Clinicians' perspectives of pain in older adults with heart failure.

Clinicians’ Practices In Pain Assessment And Management For Elderly With Heart Failure

Pain is not uncommon in older adult patients with heart failure (HF) and has been identified as a risk factor for rehospitalization of homebound patients with HF. Little is known about the pain experiences and management of older adults with HF after hospital discharge. We sought to describe pain and other symptoms among homebound older adults with HF using a qualitative and descriptive approach. We conducted semistructured interviews to obtain qualitative data and used the Brief Pain Instrument-Short Form and the Edmonton Symptom Assessment Scale to obtain descriptive data on symptom burden. We interviewed 18 participants within 10 days after hospital discharge. Participants' mean age was 75.8 ± 9.0 years; 78% were White. The mean pain score at its worst was 5.2 ± 3.1, and for pain interfering with sleep was 4.3 ± 3.41. Most participants managed pain with medications. Using thematic analysis of qualitative data, we identified three distinct categories: (1) the diversity of patients' pain experiences, (2) the diversity of pain management routines, and (3) patients' experiences with healthcare providers' pain assessment and management practices. Our findings show that homebound older adults with HF experience various pain symptoms and receive inconsistent education about how to manage pain from healthcare providers. This study supports the need for better pain assessment and education about the appropriate use of pain medications and nonpharmacologic approaches to pain control for homebound older adults with HF.

Pain assessment and management in older adults requires a special emphasis on the needs of this population, which is often not considered within general education. The purpose of this study was twofold: to determine the availability of education on pain in older adults around the world, and to present a review and synthesis of published guidelines and key papers on pain assessment and management in older adults. Following on from this study we intend to make recommendations on what work needs to be carried out in future to inform the development of a curriculum or curriculum content specifically dedicated to pain management for older adults. A discussion forum was set up through the Pain in Older Adults Special Interest Group of the International Association for the Study of Pain (IASP) at the end of 2009. This forum was initiated to determine the current level and availability of education available around the world for health professionals on pain in older adults. A number of IASP members from countries around the world participated in the discussion and identified educational courses on pain in older adults from their member country. Following on from this discussion, a number of leading experts agreed to collate guidelines and key papers and conduct a critical review using Appraisal of Guidelines Research and Evaluation (AGREE) criteria. A total of 14 guideline documents on pain assessment and management were reviewed by the group. The papers were reviewed and graded and then agreed between reviewers. From the guideline review, some recommendations can be made, but primarily, the key recommendation from this work was to develop collaboration and a review of key evidence on which future research may be developed so an educational focus may be highlighted. This article presents a summary of those documents along with recommendations for improved and consistent education informed by the guidelines currently developed, and consistent evidence-based assessment and management of chronic pain in older adults.

Objectives:Patients with heart failure (HF) experience severe pain and may have altered pain sensation; however, the underlying mechanisms of these symptoms are not yet fully understood. Identifying pain sensation and genomic biomarkers of pain in older adults with HF is a critical step toward developing personalized interventions to improve pain management and outcomes. This study aimed to investigate the differences in pain sensation, gut microbiota, self-reported pain, and symptoms in older adults with and without HF.Methods:Twenty older adults with HF and age-matched healthy controls (HCs) were recruited in the Northeastern United States. Quantitative sensory testing and conditioned pain modulation were performed on the nondominant upper arm to detect the mechanical, thermal, and pressure pain thresholds and pain modulations. Stool samples were collected, and the 16S rRNA V4 gene region of stool samples was sequenced and processed using the Mothur 1.42.3 pipeline. Self-reported pain and symptoms were measured by the Brief Pain Inventory and the NIH Patient-reported Outcomes Measurement Information System. The associations between pain sensation, gut microbiota α-diversity indices, and pain and symptoms were explored using the Spearman correlations.Results:The HF and HC subjects’ mean ages were 73.50 (SD = 8.33) and 67.10 (SD = 7.64), respectively. The HF subjects reported significantly higher pain intensity and interference, sleep disturbance, fatigue, anxiety, and depression than the HCs. The HF subjects also had a significantly lower level of physical function and participation in social roles and activities. Compared with the HCs, the HF subjects had significantly altered conditioned pain modulation heat effect and gut microbiota compositions and predicted metabolic functions. The Statistical Analysis Of Metagenomic Profiles indicated that the HF subjects had a significantly decreased cardiac muscle contraction pathway compared with the HCs. The correlation analysis showed that the quantitative sensory testing profiles and gut microbiota diversity index were significantly associated with pain and symptoms in older adults with HF.Conclusions:Older adults with HF had more severe self-reported pain and symptoms, altered pain sensation, and different gut microbiota composition and function compared with age-matched HCs. Pain sensation and gut microbiota may contribute to pain and symptoms in older adults with HF and could serve as biomarkers of pain and symptoms of HF. Further research with a larger sample size is warranted to confirm these findings.

