Pain Management in Old Age

Geriatric Nursing and Pain Management 

Pain, Pain as health Issue and Management in Geriatric Nursing.Pain Assessment and Indicators.Pharmacological and Non-Pharmacological interventions. 

Whats is Pain 

    Pain is a very common experience among older adults. The prevalence of pain in older adults ranges from 50% to 86% (Horgas, Elliott, & Marsiske, 2009). Across all care settings and most specialty areas, nurses will interact with older adults (Herr, 2010). 

    By the year 2030, it is projected that one in five US residents will be older than 65 years of age (Rosenthal & Kavic, 2004), and those older than age 85 represent the fastest growing segment of the population. 

    In 2000, adults older than the age of 65 accounted for half of all hospital inpatient days (Rosenthal & Kavic, 2004). Furthermore, approximately 50% of admissions to the intensive care unit (ICU) are adults older than the age of 65 (McNicoll et al., 2003; Pisani, McNicoll, & Inouye, 2003). 

    Thus, care of older adults is no longer restricted to nurses working in long-term care. Nurses in the acute care setting also need to be knowledgeable about the most effective strategies for assessing and managing pain in this population (Herr, 2010).

Pain as Health Care Issue

    There are many causes of pain in older adults. Acute pain is typically associated with surgery, fractures, or trauma (Herr, Bjoro, Steffensmeier, & Rakel, 2006). 

    Persistent pain (ic.. pain that continues for more than 3-6 months) is most frequently associated with musculoskeletal conditions such as osteoarthritis (The American Geriatrics Society [AGS] Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    In 2000, it was estimated that almost 9 million surgeries were performed on older adults, including 1.25 million musculoskeletal surgeries (Herr, Titler, & Schilling, 2004). 

    In addition, cancer is associated with significant pain for one third of patients with active disease and for two thirds of those with advanced disease (Reiner & Lacasse, 2006). In the acute care setting, older adults are therefore likely to have acute pain superimposed on persistent pain.

Pain in Geriatric Nursing Care

    Pain has major implications for older adults' health, functioning, and quality of life (Wells, Pasero, & McCaffery, 2008). Pain is associated with depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased health care use (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    Other geriatric conditions that can be exacerbated by pain include falls, cognitive decline, deconditioning, malnutrition, gate disturbances, and slow rehabilitation (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    In the hospital setting, older adults suffering from acute pain have been reported to be at increased risk for thromboembolism, hospital-acquired pneumonia, and functional decline (Wells et al., 2008). 

    Unrelieved acute pain has also been implicated in the development of subsequent persistent pain (Desbiens, Mueller-Rizner, Connors, Hamel, & Wenger, 1997; Desbiens, Wu, et al., 1997). Unrelieved pain, thus, has important implications for physical, functional, and mental health among older adults.

    Over the past decade, a substantial number of clinical and empirical efforts have been undertaken to improve the assessment and management of pain in older adults. 

  For instance, in 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) addressed pain assessment and management as part of the survey and accreditation process. 

    The Joint Commission (2001) asserted that patients have the right to appropriate assessment and management of pain and declared pain as the fifth vital sign. This mandate exposed some of the challenges associated with assessing and managing pain in older adults in general, and in persons with dementia in particular. 

    This, in part, spurred clinical and research activity to develop measures for assessing pain in older adults, particularly those with cognitive impairment. 

    These behavioral measures have been reviewed in several published reports (Herr, Bjoro, & Decker, 2006; Herr, Bursch, Ersek, Miller, & Swafford, 2010), including a comprehensive chapter focusing specifically on pain assessment tools in the classic reference by Pasero and McCaffery (2011). 

    In addition, there have been multiple clinical guidelines by leading scientific and clinical organizations including the AGS (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Hadjistavropoulos et al., 2007). 

    The American Pain Society (Hadjistavropoulos et al., 2007), and the American Society for Pain Management Nursing (Herr, Coyne, et al., 2006). Links to these resources are included at the end of this chapter. 

    Despite the Joint Commission mandate and the dissemination of clinical guidelines aimed at improving pain management, there is persistent evidence that pain remains ineffectively assessed and poorly managed in older adults across care settings (Herr, 2010; Herr et al., 2004; Horgas et al. ., 2009; Morrison, Magaziner, McLaughlin, et al., 2003: Titler et al., 2009). 

