Danielle Hersey, BSN, RN

Maine State Director

Danielle Watford, MS, CMQ-OE

Program Administrator

Aging Doesn’t Have to Hurt: Creating a pain language between

patient and provider

This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

CMSMAC22017091151

Learning Session

Objectives

Understanding the pain scale;

Barriers to universal pain scales;

Importance of developing a pain language;

Review other options for pain interventions;

…and discuss other resources and opportunities for training.

9/21/2017 2

‘I don’t want to be perceived as an over prescriber…’ ‘I don’t want to be perceived as an over user…’

How do we view pain

management?

Pain Definition

“An individual’s unpleasant

sensory or emotional experience”

Source:

AMDA CPG for Pain Management for Medical Directors and Attending Physicians

Empirical Evidence

• 10 residents with “difficult” behaviors were

treated with acetaminophen TID.

• Five of ten showed in behavioral episodes

• Psychoactive meds discontinued in 6 people

Source:

Douzjian et al. (1998). Annals of LTC, 174-179

Achieving a Comfort Goal

Ask them & document it

Transfer the comfort level (number) to the

electronic medical record…

Refer to the comfort level goal.

Comfort goal can change over time

Best Practices in Pain Management

Assessment

Establishing Comfort Goal

Monitoring Intervention Effectiveness

Critical Thinking

Additional Assessments as indicated

Pre and Post Documentation

Nursing Best Practice is to:

Evaluate for pain using a (validated) tool – upon report of pain

Evaluate after medicating them according to facility policy – even if he/she appears to be sleeping

Compare results with comfort goal

Measuring Pain

Pain is subjective.

“Pain is what the individual

says it is”: the gold standard in

pain management.

We are trying to put a number

on pain so that we can measure

it.

You can only

manage what you

measure!

Understand the Pain Scale

• Pre-admission

• On admission

• During Activities of Daily Living

Before it’s needed

• We use the scale to measure our progress

• No right or wrong answer

• Don’t compare to others

• We use as part of our approach to pain management

Key points

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Providing a Pain Language

13

Providing a Pain Language

14

Providing a Pain Language

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It’s more than just words…

Source:

AMDA CPG for Pain Management for Medical Directors and Attending Physicians

Change in gait or behavior

Resisting certain movements during care

Decreasing activity levels

Striking out

Sleeping poorly Breathing

heavily Restlessness Sighing

Rubbing Groaning Calling out repeatedly

Non-verbal Pain Assessment

Avoid the Rollercoaster Effect

Pain is still a Vital Sign

• “Most chronic pain is related to arthritis and

musculoskeletal problems”

• “Unrelieved chronic pain is not an inevitable

consequence of aging”

• “When older patients are treated, it may be focused on

current diagnosis or current problem: don’t forget to

address chronic pain issues too”

• “The most common reason for unrelieved pain [in the

elderly] in the U.S., is failure to routinely assess for pain”

Source:

AMDA CPG for Pain Management for Medical Directors and Attending Physicians

Myths or Beliefs about Pain by

some Elderly People

Source:

AMDA CPG for Pain Management for Medical Directors and Attending Physicians

“Acknowledging pain will mean undergoing intrusive and possibly painful tests”

“Chronic pain means death is near”

“Pain always indicates the presence of a serious disease”

“Patients say they are in pain to get attention”

“Elderly patients are likely to become addicted to pain medications”

Bias vs Brainstorm

Bias: Do you have a resident who requests prn pain

meds on the way to BINGO and you think they don’t look

like they are in pain?

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Brainstorm: Is resident afraid that pain may develop

while at activity? Is resident afraid that if she/he does not

complain about pain that you will take away the scheduled

pain meds or reduce the amount of pain meds?

Is there a TRUST issue?

Don’t make an Assumption…

Does patient understand how pain meds work, duration,

purpose, expectations of the med?

Pain is what the patient says it is.

Is there a misunderstanding or lack of understanding

about how to describe pain, what the levels of pain are,

how reporting or not reporting pain will affect care?

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What else can cause pain?

Source of information: AMDA CPG for Pain Management for

Medical Directors and Attending Physicians

Mouth pain from sores, ill-fitting dentures

Bottom “hurts” from sitting in chair too long; pressure ulcers

Feet hurt from diabetic neuropathy

Hands or back hurt from arthritis

Back pain from compression fractures

Leg cramps, Claudication, PVD

Consider…

Keep biases of caregivers out of the equation

Families may need education regarding addiction, dependence and tolerance

Individuals most likely to develop tolerance if medication used long term

The difference between addiction, dependence and tolerance

Definitions

• Tolerance is a decreased subjective and objective effect

of the same amount of opioids used over time, results in

an increasing amount of the drug to achieve the same

effect.

• Physical dependence represents a characteristic set of

signs and symptoms (opioid withdrawal) that occur with

the abrupt cessation of an opioid (or rapid dose reduction

and/or administration of an opioid antagonist).

• Addiction is a chronic disease that “represents an

idiosyncratic adverse reaction in biologically and

psychosocially vulnerable individuals”

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Source:

(ASAM, 2001). Exp Clin Psychopharmacol. 2008 Oct; 16(5): 405–416.

Non-Drug Interventions for Pain

Non-Drug Interventions

Is there a list of non-pharmacological interventions for

pain that work for the patient? Is it accessible to all

whenever needed?

Documentation what works?

Use your Team!

Other Options…

Darkened, Quiet Room

Warm/Cool Compress

Music, listening to IPOD

Relaxation and imagery

Reiki, touch

Whirlpool, shower

Laughter therapy Acupuncture Distraction and

reframing Pastoral

Counseling

PT/OT, Range of Motion

Exercise, Massage,

Repositioning Immobilization

Transcutaneous electrical nerve

stimulation (TENS)

Assistive devices

Psychotherapy Peer support

groups And more…

Identifying a Standard of Care

Based on Clinical Guidelines

• American Geriatrics Society

(AGS), Pharmacological

Management of Persistent

Pain in Older Persons (2009)

www.americangeriatrics.org

• AMDA Clinical Practice

Guideline (CPG):

Pain Management

– 1-800-876-2632

www.amda.com/tools/guidelines.cfm

• American Pain Society (APS)

Arthritis Guidelines

– 1-847-375-4715

www.americanpainsociety.org

• American Society of

Addiction Medicine

– 1-301-656-3920

– Definitions of addiction,

dependence and tolerance

www.asam.org

Other Resources

The AMDA Clinical Practice Guideline (CPG)

for Pain Management – for Medical Directors

and attending Physicians was updated in

2012.

AMDA Clinical Practice Guideline

For Pain Management

Training Tools available:

http://www.geriatricpain.org/Content/Assessment/Impaired/

Pages/PAINADToolInstructions.aspx

There is a training video for healthcare staff as well:

“How To Try This Video: Pain Assessment in Older Adults”

Auditing Tool

Advancing Excellence Campaign website,

www.nhqualitycampaign.org

This website has an auditing tool for Pain Management that

will give you data and graphs identifying several aspects of

your pain management program, including tracking percent

of residents who receive only pharmacological intervention

for pain, only non-pharmacological intervention for pain, and

percent of residents who receive both types of interventions.

Questions?

Connect with the

New England QIN-QIO online! HealthCareForNewEngland.org

For more information…