Pain symptoms are underreported in older adults (i.e., those ages ≥65), because many consider it a part of aging. Pain is highly prevalent in patients with heart failure (HF). HF is increasing in incidence with the aging population. Pain is also an important risk factor for rehospitalization among home healthcare patients with HF. However, little is known about the pain experiences of older adults with HF after hospital discharge. Accordingly, this study sought to describe pain and other symptoms among older adults with HF in the home healthcare setting using a mixed-methods approach. We conducted semi-structured interviews. We used the Edmonton Symptom Assessment Scale and Brief Pain Instrument on older adults (N=17) with HF in the home healthcare setting within 10 days of hospital discharge. The mean age was 76±9.25 years, nearly 50% were female, and most (90%) were White. The majority of participants managed pain with medications. Loss of appetite had the highest mean severity score (3.88±2.50) of symptoms measured. The mean score for pain at its worst was 4.94±3.07. Pain interfering with sleep had the highest mean score (4.24±3.36). Using content analysis we identified 4 distinct themes regarding the pain experience: (1) differences in the pain experiences before and after being diagnosed of HF, (2) symptoms accompanied with pain, (3) health care providers’ pain assessment, and (4) knowledge about pain management. These findings will contribute to the development and evaluation of a pain assessment and management protocol targeting older adults with HF in the home healthcare setting.

Background: As the number of older adults in Thailand continues to increase, along with increased incidence of surgical intervention that causes pain, the quality of pain care in older adults is needed. Nurses are primarily responsible for assessing and managing pain in older adults (Jose Closs, 2008; Prowse, 2007). The use of evidencebased practices (EBPs) improves quality of care and saves healthcare cost. However, in Thailand where empirical study of using EBP related to pain in older adults is limited, research to understand how Thai nurses use EBP acute pain in older adults is needed. Purpose: The purpose of this study is to describe current practices, perceived barriers and perceived facilitators of Thai nurses on using EBP for assessing and managing acute pain in postoperative older adults. Method: A descriptive exploratory survey was conducted in 8 mid and large-size hospitals in Thailand. The Acute Pain EBP Questionnaire (APEBPQ) (Suwanraj, 2009) was distributed to 240 Thai nurses. 236 questionnaires were returned with the response rate of 98.3 percent. Open-ended questions related to barriers and facilitators of using EBPs were coded to identify major themes. MANOVA was performed to explore the differences between years of nursing experience on perceived barriers and facilitators. Results: The majority of participants are female (96.8%) with mean age 35.5 years (range=23-54). Thai nurses reported using 51/53 recommendations from EBPG Acute Pain most of the time/always (95%). Using an equianalgesic table (1.80±1.16) and assessing MMSE in older adults with postoperative pain (1.74±1.15) were occasionally used. Research reports published in English was the greatest barriers. Nurses perceived greatest support from a Head ward than other colleagues. Nurses with 11-20 years of nursing experience had higher reported barriers than those with 1-10 years of nursing experience.

Assessment and Management of Cancer Pain in Older Adults: Strategies for Success

Influence of Studies Published by the Journal of the American Geriatrics Society: Top 20 Articles from 2000-2015.

Pain syndromes are prevalent among older individuals and generally increase in incidence as the population ages. Yet, pain often is undertreated in older patients, sometimes due to difficulties in assessing pain intensity and the effectiveness of treatment in the context of age-related cognitive impairment and physiologic changes. As a result, older patients with chronic pain conditions are more likely to experience greater functional limitations and decreased quality of life due to these and other barriers to appropriate care. This article discusses the epidemiology, assessment, and management of pain in older adults, and reviews special issues in the treatment of this population, such as adverse effects due to changes in drug metabolism and drug-drug interactions.

#### The bottom line Chronic pain is one of the most common conditions encountered by healthcare professionals, particularly among older (≥65 years) patients.1 Pain is associated with substantial disability from...

