BACKGROUND

A.  Definitions

1. Pain: Pain is defined as “an unpleasant sensory and emotional experience” (Merskey, 1994, pS74) and also as “whatever the experiencing person says it is, existing whenever he says it does” (McCaffery, 1968, p. 95). These definitions highlight the multidimensional and highly subjective nature of pain. Pain is usually characterized according to the duration of pain (e.g., acute vs. persistent) and the cause of pain (e.g., nociceptive vs. neuropathic). These definitions have implications for pain management strategies.
2. Acute pain: Defines pain that results from injury, surgery, or trauma. It may be associated with autonomic activity such as tachycardia and diaphoresis. Acute pain is usually time limited and subsides with healing.
3. Persistent pain: Defines pain that lasts for a prolonged period (usually more than 3–6 months) and is associated with chronic disease or injury (e.g., osteoarthritis; AGS, 2009). Persistent pain is not always time dependent, however, and can be characterized as pain that lasts longer than the anticipated healing time. Autonomic activity is usually absent, but persistent pain is often associated with functional loss, mood disruptions, behavior changes, and reduced quality of life.
4. Nociceptive pain: This refers to pain caused by stimulation of specific peripheral or visceral pain receptors. This type of pain results from disease processes (e.g., osteoarthritis), soft-tissue injuries (e.g., falls), and medical treatment (e.g., surgery, venipuncture, and other procedures). It is usually localized and responsive to treatment.
5. Neuropathic pain: Refers to pain caused by damage to the peripheral nervous system or CNS. This type of pain is associated with diabetic neuropathies, postherpetic and trigeminal neuralgias, stroke, and chemotherapy treatment for cancer. It is usually more diffuse and less responsive to analgesic medications.

B.  Epidemiology

1. Approximately 50% of community-dwelling older adults and 85% of nursing home residents experience persistent pain.
2. The Centers for Disease Control and Prevention estimated that over 60% of older adults in the United States experience chronic pain (Dahlhamer et al., 2018).
3. More than 19 million surgeries were performed on older adults in 2010, including 5.2 million musculoskeletal surgeries (including knee and hip replacements; Federal Interagency, 2016). Thus, older adults are at risk for pain associated with chronic diseases as well as postsurgical and procedural pain.

C.  Etiology

1. Older adults have chronic medical conditions that are typically associated with persistent or chronic pain, such as osteoarthritis and peripheral vascular disease.
2. Older adults often have multiple medical conditions, both chronic and/or acute, and may suffer from multiple types and sources of pain.

D.  Significance

1. Untreated or ineffectively treated moderate to severe persistent pain has major implications for older adults’ health, functioning, and quality of life (Horgas, 2017a).
   • Pain is associated with depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased healthcare use (AGS, 2009).
   • Other geriatric conditions that can be exacerbated by pain include falls, cognitive decline, deconditioning, malnutrition, gate disturbances, and slowed rehabilitation (AGS, 2009).
   • Unrelieved pain reduces quality of life for older adults and contributes to increased healthcare resource utilization and costs (IOM, 2011; Morrissey et al., 2014). The IOM (2011) declared chronic pain a public health problem in the United States.
2. Nurses play a key role in pain management. The promotion of comfort and relief of pain is fundamental to nursing practice. Nurses need to be knowledgeable about pain in late life in order to provide optimal care, to educate patients and families, and to work effectively in interdisciplinary healthcare teams.

ASSESSMENT PARAMETERS

A.  Assumptions

1. Most hospitalized older patients suffer from both acute and persistent pain.
2. Older adults with cognitive impairment experience pain but are often unable to verbalize it.
3. Both patients and healthcare providers have personal beliefs, prior experiences, insufficient knowledge, and mistaken beliefs about pain and pain management that (a) influence the pain management process and (b) must be acknowledged before optimal pain relief can be achieved.
4. Pain assessment must be regular, systematic, and documented in order to accurately evaluate treatment effectiveness.
5. Self-report is the gold standard for pain assessment.
6. Effective pain management requires an individualized approach.

