Persistent Pain Management in Older Adults
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Persistent Pain Management in Older Adults Authors: Paul Arnstein, PhD, RN, FAAN Keela Herr, PhD, RN, FAAN Series Editor: Howard K. Butcher, PhD, RN i Copyright Copyright © 2015 The University of Iowa and the contributing authors All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence. The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence 50 Newton Drive Iowa City, Iowa 52242 The author and the publisher of this work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. 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If medical advice is desired or required, you are strongly encouraged to seek the services of a licensed medical practitioner. 1 Persistent Pain Management Persistent Pain Management in Older Adults The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence Table of Contents Page I. Evidenced-based Practice Guideline A. Scheme for Grading the Strength/Consistency of Evidence 3 B. Introduction 4 C. Purpose 5 D. Individuals at Risk for Persistent Pain 5 E. Definition of The Practice 6 F. Assessment Tools & Forms 11 G. Management Strategies 14 H. Pharmacologic Approaches 20 I. General Pharmacological Considerations 21 J. Summary 26 i. Nursing Interventions Classification (NIC) 29 ii. Nursing Outcomes Classification (NOC) 30 K. Evaluation of Process 30 II. Appendices Appendix A: Persistent Pain Assessment Tools 31 Appendix A.1: Pain Intensity Scales 32 Appendix A.1a: Numeric Rating Scale 33 Appendix A.1b: Verbal Descriptor Scale 34 Appendix A.1c: Pain Thermometer 35 Appendix A.1d: Faces Pain Scale 36 Appendix A.2: Pain Impact Tools Appendix A.2a: Brief Pain Inventory-Short Form 37 Appendix A.2b: Functional Pain Scale (modified) 39 Continued on next page Persistent Pain Management in Older Adults Evidence-based Guideline The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence Written 2005; Revised 2015 2 Persistent Pain Management Page Appendix A.3: Pain Behavior Assessment Tools 41 Appendix A.3a: PAINAD 42 Appendix A.3b: PACSLAC-II 44 Appendix A.4: Algorithm for Cognitively Impaired Older Adults 46 Appendix B: Persistent Pain Management Knowledge Assessment Test 48 Appendix C: Persistent Pain Management Process Evaluation Monitor 51 Appendix D: Persistent Pain Management Outcomes 53 Appendix E: Definition of Key Terms 56 Appendix F: Additional Resources 57 III. References 58 IV. Contact Resources 75 Persistent Pain Management in Older Adults Evidence-based Guideline The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence Written 2005; Revised 2015 3 Persistent Pain Management The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence Scheme for Grading the Strength & Consistency of Evidence in the Guideline This guideline was developed from an exhaustive literature review and synthesis of current evidence on assessing and managing persistent pain in older adults. Research and other evidence, such as guidelines and standards from professional organizations, were critiqued, analyzed, and used as supporting evidence. The practice recommendations are assigned an evidence grade based upon the type and strength of evidence from research and other literature. The grading schema used to make recommendations in this Evidence-Based practice guideline is: Evidence from well-designed meta-analysis or well-done systematic review with results that A1 = consistently support a specific action (e.g., assessment, intervention, or treatment) A2 = Evidence from one or more randomized controlled trials with consistent result B1 = Evidence from high quality Evidence-Based practice guideline B2 = Evidence from one or more quasi experimental studies with consistent results Evidence from observational studies with consistent results (e.g., correlational, descriptive C1 = studies) C2 = Inconsistent evidence from observational studies or controlled trials D = Evidence from expert opinion, multiple case reports, or national consensus reports Persistent Pain Management in Older Adults Evidence-based Guideline The University of Iowa College of Nursing Barbara and Richard Csomay Center for Gerontological Excellence Written 2005; Revised 2015 4 Persistent Pain Management INTRODUCTION People living in the developed world can now expect to live longer than at any time in history. Although evidence-based practices in modern healthcare routinely promote longevity and save people from the brink of death (Kotter, Blozik, & Scherer, 2012; Wilke, Grube, & Bodmann, 2011); the practices believed to prevent pain, and effectively manage pain in a safe manner, are not routinely implemented (American Geriatrics Society, 2012; Herr, Titler et al., 2010; Jinks et al., 2011; Titler et al., 2009). Approximately half of older adults living in the community have persistently painful conditions (MacFarlane et al., 2011; Patel, Guralnik, Dansie, & Turk, 2013; Tsai, Liu, & Chung, 2010) with more frequently encountered pain during the final months of life (Smith et al., 2010). An even greater proportion of older adults living in institutions face this nemesis on a daily basis (Tse, Leung & Ho, 2012). Older adults should not live or die with needless pain because of the negative effects it has on health, longevity and quality of life (O'Mahony, Goulet, & Payne, 2010). Persistent intense pain can harm the person’s mind, body, spirit and social interactions; resulting in disability, despair and medical frailty (American Geriatrics Society Panel on Persistent Pain in Older Persons, 2002; Griffin, Harmon, & Kennedy, 2012; Institute of Medicine (IOM), 2011; Jakobsson, Rahm-Hallberg, & Westergren, 2004; James, Miller, Brown, & Weaver, 2005; Johansen, Romundstad, Nielsen, Schirmer, & Stubhaug, 2012; Sheiga, Dale, Andrew, Paice, Rockwood, & Weiner, 2012; Tsai, Tak, Moore, & Palencia, 2003). Chronic pain changes the structure and function of nerves throughout the