To present the third in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributors to pain and disability in older adults with CLBP. This article focuses on fibromyalgia syndrome (FMS). A modified Delphi approach was used to create the evaluation and treatment algorithm, the table discussing the rationale behind each of the algorithm components, and the stepped-care drug recommendations. The team involved in the creation of these materials consisted of a principal investigator, a 5-member content expert panel, and a 9-member primary care panel. The evaluation and treatment recommendations were based on availability of medications and other resources within the Veterans Health Administration (VHA) facilities. However, non-VHA panelists were also involved in the development of these materials, which can be applied to both VA and civilian settings. The illustrative clinical case was taken from the clinical practice of the principal investigator. Following expert consultations and a review of the literature, we developed an evaluation and treatment algorithm with supporting materials to aid in the care of older adults with CLBP who have concomitant FMS. A case is presented that demonstrates the complexity of pain evaluation and management in older patients with CLBP and concomitant FMS. Recognition of FMS as a common contributor to CLBP in older adults and initiating treatment targeting both FMS and CLBP may lead to improved outcomes in pain and disability.

Management of cancer pain: ESMO Clinical Practice Guidelines

To synthesise and appraise the evidence of the efficacy of serious games in reducing chronic pain among older adults. Chronic pain in older adults generally results in a substantial handicap due to decreased mobility, exercise avoidance and various concerns that affect their overall quality of life. While serious games have been widely used as a pain management approach, no reviews have thoroughly examined their efficacy for chronic pain management in older adult populations. A systematic review and meta-analysis. The CINAHL, the Cochrane Library, Embase, Medline, PubMed and Web of Science databases were comprehensively searched to find articles published from their inception until 17 April 2023. RoB-2 was used to assess the risk of bias in the included studies. The efficacy of serious games for pain management in older individuals was investigated using pooled standardised mean differences (SMDs) in pain reduction using a random effect model. The meta-analysis comprised nine randomised controlled trials that included 350 older adult patients with pain. Serious games effectively alleviated pain in this group (pooled SMD = -0.62; 95% confidence interval: -1.15 to -0.10), although pain-related disability and fear require further investigation. Serious games tended to effectively reduce pain in this older adult group; however, due to a lack of randomised controlled trials, the analysis found lower effectiveness in reducing pain-related disability and fear. Further studies are accordingly required to confirm these findings. The findings of the study emphasise the importance of serious games to increase the motivation of older adults to exercise as one of the safe and extensively used pain management strategies. Serious games that effectively reduce chronic pain in older adults are characterised as consisting of diverse physical activities delivered through consoles, computer-based activities and other technologies. Serious games are recommended as being potentially useful and practical for reducing pain in older adults.

Since the initial scientific statement on Secondary Prevention of Coronary Heart Disease (CHD) in the Elderly was published in 2002,1 several trends have continued that make an update highly appropriate. First, the graying of the US population and those of other industrialized countries has progressed unabated because more adults are surviving into their senior years. The number of Americans aged ≥75 years was estimated at 18.6 million in 2010, representing ≈6% of the population,2 and it is expected to double by 2050. The population aged ≥85 years is growing the most rapidly, with numbers expected to reach 19.5 million by 2040. In 2008, 67% of the 811 940 cardiovascular deaths in the United States occurred in people aged ≥75 years.3 In parallel to this increase in the older adult demographic, the number of Americans with CHD has increased to an estimated 16.3 million, more than half of whom are >65 years of age.3 Similarly, 7 million have had a stroke, the incidence of which approximately doubles with successive age decades after 45 to 54 years.3 Peripheral artery disease (PAD) affects 8 to 10 million Americans, the majority of whom are >65 years of age. Between 2015 and 2030, annual US costs related to atherosclerotic cardiovascular disease (ASCVD) are projected to increase from $84.8 billion to $202 billion.3 Moreover, given that ASCVD often undermines functional capacity and independence and increases reliance on long-term care, indirect expenses related to ASCVD are also expected to increase. Thus, the need for effective secondary prevention measures in the older adult population with known ASCVD has never been greater. Notably, the 2011 American Heart Association (AHA)/American College of Cardiology Foundation (ACCF) updated guidelines for secondary prevention of CHD broadened …

Chapter 24 - Pain Assessment and Management in Older Adults