B.  Strategies for pain assessment

1. Initial, quick pain assessment (Herr, Bjoro, et al., 2006)
   • Assess older adults who present with acute pain of moderate to severe intensity or who appear to be in distress.
   • Assess pain location, intensity, duration, quality, and onset.
   • Assess vital signs. If changes in vital signs are absent, do not assume that pain is absent (Herr, Coyne, et al., 2006).
2. Comprehensive pain assessment (AGS, 2009; Herr, Coyne, et al., 2006; Pasero & McCaffery, 2011)
   • Review medical history, physical examination, and laboratory and diagnostic tests in order to understand sequence of events contributing to pain.
   • Assess cognitive status (e.g., dementia, delirium), mental state (e.g., anxiety, agitation, depression), and functional status. If there is evidence of cognitive impairment, do not assume that the patient cannot provide a self-report of pain. Be prepared to augment self-report with observational measures and proxy report using the hierarchical approach.
   • Assess present pain, including intensity, character, frequency, pattern, location, duration, and precipitating and relieving factors.
   • Assess pain history, including prior injuries, illnesses, and surgeries; pain experiences; and pain interference with daily activities.
   • Review medications, including current and previously used prescription drugs, OTC drugs, and complementary therapies (including home remedies). Determine what pain control methods have previously been effective for the patient. Assess patient’s attitudes and beliefs about pain and the use of analgesics, adjuvant drugs, and nonpharmacological treatments. Assess history of medication or alcohol abuse.
   • Assess self-reported pain using a standardized measurement tool. Choose from published measurement tools, and recall that older adults may have difficulty using 10-point NRSs. Vertical verbal descriptor scales or faces scales may be more useful with older adults. Use the same tool consistently.
   • Assess pain regularly and frequently, at least every 4 hours. Monitor pain intensity after giving medications to evaluate effectiveness.
   • Observe for nonverbal and behavioral signs of pain, such as facial grimacing, withdrawal, guarding, rubbing, limping, shifting of position, aggression, agitation, depression, vocalizations, and crying. Also watch for changes in behavior from the patient’s usual patterns.
   • Gather information from family members about the patient’s pain experiences. Ask about the patient’s verbal and nonverbal/behavioral expressions of pain, particularly in older adults with dementia.
   • When pain is suspected but assessment instruments or observation is ambiguous, institute a clinical trial of pain treatment (i.e., in persons with dementia). If symptoms persist, assume that pain is unrelieved and treat accordingly.

NURSING CARE STRATEGIES

A.  General approach

1. Pain management requires an individualized approach.
2. Older adults with pain require comprehensive, individualized plans that incorporate personal goals, specify treatments, and address strategies to minimize the pain and its consequences on functioning, sleep, mood, and behavior.

B.  Pain prevention

1. Develop a written pain treatment plan on admission to the hospital or before surgery or treatments. Help the patient to set realistic pain treatment goals, and document the goals and plan.
2. Assess pain regularly and frequently to facilitate appropriate treatment.
3. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer analgesics 30 minutes before activities.
4. Educate patients, families, and other clinicians to use analgesic medications prophylactically before and after painful procedures.
5. Educate patients and families about pain medications; their side effects; adverse effects; and issues of addiction, dependence, and tolerance.
6. Educate patients to take medications for pain on a regular basis and to avoid allowing pain to escalate.
7. Educate patients, families, and other clinicians to use nonpharmacological strategies to manage pain, such as relaxation, massage, and the use of heat and cold.

C.  Treatment guidelines

1. Pharmacological (Horgas, 2017a; Pasero & McCaffery, 2011)
   • Administer pain drugs on a regular basis to maintain therapeutic levels. Use medications as needed for breakthrough pain.
   • Document treatment plan to maintain consistency across shifts and with other care providers.
   • For postoperative pain, choose the least invasive route. Intravenous analgesics are the first choice after major surgery. Avoid intramuscular injections. Transition from parenteral medications to oral analgesics when the patient has oral intake.
   • Choose the correct type of analgesic. Use opioids for treating moderate to severe pain and nonopioids for mild to moderate pain. Select the analgesic based on thorough medical history, comorbidities, other medications, and history of drug reactions.
   • Among nonopioid medications, acetaminophen is the preferred drug for treating mild to moderate pain. Guidelines recommend not exceeding 3 g/d (maximum 2 g/d in frail elders). The maximum dose should be reduced to 50% to 75% in adults with reduced hepatic function or history of alcohol abuse. Monitor for excess acetaminophen intake from combination drugs (e.g., opioid + nonopioid) or OTC medications that include acetaminophen. Educate patients and families about this risk and drugs to avoid.
   • The other major class of nonopioid medications, NSAIDs, should be used with caution in older adults. Monitor for GI bleeding and consider giving with a proton-pump inhibitor to reduce gastric irritation. Also monitor for bleeding, nephrotoxicity, and delirium.
   • Older adults are at increased risk for adverse drug reactions because of age and disease-related changes in pharmacokinetics and pharmacodynamics. Monitor medication effects closely to avoid overmedication or undermedication and to detect adverse effects. Assess hepatic and renal functioning.
2. Nonpharmacological (Horgas, 2017b; Pasero & McCaffery, 2011)
   • Investigate older patients’ attitudes and beliefs about, preference for, and experience with nonpharmacological pain treatment strategies.
   • Tailor nonpharmacological techniques to the individual.
   • Cognitive behavioral strategies focus on changing the person’s perception of pain (e.g., relaxation therapy, education, distraction) and may not be appropriate for cognitively impaired persons.
   • Physical pain relief strategies focus on promoting comfort and altering physiological responses to pain (e.g., heat, cold, TENS units) and are generally safe and effective.

D.  Follow-up assessment

1. Monitor treatment effects within 1 hour of administration, and at least every 4 hours.
2. Evaluate patient for pain relief and side effects of treatment.
3. Document patient’s response to treatment effects.
4. Document treatment regimen in patient care plan to facilitate consistent implementation.

EXPECTED OUTCOMES

A.  Patient will

1. Be either pain free or pain will be at a level that the patient judges as acceptable.
2. Maintain highest level of self-care, functional ability, and activity level possible.
3. Experience no iatrogenic complications, such as falls, GI upset/bleeding, or altered cognitive status.

B.  Nurse will

1. Demonstrate evidence of ongoing and comprehensive pain assessment.
2. Document evidence of prompt and effective pain management interventions.
3. Document systematic evaluation of treatment effectiveness.
4. Demonstrate knowledge of pain management in older patients, including assessment strategies, pain medications, nonpharmacological interventions, and patient/family education.

C.  Institution/Facilities will (Dirks, 2010; Gordon et al., 2005)

1. Maintain strong institutional commitment and leadership to improve pain management. Evidence of institutional commitment includes:
   • Providing adequate resources (including compensation for staff education and time; necessary materials)
   • Clear communication of how better pain management is congruent with organizational goals
   • Establishment of policies and standard operating procedures for the organization
   • Requiring clear accountability for outcomes
2. Establish an internal pain team of committed and knowledgeable staff who can lead quality-improvement efforts to improve pain management practices.
3. Require evidence of documentation of pain assessment, intervention, and evaluation of treatment effectiveness. This includes adding pain assessment and reassessment questions to flow sheets and electronic forms.
4. Provide evidence of using a multispecialty approach to pain management. This includes referral to specialists for specific therapies (e.g., psychiatry, psychology, physical therapy, interdisciplinary pain treatment specialists; clinical pathways and decision support tools will be developed to improve referrals and multispecialty consultation).
5. Provide evidence of pain management resources for staff (e.g., educational opportunities, print materials, access to Web-based guidelines and information).

ABBREVIATIONS

AGS            American Geriatrics Society

CDC            Centers for Disease Control and Prevention

CNS            Central nervous system

IOM            Institute of Medicine

NSAID        Nonsteroidal anti-inflammatory drug

OTC            Over the counter

---

Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 22: Horgas, A., Laframboise-Otto, J., Aul, K., & Yoon, S. (2021) Pain Management in the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 353-373).  New York: Springer.