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Ltlsp2002

Published by
the

Missouri
Association
of

Long-Term
Multifacility Medical Director, St. Louis MO Care
Physicians
and the

Pain is common at the end
mood disturbances can increase and
Department
of life, due to the prevalence of
compound untreated pain. Dimin-
of Family &
arthritis, circulatory disorders,
ished ambulatory status from pain
Community
immobility, cancer, neuropathy, and
can result in decreased socialization
Medicine
similar age-related processes.
and increased healthcare utilization.
Functional impairment and de-
Many Facility Quality Indicators
University of
creased quality of life may occur in
are affected by chronic pain:
Missouri-
45 to 80% of patients.1 Unfortu-
Columbia
nately, many elders, families and
s Prevalence of behavioral symp-
staff accept pain as an inevitable
toms affecting others
of Medicine
part of age and disease, and do not
s Prevalence of symptoms of
accurately report it. Some residents
depression
may not report pain for fear of
s Prevalence of bladder or bowel
being labeled as complainers. Fear
incontinence
of addiction and accelerated decline
s Prevalence of weight loss
may hinder acceptance of pain
Minimum Staffing
s Prevalence of bedfast residents
Levels Update
medication. Some may see com-
s Decline in late loss ADLs
plaints of pain as attention seeking
s Prevalence of antipsychotic use in
and manipulation. Others mistak-
·Tougher Surveys
the absence of psychotic related
enly believe geriatric residents don’t
conditions
sense pain as well as younger
s Prevalence of anti-anxiety/
·Pain Assessment &
persons. Mood disorders and
hypnotic use
Basic Management
dementia may cause pain to present
s Relevance of hypnotic use more
in non-classic manners, making
than twice in the last week
symptom reporting and assessment
s Prevalence of daily restraint use
difficult. Staff turnover and lack of
s Prevalence of little or no activity
training may hinder recognition
s Prevalence of skin ulcers
and appropriate treatment of pain.
Some staff feel they don’t have the

Pain can be addressed only
time to manage pain well.
through a stepwise multidisciplinary
approach. Assessment, intervention,
Untreated pain can lead to
and reevaluation are all needed to
many unintended consequences.
manage pain for the individual
Depression, agitation, and other
resident.
General Assessment
of pain in elderly residents.
Pain can be quanti-
Pain may need to be indirectly
fied by several measures.
observed by behaviors (de-
RNs and LPNs, in addition
scriptive indicators) such as:2
to MDs, should ask resi-
dents to describe their pain,

Furrowed brow
Eyes shut tight
keeping these descriptors in
Grimacing
Yelling out
Weight loss
Intensity. A standardized pain
Published quarterly by the
scale should be used to ensure
Teeth clenching
Eyes kept wide open
Missouri Association of Long-
consistency. Simple verbal
Warding off care
Term Care Physicians and the
scales (mild, moderate, severe)
Guarding body parts
Depatment of Family and
may not be as helpful as
Loss of appetite
Sleep disturbance
Community Medicine at the
combined visual analog-
Withdrawal
University of Missouri-
numeric scales. Pain scales
Repetitive facial movements
Columbia School of Medicine,
should be easily accessible.
Respective body movement
Sudden change in behavior
Columbia MO 65212. Phone
Facial expression and number
Sudden social changes
(573) 882-4991. Fax (573)
scales can be used to measure
Sudden change in function
882=9096.
pain by all team members.
Physical or verbal agitation
Assessments can easily be made
Repetitive verbal behaviors
and recorded during medication
If there is a question
passes and vital signs. Certain
Steven Zweig, MD
of whether pain is present in a
residents may need individual-
Editorial Board:
resident, a careful history of
ized assessments (e.g., dementia
David Mehr, MD
how pain was shown in the
Larry Lawhorne, MD
patients, or those who are vision
past should be sought from
Michael Hosokawa, EdD
impaired).
friends and family. Changes in
Marilyn Rantz, RN, PhD
Managing Editor:

Quality. Ask the patient what
resident status as shown above
Susan Kauffman
the pain is like (e.g., burning,
may be indicators for a trial of
aching, sharp, etc.), and whether
scheduled (not prn) pain
Missouri Association of Long-
it changes with time (e.g., new/
management. This could be
Term Care Physicians
old, frequency/duration).
for a limited time period, and
President:
Charles Crecelius, MD, PhD

would require frequent reas-
Location. Determine the specific
sessment of descriptive
or generalized location of all
Vice-President:
indicators. The patient and
David Cravens, MD, MSPH
sites, and whether it radiates.
family should be involved and
Columbia
in agreement with the pain/
Secretary-Treasurer:
Aggravating and Precipitating
Cary Bisbey, DO
Factors. Ask what makes the
comfort care plan.
Springfield
pain better or worse. Time of
Board of Directors:
day, movement, position; use of
Jeffrey Kerr, DO, Rolla
heat/cold, medications, massage
MDS Version 2.0 and Pos-
Babu Dandamudi, MD, St Louis
are all examples.
Paul Schoephoerster, MD, Fayette
sible Pain Indicators
Steven Zweig, MD, Columbia
The Minimum Data
Effect. Ask both how effective
Set has several components
current treatments are, and the
which may directly or indi-
effect the pain has on the
rectly measure pain. These
resident’s life.
could be helpful in finding or
Atypical Presentations of
tracking pain in nursing home
residents.3
Many residents don’t
Sleep cycle (E1)
show pain in normal ways.
Change in mood (E3)
Complaints, mobility, medica-
Sad, apathetic, anxious appearance
tions used, sleep and vital
Resisting care (E4)
signs aren’t reliable indicators
Change in behavior (E5)
Long-Term Links
Page 2 Spring 2002
Functional change in range of
motion (G9)
worse with pressure or move-
Footnotes
Change in ADL function (G9)
ment. Examples include
Pain symptoms (J2)
1. Stein WM, Ferrell BA. Pain in the
Mouth pain (K1)
cancer, metastatic to bone,
nursing home. Clin Geriatr Med
Oral status (L1)
fractures, and very severe
1996; 12(3):601-13.
Other skin problems (M4)
2. Hurley ACVolicer BJ, Hanrahan PA,
Range of motion restorative care
osteoporosis. NSAIDS and
Houde S, Volicer L. Assessment of
opiates work well.
Loss of sense of initiative/
discomfort in advanced Alzheimer
involvement (F1)
patients. Res in Nurs & Health
Any disease associated with chronic
Neuropathic. This non-nocicep-
1992; 15:369-77.
pain (I1)
tive pain results from injury to
3. Chronic Pain Management in the
Pain site (J3)
Long-Term Care Setting, Clinical
Weight loss (K3)
central or peripheral nerves.
Skin lesions (M1)
Practice Guideline 1999. American
Pain is perceived (nerves
Medical Directors Association.
Foot problems (M6)
discharge) without a normal
(nociceptive) stimulus. Pain is

Types of Pain
normally described as burn-
Pain can be divided
ing, aching, stabbing, tingling,
into two types -- nociceptive
pins and needles, or shock-like.
and neuropathic. Each has
Neuropathic pain may show
characteristics which help
hyperesthesia (hypersensitiv-
guide therapy. Nociceptive
HHS Secretary Tommy
ity to any stimulus), allodynia
pain can be subdivided into
Thompson announced a new
(pain to non-painful stimulus),
three types -- somatic, visceral,
proposal in April to improve
or sensitization (surrounding
and bone.
the quality of care for nursing
tissue becomes sensitive).
home residents by allowing for
Examples include diabetic
Somatic. This nociceptive pain
trained assistants to help
neuropathy, post-stroke pain,
comes from skin, muscle and
residents eat and drink.
phantom limb pain after
connective tissue. It tends to
“Allowing trained feeding
amputation, and cancer
be well-localized, sharp to dull,
assistants will mean better
metastatic to nerve plexus.
may be constant, achy or
care for residents, especially at
Simpler pain medications and
intermittent, and tends to be
mealtimes, which can be the
opiates often don’t work well.
worse with any movement or
busiest times in nursing
touch. Examples include
homes,” Secretary Thompson
See Insert for treat-
sprains, headaches, cuts, and
said. “Trained feeding assis-
ment principles and sugges-
most arthritic pains. Most
tants will free nurses and aides
pain medications will help.
to focus on residents’ other
health care needs. The result