    The purpose of this chapter is to provide the best evidence on the assessment and treatment of pain in older adults, especially those with cognitive impairment. It is hoped that the information here can be used to establish, implement, and evaluate protocols in the acute care setting that will improve pain management for older adults.

Pain Assessment 

    Pain is defined as a complex, multidimensional subjective experience with sensory, cognitive, and emotional dimensions (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Melzack & Casey, 1968). For clinical practice, Margo McCaffery's classic definition of pain is perhaps the most relevant. 

    She states Pain is whatever the experiencing person says it is, existing whenever he says it does (McCaffery, 1968). This definition serves as a reminder that pain is highly subjective and that patients' self-report and description of pain is paramount in the pain assessment process. 

    This definition, however, also highlights the difficulty inherent in pain assessment. There is no objective measure of pain; the sensation and experience of pain are completely subjective. As such, there is a tendency for clinicians to doubt patients' reports of pain. 

    Pasero and McCaffery (2011) provided a comprehensive chapter on biases, misconceptions, and misunderstandings that hampered clinicians' assessment and treatment of patients who reported pain. These issues apply to patients across the life span, and led the authors to conclude the following:

    A veritable mountain of literature published during the past three decades attests to the undertreatment of pain. Much of this literature is consistent with the hypothesis that human beings, including health care providers in all societies, have strong tendencies or motivations to deny or discount pain, especially severe pain, and to avoid relieving the pain. 

    Certainly we should struggle to identify and correct personal tendencies that lean to inadequate pain management, but this may not be a battle that can be won. 

    Perhaps it is best to assume that there are far too many biases to overcome and that the best strategy is to establish policies and procedures that protect patients and ourselves from being victims of these influences. 

    Among older adults, there is persistent evidence that pain is under detected and poorly managed among older adults (Herr, 2010; Horgas et al., 2009; Horgas & Tsai, 1998; Smith, 2005). There are a number of factors that contribute to this situation, including individual based, caregiver-based, and organizational-based factors. 

    Individual-based factors that may impair pain assessment include the following: 

(a) belief that pain is a normal part of aging

(b) concern of being labeled a hypochondriac or complainer

(c) fear of the meaning of pain in relation to disease progression or prognosis

(d) fear of narcotic addiction and analgesics

(e) worry about health care costs

(f) a belief that pain is not important to health care providers (AGS Panel on Persistent Pain in Older Persons, 2002 ; Gordon et al., 2002). 

    In addition, cognitive impairment is an important factor in reducing older adults' ability to report pain (Horgas et al., 2009; Smith, 2005).

    Pain detection and management are also influenced by provider-based factors. Health care providers have been found to share the mistaken belief that pain is a part of the normal aging process and to avoid using opioids due to fear about potential addiction and adverse side effects (Pasero & McCaffery, 2011). 

    Similarly, cognitive status influences providers' assessment and treatment of pain. Several studies have documented that cognitively impaired older adults were prescribed and administered significantly less analgesic medication than were cognitively intact older adults (Horgas & Tsai, 1998; Morrison. Magaziner, Gilbert, et al., 2003). 

    This finding may reflect cognitively impaired adults' inability to recall and report the presence of pain to their health care providers. It may also reflect caregivers' inability to detect pain, especially among frail older adults. 

    Health care providers should face the challenge of pain assessment by first systematically examining their own biases, beliefs, and behaviors about pain, and eliciting and understanding the challenges and beliefs their patients bring to the situation as well (Pasero & McCaffery, 2011).

Self Reported Pain

    There is no objective biological marker or laboratory test for the presence of pain. Thus, the patients' self-report is considered the gold standard for pain assessment (AGS Panel on Persistent Pain in Older Persons, 2002, AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    The first principle of pain assessment is to ask about the presence of pain in regular and frequent intervals (Pasero & McCaffery, 2011). It is important to allow older adults sufficient time to process the questions and formulate answers, especially when working with cognitively impaired older adults. 

    It is also important to explore different words that patients may use synonymously with pain, such as discomfort or aching.

    Pain intensity can be measured in various ways. Some commonly used tools include the numerical rating scale, the verbal descriptor scale, and the faces scale (Herr, 2002a). The numerical rating scale (NRS) is widely used in hospital settings. Patients are asked to rate the intensity of their pain on a 0-10 scale. 

