Pain treatment and functional improvement in home health care: Relationship with dementia

Abstract

Background Pain management is important to post‐acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD. Methods We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60‐day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non‐opioid analgesic, and opioid. ADRD was identified from ICD‐10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode. Results ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non‐opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = −0.43, 95% CI: −0.73, −0.13, p = 0.004) and non‐opioid analgesic use (β = −0.31, 95% CI: −0.56, −0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status. Conclusions HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

A Description of Persons With Alzheimer Disease and Related Dementias Receiving Home Health Care

“…These symptoms raise questions about clinical management of ADRD and/or cognitive impairment in the HHC setting. Indeed, previous work 20,36 has suggested that pain is inadequately managed for HHC patients with ADRD; without access to data from OASIS care plans, we are unable to shed light on care processes associated with these symptoms.…”

Antipsychotic use among older patients with dementia receiving home health care services: Prevalence, predictors, and outcomes

“…Serving over 3.3 million Medicare beneficiaries every year, 34,35 HHC is a leading provider of home-based care for older adults, 36 including home medication review and reconciliation, 19,37 making them an invaluable source for identifying antipsychotic use. Moreover, HHC clinicians should play a bigger role in deprescribing antipsychotics as they can help meet the underlying needs that cause BPSD, 14 such as by assessing and managing pain, 38,39 monitoring symptom changes in medical conditions, 40 removing stressors in the home (e.g., noise, temperature, light), and educating the patients and caregivers, as well as providing social contact. For patients living with ADRD who experience BPSD, better access to behavioral interventions should be provided that includes insurance coverage, prescriber awareness, and patient and caregiver access to dementia care and support resources.…”

Pain Management in Cognitively Impaired Older Adults

“…According to Beers criteria, those with chronic kidney and liver failure should avoid non-steroidal anti-inflammatory drugs (NSAIDs), [28] narrowing the options for pharmacological pain medication in this population. Some alternative pain medications include acetaminophen, lidocaine patches, and selective norepinephrine reuptake inhibitors (SNRIs) [28] Non-opioids should be considered first-line therapeutics, and include aspirin and acetaminophen, gabapentin, and SNRIs [12] Gabapentin/ pregabalin, lamotrigine, or SNRIs should be used in neuropathic pain instead of tricyclic antidepressants (TCAs) due to their cardiovascular contraindications [29].…”

“…Nurses play the most important roles in pain identification, assessment and management in CIOAs as they are at the patient's bedside providing direct care, often spending the most time with the patient, building rapport, and gaining invaluable information regarding the patient's condition and behaviors. However, recent survey studies reported nurses caring for CIOAs having fears, lack of confidence and experience, and limited knowledge of dementia care [7,8] These factors have been linked to the delay of pain identification and assessment, underuse of pro re nata (PRN) pain medication, and suboptimal treatment compared to their cognitively intact counterparts [4,7,9,[10][11][12].…”