Ancillary Methods
Visceral. This nociceptive pain
will be that residents will
Environmental sup-
comes from internal organs. It
receive better nutrition and
port and a positive, focused
tends to be poorly localized
care.”
attitude toward pain relief
and even referred to other sites,
shouldn’t be underestimated.
more constant and dull, and
Under the CMS
Music and other relaxation/
less affected by ovement or
proposal, individuals would be
distraction techniques can be
position. Examples include
required to complete a state-
helpful. Local balms, thermal
appendicitis, gastritis or ulcer
approved course to qualify as
(ice and heat) and massage
pain, and angina. Stronger
trained feeding assistants.
therapy can be helpful for
pain medications in general
“Feeding residents is often a
arthritic and musculoskeletal
will be needed to treat these
slow process and competes
pain. Occupational therapy
with more complex tasks, such
can help with difficult position-
as bathing, toileting and
ing, and physical therapy with
Bone. This nociceptive pain
dressing changes, as well as
mobility and safety issues.
comes from very sensitive
urgent medical care,” CMS
Setting realistic goals and
nerve fibers on the outer
administrator Tom Scully said.
providing psychologic and
surface of bone. It tends to be
psychiatric services as needed
Ifrom Missouri Association of
constant, more intense, and
should not be forgotten.
Homes for the Aging Hotline
Long -Term Links
Page 3 Spring 2002
President, Missouri Association of Long-Term Care Physicians I Surveys are Tougher and Families are Finding Out Your instincts are
potential problems with both
facilities having four or more
correct if you feel surveyors
sites. Much of the data may
actual harm violations in the
are handing out more deficien-
be old or incomplete, and not
last four years. Fort Wayne
cies. The average number of
indicative of current efforts
IN and Detroit MI were
deficiencies per nursing home
and performance. Survey data
second and third. Twenty-two
survey jumped from 2.7 in
is slow to be updated, and
cities made the worst cities list,
1996 to 6.3 in 2001. In the
complaint surveys are not
defined as 40% or more actual
last 12 months, 32% of nurs-
considered by the CMS
harm violations in the same
ing homes had at least one
website. HealthGrades’
four-year period. Nashville
deficiency involving actual
rankings used weighting
TN was the best, with 57% of
harm to a resident. Fifteen
factors on a variety of selected
homes having no actual harm
percent of nursing homes had
indicators to arrive at general
violations in four years. Baton
more than five formal com-
groups (top 30%, next 40%,
Rouge LA and Jacksonville FL
plaints filed in the last year,
etc.) Importantly, neither
were numbers 2 and 3.
resulting in 9% more com-
completely address surveyer
plaint-based surveys.
variability, case-mix consider-
While consumers are
ations, plans of correction
entitled to information to help
Families can easily
outcomes, or historical pat-
them select a home for their
access not only general infor-
loved one, it isn’t clear that an
mation such as that above, but
answer has been found. Physi-
also facility-specific informa-
Barring these consid-
cians should know their
tion. Two websites can supply
erable concerns, the Health-
facilities’ “report cards” and be
survey-related data that may
Grade website recently made
able to respond meaningfully
be interesting, but perhaps not
widespread news coverage
to current and prospective
truly informative. The gov-
when it listed the best and
family concerns. Knowledge
ernment offers Nursing Home
worst cities for nursing home
of the population served,
Compare through CMS’s
care. They used four years of
quality indicator coneerns and
website (www.medicare.gov).
survey results in cities with 20
interventions, current deficien-
HealthGrades Inc. offers a
or more nursing homes, and
cies, implementation of plans
proposed “report card” through
calculated the percentage of
of corrections and trends in
its website, listing both facil-
violations involving actual
survey results and quality
ity- and city-specific data
harm as a marker of poor
indicators can better detail
(general ratings free, complete
care. Wichita KS topped the
your facilities’ quality than a
reports for a fee, at www.
“worst” list, with 80% of
simple grading system.
healthgrades.com). There are
ment of Health and Human
The long-awaited
contained the major points.
Services Secretary Tommy
second half of the Department
The report does not support
Thompson noted that other
of Health and Human Services
mandatory staffing levels.
issues such as the importance
(HHS) report on minimum
This is in good part because
of training and management,
staffing levels in nursing
of the high costs of funding
staff shortages, and staff mix
homes, ordered by Congress in
the increased staff proposed,
make using the suggested
1990, was released on March
estimated at $7.6 billion a
staffing ratios “improper” as
19, 2002. The draft version
year, or 8% over current costs,
was leaked a month earlier and
with no mechanisms for
Continued at bottom of Page 5 -->
providing this money. Depart-
Long-Term Links
Page 4 Spring 2002
AMDA’s presence was
ing clinical situations that are
continues to work on this
heard on a recent CMS confer-
beyond their scope of practice.
issue, he believes that surveyor
ence call for the Skilled Nurs-
Moreover,” continued Dr.
guidance is reasonable. “CMS
ing Facility/Long Term Care
Isaacs, “patients in long-term
does not prohibit the states’
Open Door Forum. Fred
care are complex, multi-
use of physicians as consult-
Isaacs, MD, CMD, past presi-
diseased people, and the
ants to the survey process,”
dent of the Michigan Medical
decision-making that goes into
said Mr. Pelovitz. “In addition,
Directors Association, ex-
treating these patients is very
CMS has made it a priority for
pressed concern that most
complex.”
their regional offices to have
states do not have physicians
physicians on staff.”
involved in the survey process.
Steve Pelovitz, CMS
“Since many surveyors are
Director of Survey and
I from AMDA’s
nurses and pharmacists,” Dr.
Certification Group, responded
Health Policy Advisor Newsletter,
Isaacs said, “they are evaluat-
by saying that while CMS
March 2002
Staffing Levels Update
(continued)
standards. However, the

below HHS suggested levels.
The National Citizens
report does recommend a new
Coalition for Nursing Home
provider requirement to
The HHS report did
Reform (NCCNHR) has
electronically submit accurate
find a “pattern of incremental
already stated that it will press
data on the number of nursing
benefits” of higher staffing to a
Congress to adopt minimum
staff employed. This would be
certain point, beyond which a
staffing levels, and has almost
shared with consumers, who
threshold of little further
90,000 signatures from 49
could use nursing home
benefit was seen. These
states to support the cause.
staffing levels as part of their
thresholds varied on the
The staffing crisis is well
selection criteria. In theory
facility case mix, and are:
recognized by all professional
Nursing aides:
this would promote increased
groups. The American Health
2.4-2.8 hrs/resident/day
staffing by public demand and
Care Association has noted
Licensed staff:
market forces. Currently, the
staffing problems are indica-
1.15-1.3/hrs/resident/day
only federal staffing standard
Registered nurses:
tive of chronic underfunding
for nursing facilities that
.55-.75 hrs/resident/day
of Medicaid and Medicare.
participate in Medicare or
The American Medical Direc-
Medicaid is rather subjective:
According to the
tors Association acknowledges
to provide licensed nursing
report, fewer than one of 10
the need for more and better-
coverage 24/7 (including an
nursing homes currently meet
supported staff, but has stated
RN for eight consecutive hours
these standards. While no
it could not support simplistic
a day) and to have sufficient
mandatory levels have been
levels derived only on staff-to-
nurses and staff to ensure that
recommended, the report does
resident ratios, not taking into
residents attain their highest
call for further study of the
account resident acuity. Unfor-
practicable level of well-being.
costs and quality improvment
tunately, what could be ideal
While most states have some
potential of the proposed
levels may fall victim to stark
form of minimum levels, the
staffing levels.
financial, political and
majority are significantly
workforce realities.
Long-Term Links
Page 5 Spring 2002
Pain Assessment and Basic Management by CNA’s Everyone experiences
Other misconceptions include:
s Loss of ADLs
pain differently. Because it
s Sadness, anxiety or depression
cannot be measured like blood
s Signs of pain will be obvious.
s Difficulty in walking or transfer-
pressure or temperature, we
Some people mistakenly believe
ring; can become bedbound
must rely on the patient to tell
pain will manifest itself in
us where the pain is and what
typical signs like moaning, a
What Can Cause Pain?
it’s like. Severe pain to one
change in vital signs, or lack of
Illness or disease. Often
person may feel like almost
appetite. But people can adapt
when we think of pain, we
even to severe pain, and show no
nothing to another. Health-
think of cancer, but almost
care workers sometimes take it
any disease can cause pain.
upon themselves to determine
Even if the healthcare worker
People with arthritis, decubitus
if the patient is telling the
doesn’t believe what the resident
ulcers, heart disease, stroke,
truth. But according to pain
is saying about their pain, try to
pneumonia (and the list goes
experts, the patient’s self
set aside your personal beliefs
on!) all can have pain.
report of pain is the single
and accept the report of pain.
most reliable indicator. How-
Immobility can cause
ever, some residents and
s Anxiety always makes pain
pain, and pain can cause
families simply accept pain as
worse. Anxiety and pain often go
immobility. If it hurts when a
together, but it is not proven that
an inevitable part of disease,
person moves, of course they
anxiety causes pain. Pain often
and don’t report it regularly.
don’t want to move. If they
does cause anxiety.
don’t move, they are at high
Everyone’s role is
s Pain is a normal part of aging.
risk for contractures and
important in helping residents
Often residents themselves
decubitus ulcers, which can
in pain. Caregivers spend
believe this. They may be afraid
cause more pain.
more time with the resident
to say they’re in pain because
than anyone else. Doctors and
they think they may become
External factors. This
charge nurses may have more
addicted to pain medications, or
could be as simple as an
control over pain medications,
because they want to be “brave”
undergarment that is fastened
but they don’t see residents as
and “not bother the staff.”
too tight or a wheelchair leg
often. Sometimes a patient can
rest with a rough edge. Look
appear pain-free when they
What Happens if Pain Isn’t
around the resident for easily
are still, but caregivers see the
Properly Treated?
corrected things that could
pain when they help them
There are many effects
cause pain. Also, a room that
move or do ADLs, or patients
of poorly treated pain. Not
is too cold or hot, a bright
may share information with
only can it make the patient
light, or loud noises can all
caregivers during personal
miserable, but it can make
make pain harder to tolerate.
care. It is especially important
their care more difficult. It can
that CNAs watch for signs of
certainly affect Facility Quality
Emotional factors. Pain
pain and report them to the
Indicators and survey findings
does increase anxiety, and
charge nurse.
anxiety may increase pain.
Other effects can be:
While treating anxiety helps, it
s Poor appetite and weight loss
Misconceptions
shouldn’t be treated only with
Sleep disturbance
A common misconcep-
medicines. A warm bath, soft
Withdrawal from social activities,
tion about pain is that the
or even talking
music, hand-holding, hugs, and
person caring for the patient is
s Development of skin ulcers
just listening all can decrease
the best judge of that person’s
s More likely to become inconti-
anxiety. Letting the resident
pain. It is the patient who
know you believe their pain is
best knows their own pain.
s More likely to use restraints
real and that you want to help
is also extremely important

Long-Term Links
Page 6 Spring 2002
and helpful.
Facility staff should
rigidity, rubbing, holding body
consider some guidelines when
Assessing Pain
assessing those with dementia
Vocalizations: moaning, repeated
or communication problems:
phrases, yelling, loud breathing
General.
Social: sleepless, agitated,
Everyone in
s Ask the resident if he/she is having
combative, crying, trying to get
the nursing home is respon-
pain. You might be surprised at
attention, refusal to go to activi-
sible for finding and describing
what he understands and the
ties, loss of appetite.
pain in residents. Doctors,
response you get. Residents with
significant cognitive impairment

nurses, aides, and even admin-
can often understand a simple
What Everyone Can Do for
istrators, dietary staff and
question about pain and respond
housekeepers should know the
to it. You might want to use a
While it is the role of
basics of identifying pain. It
term other than “pain.” Try hurt,
the doctor, nurse, therapist and
helps to assess pain if you can
discomfort, uncomfortable, aching or
family to determine pain
soreness.
treatment (medicine, whirl-
pools, braces, ultrasound or

s What seems to bring on the pain.
s Consider the disease condition and
massages), there are very
Movement, position, meals,
procedures that might cause pain. A
important things that anyone
family visits, urination or bowel
skin tear from a wheelchair’s
movements are all possibilities.
rough edge, a fractured hip, an
elbow bruise from a fall, daily

s Show that you care. A kind,
Where is the pain and what does
physical therapy goals for ambu-
reassuring word and a soft touch go a
it feel like? Is it dull, achy,
lation would be reasons to medi-
long way.
sharp, or stabbing? Is it constant
cate for pain. If you were the
or occasional? How many areas
resident, would you want
s Tell the resident what you are going
hurt and exactly where are they?
something for pain?
to do, even if they don’t understand.
Talk to, not around the resident.

s What makes the pain worse?
s Use proxy pain reporting. Families
Remember, hearing is the last sense
Sitting up in a chair, putting on a
often report to the nurse that their
brace or dressing, a change in
loved one is in pain. Housekeep-
room temperature, or time of
ers, maintenance workers, social
s Make the room pleasant. A comfort-
services, activity aides and
able temperature, soft lighting, soft
music and noise control can all

dietary staff observe the resident
increase pain tolerance.
What makes the pain better?
throughout the day and should be
Can you calm the patient with
encouraged to report pain.
sTake care of the basics. Reposition-
touch or verbal reassurance?
ing, eyeglasses and hearing aids, dry
Does prescribed medicine really
s Be alert for behaviors that may
clothing, a comfortable bed or chair,
help? What about heat, cold, or
indicate pain. Actions may speak
toileting, food and fluids are often
massage?
louder than words. Pay attention
more important to the resident than
to physical or verbal aggression,
any pill.
facial expressions, restlessness,
Assessing Pain in Residents
resistance to caregivers. When
s Communicate with your team. Let
others know what works best for the
with Dementia or Communi-
implementing a facility behavior
resident.
cation Difficulties
intervention program, start by
considering the pain assessment

s Always report pain to the charge
While a resident’s
of each resident. Any of these
nurse or team. Pain is not a normal
actions may signal pain:
report of pain is the best
part of aging, and everyone should
method for assessing it, some
have treatement for it!
Facial expression: frown, grimace,
residents are unable to report.
fearful, sad, clenched teeth, eyes
s Understand the care plan for pain.
Those with dementia or other
wide open or shut tight.
Not all pain can be cured, but it can
cognitive disabilities will have
Physical movements: restlessness,
be treated in a thought-out, effective
difficulty communicating their
fidgeting, slow, cautious or no
fashion. A care plan for any resident
pain symptoms.
movement, guarding, rocking,
with problem pain should have a team
approach.

Long-Term Links
Page 7 Spring 2002
In a recent hearing,
pharmacists with geriatric
The report, Medical
Sen. John Breaux, Chairman of
training. The need to better
Never-Never Land: 10 Reasons
the Senate Special Committee
recruit and train these
Why America’s Not Ready for
on Aging, urged his colleagues
healthcare professionals is
the Coming Age Boom, focuses
to take immediate action to
growing ever more dire as 77
on ten barriers that preclude
remedy the coming shortfall in
million baby boomers begin to
America’s health professionals
the numbers of geriatric-
reach retirement age.
from being adequately pre-
trained healthcare profession-
pared for the coming age
The Alliance for Aging
boom. The report can be
Research released a new report
accessed online at
Sen. Breaux called the
at the hearing, which high-
www.agingresearch.org.
hearing to illustrate how
lights the lack of formal
elderly patients suffer from a
training in geriatric care in
I from AMDA’s
lack of doctors, nurses, social
many healthcare professions.
Health Policy Advisor
workers, psychologists and
Program will include presentations on:
s The Role of the Consultant Pharmacist
Pneumonia and dementia
Falls Assessment
s Parkinson’s Disease
s Quality of Care and Staffing
s Diabetes Medications for the Elderly
s Chronic MRSA in Nursing Home Residents
s Evaulation and Managementof the Im-
s Drug Therapy for Alzheimer’s Disease
paired Older Adult Driver
s Update of Federal Regulations and the
s Geriatric Dermatology
Survey Process
s Depression and Panic in the Elderly
s Treatment of Venous Ulcers
s A Closer Look at the Strengths and Gifts of
s PACE (Program for All-Inclusive Care of the
Persons with Alzheimer’s Disease
Elderly)
s Spirituality Among Alzheimer’s Patients
s Community Options for Long-Term Care -
s Furthering Education for Nurses Who Care
Lessons from the VA
for the Elderly
Sponsored by:
s University of Missouri Health Care
s Department of Family and Community Medicine
s MU Sinclair School of Nursing
Special Preconference Workshop:
s MU School of Health Professions
Dying in the Nursing Home
s Missouri Association of Long-Term Care Physicians
s Mid-Missouri Area Health Education Center
Conference information and registration can be found online at www.muhealth.org/~cme.frail
or call (573) 882-0366
Long-Term Links
Page 8 Spring 2002
What You Can Do Now
An important factor influencing a nursing home’s performance is the degree of
involvement by the medical director. The medical director, with strong support from
administration, can serve as the leader of change by assuming greater authority and
responsibility for the type of care provided by the facility. Most successful change comes
through strong leadership. There are several things the medical director can do to
prepare for this initiative:

1. Support quality improvement efforts in your individual facility. In effecting change, the
medical director can assist facility staff both in reviewing current clinical practices and
in making changes to better meet residents’ clinical needs. Securing the support of
other physicians who care for residents in the facility is essential to effecting change in
care practices. The medical director is the perfect liaison for recruiting physicians’
support.

2. Give us your feedback. When this initiative is rolled out nationally, MissouriPRO will
select up to five of the measures on which to focus our statewide quality improvement
efforts. They would like you to tell them what measures you are interested in, as well
as what types of assistance you believe would be most beneficial to your efforts. A
“needs assessment” was mailed to a randomly selected group of nursing home admin-
istrators. If your facility received this survey, encourage administrators to complete
and return it to us. Or you can give your feedback by filling out a short survey on the
website -- www.mpcrf.org/MU/files/nursing_home_survey.html.

CMS’s Pilot Nursing Home Project Quality Measures
Late loss ADL decline
Prevalence of infections
Weight loss prevalence
Inadequate pain management
Pressure ulcer prevalence
Use of physical restraintsPost-Acute Care
Prevalence of delirium
Inadequate pain management
Improvement in walking

Pain Treatment
Principles and Guidelines
General Treatment
Basic principles of pain management should always be considered. To summarize:

s Use the lowest effective dose by the simplest (e.g. oral) route.
s Start with the simplest single agent, and maximize its potential before adding other drugs. If combination therapy
is necessary, use complementary medication to potentiate effectiveness.
s Use scheduled, long-acting pain medications for constant/frequent pain, with prn, short-acting medication available
for breakthrough pain.
s Treat breakthrough pain with one-third the 12-hour scheduled dose.
s If three or more prn doses are used in a day, increase the scheduled dose.
s Treat or prevent side effects of pain medications, such as constipation and nausea. Change meds as necessary.
s Use the WHO stepwise approach described below.
s Reevaluate and adjust medications at regular intervals and as necessary.
s Do not stop pain medications in terminal patients. Change the route if needed.
WHO (World Health Organization) Ladder. Three-step ladder approach appropriate for all nociceptive pains.
Step 1: Mild Pain
Acetaminophen

Advantages: lack of toxicities, good relief of simple pain, opioid sparing, and easily available.
Disadvantages: ceiling effect (4 grams in younger patients. For the elderly, some have suggested maximum
dose between 2.5 and 4 grams daily).

NSAIDS (non-steroidal anti-inflammatory drugs)
Advantages: broad indications in mild or moderate pain, opioid sparing, and complementary to other drugs.
Disadvantages: caution in renal, cardiac, GI and anticoagulated patients.

Step 2: Mild to Moderate Pain
Combination analgesics (opioid combinations)

Advantages: simple mixture of low dose opioid and acetaminophen, and relative good tolerance.
Disadvantages: ceiling effect due to acetaminophen, and mild opioid side effects. Hydrocodone and
oxycodone preparations are preferred. Propoxyphene (Darvocet, Darvon), codeine (Tylenol #3) and
butalbital (Fiorcet or Fiorinal) are in general more likely to have CNS, GI and/or liver/kidney side effects.

Tramadol (Ultram)
Advantages: non-controlled status, relatively low risk for abuse, analgesic efficacy to Tylenol #3.
Main disadvantage -- expense.

Adjuvant medication can be added to the above, as described on the other side.
Step 3: Moderate to Severe Pain
Opioid (narcotic) analgesics. Advantages: No ceiling effect, wide dosage forms (pills, elixir, suppositories, patches),
availability of short- and long-acting formulations. Disadvantages are mainly dose-related, but can be anticipated
and treated. Respiratory depression and sedation are normally transient with tolerance occuring in a few days.
Nausea and vomiting are more constant with tolerance occuring slowly, but can be treated with anti-emetics if
needed. Tolerance doesn’t occur with constipation, which requires stimulant laxatives (e.g., Senekot, Miralax).
Confusion usually requires dose reduction or change in medication. Myoclonus normally results from metabolite
accumulation, and can be treated with benzodiazepines or change of opioids.

Adjuvant medication can be added, as described on the other side.
Specific Opioids
Morphine.

Inexepensive, popular with hospice due to flexible dosing. IM dosing is painful and
unnecessary given efficacy of high concentration oral solutions. MS Contin (12-hour efficacy) and
Kadian (24-hour efficacy) are popular brands.

Oxycodone
More expensive, available in rapid release (Oxyfast), short-acting (OxyIR) and long-acting
(Oxycontin) formulations.

Fentanyl
More expensive transdermal patch system, convenient for resident, but harder to titrate quickly due
(Duralgesic)
to slower peak effect. Absorption may vary depending on fever and body fat.
(continued on other side)
Specific Opioids (continued)
Hydromorphine Oral, IV and rectal doses may be helpful. A sustained release product will be available soon.
(Dilaudid)

Opioids not recommended
Meperidine (Demerol) more likely to cause nausea/vomiting, has toxic metabolites that can cause tremor, seizures
and confusion. Federal regulations strongly discourage the use of Demerol. Pentazocine (Talwin), butorphanol
(Stadol), and buprenorphine (Buprenex) have partial or mixed agonist effects that are undesirable and have a
ceiling effect.

Adjuvant Medications
Tricyclic

Amitryptiline (Elavil), nortryptiline (Pamelor) and desipramine (Norpramin) suppress signals from
antidepressants damaged neurons, can augment nociceptive pain relief, and be used as primary treatment for
neuropathic pain. Effective at low doses (1/8 to 1/2 doses to treat depression). Can have significant
side effects: dry mouth, constipation, postural hypotension, confusion. Should be used with caution
and appropriate documentation according to federal regulations.

Mirtazapine (Remeron) and venlafaxine (Effexor) have been reported to have adjuvant pain
properties.
antidepressants SSRI antidepressants seem to have less utility in this regard.

Anticonvulsants Carbamazepine (Tegretol) gabapentin (Neurontin), and valproate (Depakote) also can be used for
nociceptive and neuropathic pain. Doses should be started low and titrated carefully. Serum drug
levels don’t correlate with clinical effectiveness, useful mainly to investigate suspected toxicity.

Corticosteroids Prednisone, prednisolone, and dexamethasone all decrease spontaneous neuronal discharge and
inhibit edema, lessening pain. Can also help nausea and appetite. Have obvious long-term side
effects, should be used at lowest doses possible.

Clonidine
Useful primarily for regional complex pain syndromes such as reflex sympathetic dystrophy and
causalgia (sympathetically modulated pain). Not useful for nociceptive pain.

Lidocaine patch FDA approved for post-herpetic neuralgia, uncertain utility in nociceptive pain. Has minimal
(Lidoderm)

systemic absorption, can be cut to size, should be left off half the time to prevent skin irritation.
Capsaicin
Useful for neuropathic and arthritic/musculoskeletal pain. Acts via substance P, a pain modulator.
(Zostrix)
Can cause burning, should not be used on irritated skin. Low strength (0.25%) is over the counter.
Co-analgesics
Lorazepam (Ativan), alprazolam (Xanax) and diazepam (Valium) can be cautiously used to augment
pain and nausea relief. Can potentate sedation. Use of Valium in particular should be well docu-
mented given federal regulations.

Hyperstimula-
TENS units and acupuncture can both treat nociceptive pain; indications and long-term efficacy are
tion Analgesics uncertain.
Strontium-90
Useful for bone pain from bony metastasis, given by radiation oncologist. Can only be used every 90
(Metastron)
days, with possible initial flare of pain and delayed onset of pain relief (10-21 days).
Radiation therapyUseful for control of oncologic pain if tumor is radiosensitive.
Nerve blocks
Local anesthetic blocks performed by anesthesiologists or pain experts can help local nerve induced
pain syndromes for up to several months. Success rates variable, may require repeated injections to
assess initial results.

Neurosurgical
Reserved for localized intractable pain, these pemanent procedures (e.g., rhizotomy, cordotomy,
procedures
deep brain stimulators) are infrequently used in long-term care patients, but should be considered in
difficult cases.

Source: http://fcm.missouri.edu/PDFs/longtermlinksspring02.pdf

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