    The NRS requires the ability to discriminate differences in pain intensity and may be difficult for some older adults to complete. The verbal descriptor scale, however, has been specifically recommended for use with older adults (Herr, 2002a). 

    This tool measures pain intensity by asking participants to select a word that best describes their present pain (eg, no pain to worst pain imaginable). This measure has been found to be a reliable and valid measure of pain intensity and is reported to be the easiest to complete and the most preferred by older adults (Hen, Bjoro, & Decker, 2006).

     Pictures of faces are also used to measure pain intensity, especially among cognitively impaired older adults. The Faces Pain Scale (FPS), initially developed to assess pain intensity in children, consists of seven facial depictions, ranging from the least pain to the most pain possible (Herr, Bjoro, & Decker, 2006). 

    Among adults, the FPS is considered more appropriate than other pictorial scales because the cartoon faces are not age-, gender-, or race-specific. 

    However, the FPS has relatively low reliability and validity when used among older adults with cognitive impairment and is not recommended for use in this population (Herr, Bjoro, & Decker, 2006). See the Resources section for information on accessing these measurement tools.

Pain Indicators

    Dementia compromises older adults' ability to self-report pain. In patients with dementia, and other patients who cannot provide self-report, other assessment approaches must be used to identify the presence of pain. A hierarchical pain assessment approach is recommended that includes four steps:

1. attempt to obtain a self-report of pain

2. search for an underlying cause of pain, such as surgery or a procedure

3. observe for pain behaviors

4. seek input from family and caregivers (Herr, Coyne, et al., 2006; Wells et al., 2008). 

    If any of these steps are positive, the nurse should assume that pain is present and a trial of analgesics can be initiated. Pain behaviors should be observed before and after the analgesic trial in order to evaluate if the analgesic was effective or if a stronger dose is needed.

    Observational techniques for pain assessment focus on behavioral or nonverbal indicators of pain (Hadjistavropoulos et al., 2007; Herr, Coyne, et al., 2006; Horgas et al., 2009). 

    Behaviors such as guarded movement, bracing, rubbing the affected area, grimacing, painful noises or words, and restlessness are often considered pain behaviors (Horgas & Elliott, 2004; Horgas et al., 2009). 

    In the acute care setting, vital signs are often considered physiological indicators of pain. It is important to note, however, that elevated vital signs are not considered a reliable indicator of pain, although they can be indicative of the need for pain assessment (Herr, Coyne, et al., 2006; Pasero & McCaffery, 2011).

    A number of observational measures have been developed over the past decade. These behavioral tools are typically either pain behavior scales (scored by identifying the number and intensity of behaviors) or pain checklists (identifying the number and types of behaviors that individuals display, without intensity ratings:Wells et al., 2008).

     Although there is no perfect behavioral measure of pain, three specific tools have been recommended for use in patients who cannot self-report (Pasero & McCaffery, 2011). 

    These are the Checklist of Nonverbal Pain Indicators (CNPI; Feldt, 2000), the Pain Assessment in Advanced Dementia (PAINAD) scale (Warden. Hurley, & Volicer, 2003), and the Pain Assessment Checklist for Seniors with Severe Dementia (PACSLAC; Fuchs-Lacelle & Hadjistavropoulos, 2004). 

    A comprehensive review of these measures, as well as other similar tools, is available on the City of Hope website (see Resources section).In addition, the Hartford Institute for Geriatric Nursing provides online resources for pain assessment in older adults with dementia that include information on the PAINAD tool, and an instructional video on how to use it (see Resources section for link). 

    Several caveats about observational tools must be noted: 

(a) the presence of these behaviors is suggestive of pain but is not always a reliable indicator of pain

(b) the presence of pain behaviors does not provide information about the intensity of pain ( Pasero & McCaffery, 2011; Wells et al., 2008). 

    As such, pain behavior tools are one part of a comprehensive pain assessment.In summary, pain assessment is a clinical procedure that can be hampered by many factors. Systematic and thorough assessment, however, is a critical first step in appropriately managing pain in older adults. 

    Assessment issues are summarized in the recommended pain management protocol. The use of a standardized pain assessment tool is important in measuring pain. 

    It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family. 

    Comprehensive pain assessment includes measures of self-reported pain and pain behaviors. Information from family and caregivers should also be obtained, although these data should be considered supplemental rather than definitive (Horgas & Dunn, 2001).

Interventions And Care Strategies 

    Managing pain in older adults can be a challenging process. The main goal is to maximize function and quality of life by minimizing pain whenever possible (Herr, 2010; Wells et al., 2008). 

    Optimal pain treatment uses a multimodal approach, tailored to the patient, that combines pharmacological and nonpharmacological strategies (Wells et al., 2008). Pharmacological interventions are an integral component of pain management in older adults (Pasero & McCaffery, 2011). 

    Important considerations regarding the use of pharmacological pain management must be taken into account. given the physiological changes that occur with aging. 

    It should be emphasized that pharmaceutical pain management is often more imperative in older adults with dementia because their ability to participate in nonpharmacological pain management strategies may be limited by their cognitive capacity (Buffum, Hutt, Chang, Craine, & Snow, 2007). .

    When choosing pain strategies, consideration should be given to severity of pain because moderate and severe pain often require different modalities in order to provide adequate pain relief. 

    Additionally, cognitive impairments are often confused by visual and hearing impairments in older adults. Therefore, to optimize pain relief while minimizing the potential for poor outcomes, careful consideration should be given to an individual's ability to adhere to treatment (Pergolizzi et al., 2008).

    Several excellent pain management guidelines and protocols have been developed for use in the management of pain in older adults. For instance, the AGS has recently updated their clinical practice guidelines for managing persistent pain in older adults (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    The consensus statement by the World Health Organization (WHO) on the use of Step III opioids for chronic, severe pain in older adults provides detailed guidelines pertaining to the assessment of pain and use of opioids for cancer and non-cancer-related pain (Pergolizzi et al., 2008). 

    In addition, there are other published guidelines for the assessment and management of pain in specific diseases, such as osteoarthritis (American Pain Society, 2002; American Pain Society Quality of Care Committee, 1995). 

    Pasero and McCaffery (2011) also provide one of the most comprehensive guides for pain management, including a recently updated edition that addresses pain management in older adults. See Resources section of Protocol 14.1 for more information on accessing these resources.

Pharmacological Pain Treatment

    Pain treatment with medications involves decision making based on multiple considerations. Ideally, it is a mutual process among health care providers, patients, and caregivers, with the goal of optimizing quality of life and functioning (Wells et al., 2008). 

    An effective pain management strategy includes a careful discussion of risks versus benefits, frequent reviews of drug regimens used by older adults, and the establishment of clear goals of therapy with the patient. It is often a process of trial and error that aims to balance medication effectiveness with management of side effects.

    Guiding principles for optimal pain management in older adults include the following components (Buffum et al., 2007; Gordon et al., 2005). 

    First, the treatment of pain should be initiated immediately upon the detection of pain. 

    Secondly, regularly scheduled (rather than “as-needed”) dosing of pain medications should be employed. 

    Additionally, multiple modalities for the evaluation of pain control should be used, including verbal, behavioral, and functional responses to pain medication. Pain medication should be titrated according to these responses, and a pain medication regimen should be chosen based on what is known about each individual patient. 

    This includes the severity of cognitive impairment and how this affects the patient's ability to express pain, interaction of pain medications with other medications, and knowledge of pain medication side effects, such as constipation.

    For individuals with cancer-related pain, the WHO provides a three-step analgesic ladder that has been widely used as a guide for treating pain in this population. Choices are made from three drug categories based on pain severity: the nonopioids, opioids, and adjuvant agents. 

    Combinations of drugs are used because two or more drugs can treat different underlying pain mechanisms, different types of pain, and allow for smaller doses of each analgesic to be used, thus minimizing side effects. 

    In 2008, the WHO established guidelines for the use of Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, and oxycodone) in older adults with cancer and noncancer pain (Pergolizzi et al., 2008). 

    Their criteria for the selection of analgesics in older adults with cancer are based on the type of pain, efficacy of the medication, side-effect profile, potential for abuse, and interactions with other medications (Pergolizzi et al., 2008). 

    These guidelines make it clear that Step III opioids are the gold standard of treatment for cancer pain and are also efficacious in non cancer diseases. The authors point out, however, a dearth of specific studies investigating the use of these drugs in older adults.

Special Considerations for Administering Analgesics

    When considering the addition of pain medication to an older, and potentially frail person's medication regimen, several issues must be evaluated. Confounding factors for medication side effects include comorbidities, the use of multiple medications, and drug-to-drug interactions (Klotz, 2009). 

    Normal physiological changes that occur with aging, superimposed on comorbidities, place older adults at higher risk for side effects. Specific age-related changes influence the pharmacodynamics (mechanisms of drug action in the body) and pharmacokinetics (processes of drug absorption, distribution, metabolism, and elimination in the body; Klotz, 2009). 

  Specific side effects to consider when prescribing and/or administering pain medications to the older adult include risks for sedation, mental status changes and cognition, balance, and gastrointestinal side effects including bleeding and constipation (Buffum et al., 2007).

    Recommendations for beginning pain medication treatment include starting at low doses and gradually titrating upward, while monitoring and managing side effects. The adage “start low and go slow” is often used. 

    Titrate doses upward to desired effect using short-acting medications first, and consider using longer duration medications for long-lasting pain, once drug tolerability has been established. For most older adults, choose a drug with a short half-life and the fewest side effects if possible (Pasero & McCaffery, 2011; Wells et al., 2008).

    Multiple drug routes are available for administration of pain medications. As long as patients are able to swallow safely, the oral route is the first choice because it is the least invasive and very effective. 

    The onset of action is within 30 minutes to 2 hours. For more immediate pain relief, intravenous administration is recommended, particularly in the immediate postoperative period. Intramuscular injections should be avoided in older adults because of the potential for tissue injury and unpredictable absorption, and because they produce pain. 

    Overall, adopting a preventive approach to pain management, whenever possible, is recommended. By treating pain before it occurs, less medication is required than to relieve it (Wells et al., 2008). Examples of pain prevention are around-the-clock dosing and dosing prior to a painful treatment or event.

Types of Analgesic Medications

    The AGS has recently published updated guidelines for pain management in older adults (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). Information on accessing these guidelines is included in the Resources section at the end of this chapter. 

    The guidelines provide comprehensive information about managing persistent pain, but the recommendations apply to acute pain management as well. Thus, the reader is referred to these guidelines for more comprehensive information.

    Nonopioid Medications. Acetaminophen is considered the drug of choice for mild-to-moderate pain in older adults (Herr, Bjoro, Steffensmeier, et al., 2006). It is recommended that the total daily dose should not exceed 4 g per day (maximum 3 g/day in frail elders). 

    Because of the potential for hepatic toxicity, the maximum dosage should be reduced by 50%-75% in adults with impaired hepatic metabolism, renal disease, or a history of alcohol abuse (Herr, Bjoro, Steffensmeier, et al., 2006).

    Nonsteroidal anti-inflammatory drugs (NSAIDs), commonly used to treat pain in the general population, are not recommended for use in persons older than the age of 75 (Kuehn, 2009). 

  There are two types of NSAIDs: nonselective (eg, ibuprofen, naproxen) and cyclooxygenase (COX)-2 selective inhibitors. Several of the COX-2 drugs have been removed from the market because of serious, life-threatening cardiovascular side effects, and those that remain available should be used with caution and only within the recommended dosages (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

    NSAIDs are associated with serious cardiovascular and gastrointestinal side effects. and gastric damage is the most common side effect. All adults older than the age of 65 are considered to be at moderate risk for gastrointestinal side effects and should receive gastric protective therapy with proton pump inhibitor (Kuehn, 2009).

    Opioid Medications. Opioid drugs (eg, codeine and morphine) are effective at treating moderate-to-severe pain from multiple causes. According to the AGS (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009), opioid analgesics can be used safely and effectively in older adults if they are properly selected and monitored. 

    All providers caring for older patients should prescribe opioids based on clearly defined therapeutic goals. Prescribing should occur based on serial attempts to reach these goals, with the lowest doses chosen based on efficacy and side effects.

    Many older adults and health care providers are reluctant to use opioids because of fears of addiction, side effects, and intolerance. Potential side effects include nausea, pruritus, constipation, drowsiness, cognitive effects, and respiratory depression. 

    The most serious side effect, respiratory depression, is rare and can be mitigated by slow dose escalation and careful monitoring for signs of sedation (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Wells et al., 2008). 

    To prevent constipation, preventive measures should be initiated when the opioid is started (eg, stool softeners, adequate fluid intake, moderate activity; AGS Panel on Persistent Pain in Older Persons, 2002).

     Adjuvant Drugs. Adjuvant drugs are those drugs administered in conjunction with analgesics to relieve pain. 

    They are often administered with nonopioids and opioids to achieve optimal pain control through additive analgesic effects or to enhance response to analgesics, especially for neuropathic pain (AGS Panel on Persistent Pain in Older Persons, 2002; Wells et al., 2008). 

    Although tricyclic antidepressants (eg, nortriptyline, desipramine) have shown dual effects on both pain and depression, they are inappropriate for pain management in older adults because of high rates of serious anticholinergic side effects (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Fick et al., 2003). 

    With the advent of antidepressants that exert serotonin reuptake inhibition, and mixed serotonin and norepinephrine uptake inhibition. 

    Pain management with these types of medications has become more common in older adults because they are effective in the treatment of neuropathic pain and have a better side-effect profile (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    Anticonvulsants (eg, gabapentin) may be used as adjuvant drugs for neuropathic pain, such as trigeminal neuralgia and postherpetic neuralgia, and they have fewer side effects than tricyclic antidepressants (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009). 

    Local anesthetics, such as lidocaine as a patch, gel, or cream, can be used as an additional treatment for the pain of postherpetic neuralgia.

    Equianalgesic refers to equivalent analgesia effects. Understanding equianalgesic dosing (eg, dose conversion chart, conversion ratio) improves prescribing practices for managing pain in older adults. 

    Equianalgesic dosing charts provide lists of drugs and doses of commonly prescribed pain medications that are approximately equal in providing pain relief and can provide practical information for selecting appropriate starting doses when changing from one drug to another or finding optimal drug combinations (AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Pasero & McCaffery, 2011; Pasero, Portenoy, McCaffery, 1999).

Drugs to Avoid in Older Adults

Some medications should be generally avoided in older adults because they are either ineffective for them or cause higher risk of having side effects. Meperidine (Demerol), ketorolac (Toradol), and pentazocine (Talwin) are considered inappropriate analgesic medications for older adults. 

    These medications cause central nervous system side effects, including confusion or hallucinations, and may not be effective enough when administered at the commonly prescribed dose or may produce more side effects than positive analgesic effect (Fick et al., 2003). 

    Additionally, sedatives, antihistamines, and antiemetics should be used with caution because of long duration of action, risk of failures, hypotension, anticholinergic effects, and sedating effects (Gordon et al., 2005).

Non-Pharmacological Pain Treatment

    Nondrug strategies are an important component of pain management. Many older adults report using several nonpharmacological modalities to manage pain (AGS Panel on Persistent Pain in Older Persons, 2002; Barry, Gill, Kerns, & Reid. 2005; Herr, 2002b). 

    The most commonly reported nonpharmacological strategies used in the acute care setting were relaxation (eg, breathing, meditation, imagery, music), activity modification, massage, and heat or cold application (Wells et al., 2008). 

    Older adult patients should be encouraged to use nonpharmacological treatment in combination with pharmacological treatment.

Types of Non-Pharmacological Treatment Strategies

    Nonpharmacological pain treatment strategies generally fall into two major categories: physical pain relief modalities and psychological pain relief modalities. Physical pain relief modalities include, but are not limited to, transcutaneous electrical nerve stimulation (TENS), physical therapies, use of heat and cold, massage, and movement. 

    Psychological pain relief modalities focus on changes in the person's perception of the pain and improvement of coping strategies (Rudy, Hanlon, & Markham, 2002). These include relaxation, distraction, guided imagery, and hypnosis. 

    Cognitive behavioral treatment, meditation, and biofeedback are strategies used for persistent pain. Various types of dietary supplements are also commonly used nonpharmacological pain treatments among older adults. To date, a few of these nonpharmacological strategies have been empirically evaluated for their effectiveness in pain management (Wells et al., 2008). 

    For persistent pain, several physical strategies such as exercise, electrical stimulation (eg. TENS), and low-level laser therapy have been evaluated, but the results are equivocal (Furlan, Imamura, Dryden, & Irvin, 2009). 

    The AGS Panel on Exercise and Osteoarthritis (2001) provided guidelines of exercise prescriptions for older adults with osteoarthritis pain. Recommendations should be individualized based on the person's comorbidities, adherence, personal preference, and feasibility of exercise. 

    Massage therapy may be effective to manage chronic low back pain and can be more beneficial when it is combined with education and exercise (Furlan et al., 2009). Despite many trials of tai chi, the effectiveness of this intervention for chronic pain in older adults is still inconclusive because of methodological issues in the studies (Hall, Maher, Latimer, & Ferreira, 2009). 

    Electrical stimulation, including TENS, has shown significant benefits for shoulder pain after stroke (Price & Pandyan, 2001).

    Psychological pain relief modalities, such as cognitive behavioral therapy, biofeedback, and meditation, are commonly used for persistent pain (Middaugh & Pawlick, 2002). 

    Cognitive behavioral treatments, including relaxation, guided imagery, and meditation, have also shown significant improvement in pain and mobility due to osteoarthritis among older adults (Baird, Murawski, & Wu, 2010). 

    In the acute care setting, relaxation, massage, and music are often used to help manage acute pain (Wells et al., 2008). Each of these nondrug approaches has demonstrated mixed results, largely because of individual patient preferences and methodological differences in how the studies were conducted. 

    Thus, there is no conclusive evidence that these modalities relieve pain. Instead, they should be considered on an individualized basis, depending on patient preference and response, and as an adjunct to pharmacological treatment.

    In summary, nonpharmacological treatments are widely used comfort measures to help manage pain. These approaches are challenging to study because it is difficult to find a convincing placebo and to control the dose of the treatment. 

    In addition, studies have contributed inconsistent findings because of differences in study designs, inconsistent measures, and mixed intervention durations. 

    Despite the lack of rigorous support for these nondrug approaches, older adults express interest in using these strategies to manage their pain (Dunn & Horgas, 2000; Herr, 2002b; Horgas & Elliott, 2004). Thus, nurses should consider all possible options for managing pain and discuss these approaches with their older adult patients. 

    Special Considerations of Using Nonpharmacological Treatment for Older AdultsIndividuals vary widely in their preferences for and ability to use nonpharmacological interventions to manage pain. Spiritual and/or religious coping strategies, for instance, must be consistent with individual values and beliefs. 

    Other strategies, such as guided imagery, biofeedback, or relaxation, may not be feasible for cognitively impaired older adults. Therefore, it is important for health care providers to consider a broad array of nonpharmacological pain management strategies and to tailor selections to the individual. 

    It is also important to gain individual and family input about the use of home and folk remedies because use of herbals or home remedies is often not disclosed to health care providers and may result in negative drug-herb interactions (Yoon & Horne, 2001; Yoon , Horne, & Adams, 2004; Yoon & Schaffer, 2006).

Improving Pain Management In Care Settings

    Nurses have a critical role in assessing and managing pain. The promotion of comfort and relief of pain is fundamental to nursing practice and, as integral members of interdisciplinary health care teams, nurses must work collaboratively to effectively assess and treat pain. 

    Given the prevalence of pain in older adults and the burgeoning aging population seeking care in our health care systems, this nursing role is vitally important. In addition, nurses have the primary responsibility to teach the patient and family about pain and how to manage it both pharmacologically and non-pharmacologically. 

    As such, nurses must be knowledgeable about pain management in general, and about managing pain in older adults in particular. Furthermore, nurses are responsible for basing their practice on the best evidence available, and helping to bridge the gap between evidence, recommendations, and clinical practice.

    Nurses, however, must work within an organizational climate that supports and encourages efforts to improve pain management. These efforts must go beyond simply distributing guidelines and recommendations because this approach has not been effective (Dirks, 2010). 

    Some quality improvement processes that should be considered in promoting improved pain management include the following (Dirks, 2010):

1. Facilities/institutions must demonstrate and maintain strong institutional commitment and leadership to improve pain management.

2. Facilities/institutions will establish an internal pain team of committed and knowledgeable staff who can lead quality improvement efforts to improve pain management practices.

3. Facilities/institutions must establish 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. Facilities/institutions will provide evidence of using a multispecialty approach to pain management. This includes referral to specialists for specific therapies (eg psychiatry, psychology, physical therapy, interdisciplinary pain treatment specialists). Clinical pathways and decision support tools will be developed to improve referrals and multispecialty consultation.

5. Facilities/institutions will provide evidence of pain management resources for staff (eg, educational opportunities; print materials, access to web-based guidelines and information).