …”