Pain in Long Term Care: It Takes a Team

1. Pain in Long Term Care:It Takes a Team Debra K. Weiner, M.D. Department of Medicine, Anesthesiology & Psychiatry University of Pittsburgh Geriatric Research Education & Clinical Center VA Pittsburgh Healthcare System January 24, 2013

2. DISCLOSURE No conflict of interest

3. Learning Objectives Understand the drivers of pain behaviors in long term care (LTC) residents. Formulate an interdisciplinary approach to identifying, treating and tracking the LTC resident’s unique pain signature.

4. Principles of Pain in LTC • Principle #1: Most pain that nursing home residents experience is chronic. • Chronic pain: • Lasts beyond the expected time of healing • > 3-6 months • Corollary: Since chronic pain cannot be eradicated, residents will continue to report/manifest pain even after it is treated well.

5. 10 clinical trials, 2724 subjects • DPN, PHN, CLBP, FM, OA • “much improved” or “very much improved” correlated with 30% or 2 point decrease

6. Who are we evaluating/treating? Intact Impaired non-reporters Impaired reporters

7. Principles of Pain in LTC Principle #2: If a LTC resident can speak, (s)he can usually report pain reliably.

8. THE PAIN IS ALMOST UNBEARABLE VERY BAD PAIN QUITE BAD PAIN MODERATE PAIN LITTLE PAIN NO PAIN Pain Thermometer(verbal descriptor scale) Weiner 1998; Aging Clin Exp Res 10: 411-20

9. N = 60 LTC residents • MMSE = 21 (6-30) • Test-retest: 1 hour • Kappa: 0.6-0.9 Weiner 1998; Pain 76: 249-57

10. Pain Behaviors • Pain reporting • Body posturing or facial expressions that imply a patient is experiencing pain • Interactive behaviors • Social behaviors • Cooperation with staff

11. Pain Behaviors: Those Unable to Report Pain • Body posturing or facial expressions that imply a patient is experiencing pain • Interactive behaviors • Social behaviors • Cooperation with staff

12. PAINAD (Pain Assessment in Advanced Dementia) 0-10 scale Summary score based on 5 items, 0-2 each Warden 2003; J Am Med Dir Assoc 4: 9–15 • Breathing independent of vocalization • Negative vocalization • Facial expression • Body language • Consolability

13. PACSLAC(Pain Assessment Checklist for Seniors with Limited Ability to Communicate) Fuchs-Lacelle 2004; Pain Manage Nurs 5: 37-49 • 60 items • 4 categories • Facial Expression • Activity/Body Movement • Social/Personality/Mood • Other (Physiological Changes/Eating & Sleeping Changes/Vocal Behavior)

14. Principles of Pain in LTC Principle #3: Behavioral indicators of “pain” may or may not indicate that a patient is experiencing pain.

15. Shega et al 2008; J Am Geriatr Soc 56: 1631-7

16. Weiner et al 1996; Pain 67: 461

19. Principles of Pain in LTC Principle #4: The presence of pain should not be interpreted as the presence of suffering. Corollary: Treat pain if it is causing suffering (i.e., impairing function or quality of life).

20. Case ID/CC: 80 year old LTC resident who “reports pain.” HPI: Patient without complaints No pain behaviors Call placed to LTC staff: “Patient does not talk about pain or appear to suffer from pain…..Just reports when we ask.”

21. “Why was the consult placed?” “Resident continues to report pain.” “Is either he or the staff disturbed by this reporting?” “No.” “Would the staff be comfortable with not treating the resident as long as they know he is not suffering?” “Yes.”

22. Rx: Staff reassurance

23. Principles of Pain in LTC Principle #5: People with dementia process pain differently than those who are cognitively intact.

24. cognitive processes descending modulatory influences +/- NE , 5-HT, glut, NMDA, GABA motivational-affective sensory-discriminative (nociceptive channel) PCPR Pittsburgh Center for Pain Research What is Pain? skin muscle joints spinal cord viscera Slide used with permission from Gerald F. Gebhart, PhD, Director, PCPR

25. Pain-related brain activity: AD vs. controls Cole et al 2006; Brain 129, 2957

26. Facial Expression versus Verbal Rating of Pain Kunz 2007; Pain 133: 221-228 Experimental pain (mechanical) N = 96 (42 demented; 54 intact) Verbal rating: none, mild, moderate, strong, very strong, extremely strong Facial expression: video, rated with Facial Action Coding System

27. Kunz et al, Pain 2007; 133: 221-228

28. Kunz et al, Pain 2007; 133: 221-228

29. AD & Facial response to acute pain General anxiety Fear of needle sticks Pre-venipuncture anxiety Porter et al 1996; Pain 68, 413

30. IMPLICATIONS • Standard behavioral manifestations of pain may overestimate pain severity in those with dementia

31. PAIN BEHAVIORS e.g. verbal pain reports grimacing crying for help General signals of distress ? Pain perseveration Pain-related suffering

32. Case ID/CC: 82 y.o., LBP/R leg pain X 2 yrs., SS on MRI HPI: Forced to retire 2 years ago. Pain is worse with standing, walking, OK at night, better with heat, no constitutional symptoms. Increasing trouble with heavy housework, afraid to go on bus by self. Reports passive suicidal ideations. Frequent near falls at home.

33. PE: • Poor balance • Impaired clock-drawing test • Kyphoscoliosis, SI/ paraspinal/ TFL pain • Leg strength impaired from pain.

34. Medications • Gabapentin • Oxycodone CR • Celecoxib • Tramadol • Olanzapine • Escitalopram • Lorazepam

35. What We Prescribed Short NH stay for detox. and balance/gait retraining. D/C’ed on tramadol + acetaminophen. Did very well while in NH. Recommendation to family: Assisted Living placement, but family refused and continued to focus on pain

36. Following Discharge… Immediate deterioration at home with frequent calls Escalation of need for analgesics. Her condition continued to deteriorate (eventual morphine pump trial), until she was admitted to an assisted living facility, where she did well.

37. Case ID/CC: 85 y.o. veteran whose PCP notes, “Patient continues to report pain.” HPI:Obtained from wife of 60 years, as patient unable to provide history because of advanced dementia. Low back pain present for many years; as patient always acknowleged pain when asked by health care providers, analgesic trial ended with fentanyl.

38. Because of no change in clinical status, dose was escalated to 100 mcg/hr and patient became comatose and was hospitalized. In hospital, dose was weaned back to 50 mcg/hr and patient woke up and when asked about pain, he reported it. Presented to Pain Clinic. When wife asked whether patient was suffering from or reporting pain: “He’s just talking about it.”

39. PE: NAD, sitting in wheelchair with wife and daughter at side; pleasant, smiling. When asked if anything bothering him, he smiled widely: “No.” Rx: 1. Taper fentanyl to off; 2. Day care for distraction and caregiver respite.

40. Principles of Pain in LTC Principle #6: Chronic pain is a multifactorial syndrome requiring multi-pronged management that is designed to optimize function and quality of life.

41. The Pain Signature(cognitively intact)

42. Follow-Up

43. How to Evaluate Pain in LTC?

44. Tips on Behavioral Observation Multiple observers Multiple disciplines Multiple times of the day (i.e., all 3 shifts) BE CREATIVE. BE FACILITY-FOCUSED. UTILIZE THE INTERDISCIPLINARY TEAM.

45. Principles of Pain in LTC Principle #7: Treatment of pain in LTC residents should utilize a multidisciplinary stepped-care approach.

46. Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach STEP 5: SYSTEMIC ORAL ANALGESICS STEP 4: LOCAL & MORE INVASIVE RX. ADJUNCTIVE NON-PHARMACOLOGIC MODALITIES STEP 3: LOCAL & MINIMALLY INVASIVE RX. STEP 2: TOPICAL PREPARATIONS STEP 1: NON-PHARMACOLOGIC MODALITIES

47. Prescription of Analgesia in the Nursing Home: A Stepped-Care Approach Should treatment focus on pain or dementia-related behaviors or fear or……? ADJUNCTIVE NON-PHARMACOLOGIC MODALITIES

48. DISTRACTION Falsely escalate pain severity & impact Undermine dementia Pain perseveration

49. Activity Avoidance Pain FEAR Reassurance Support Desensitization PATIENCE

50. Step 1: Non-Pharmacological Modalities Distraction (i.e., CBT) Positive communication Alleviation of fear Gentle touch Massage Assistive devices