Movement-Evoked Pain in Older Adults with Musculoskeletal Conditions: Assessment and Management.

Chapter 24 - Pain Assessment and Management in Older Adults

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

Low back pain (LBP) is highly prevalent and disabling for older adults. Movement-evoked pain is an emerging measure that may help to predict disability; but is not currently a part of geriatric LBP clinical care. This study tested the safety and feasibility of a new Movement-Evoked Provocation Test for Low Back Pain in Older Adults (MEPLO). We also compared associations between movement-evoked pain via 2 different scoring methods and disability-associated outcomes. Thirty-nine older adults with persistent LBP provided baseline recalled and resting pain ratings, self-reported physical function, and usual gait speed. Participants then completed MEPLO, involving 4 tasks essential for functional independence: chair rises, trunk rotation, reaching, and walking. Movement-evoked pain was then quantified using the traditional change score (delta) method of pain premovement to postmovement; and also, a new aggregate method that combines pain ratings after the 4 tasks. No safety or feasibility issues were identified. Compared with the delta score, the aggregate score was more strongly associated with self-reported physical function (beta: -0.495 vs. -0.090) and usual gait speed (beta: -0.450 vs. -0.053). Similarly, the aggregate score was more strongly associated with self-reported physical function than recalled and resting pain (beta: -0.470, -0.283, and 0.136, respectively). This study shows the safety and feasibility of testing movement-evoked pain in older adults with persistent LBP, and its potential superiority to traditional pain measures. Future studies must validate these findings and test the extent to which MEPLO is implementable to change with geriatric LBP standard of care.

Assessment and measurement of pain in older adults

Chronic Pain in Older Adults

This paper is a report of a literature review conducted to identify barriers to successful pain assessment in older adults with dementia and possible strategies to overcome such barriers. Pain is frequently undetected, misinterpreted, or inaccurately assessed in older adults with cognitive impairment. These people are often unable to articulate or convey how they feel and are often perceived as incapable of experiencing or recalling pain. Searches were conducted of CINAHL, Medline and other databases for the period 1993-2007 using the search terms pain, dementia, assess*, barrier* and obstacle*. Studies were critically appraised by two independent reviewers. Data were extracted using instruments specifically developed for the review. Studies were categorized according to levels of evidence defined by the Australian National Health and Medical Research Council and Joanna Briggs Institute. Perceived barriers to successful pain assessment in people with dementia included lack of recognition of pain, lack of sufficient education and/or training, misdiagnosis or late diagnosis, and non-use of assessment tools. Barriers related to people with dementia included insufficient evidence, the possibility of a 'no pain' subset of people with dementia, type of pain, and stoical attitudes. Strategies proposed as means of overcoming these barriers included knowing the person, knowing by diversity/intuitive perception, education and training, and use of adequate tools. More extensive education and training about the relationship between pain and dementia are urgently needed, as is the development and implementation of an effective pain assessment tool specifically designed to detect and measure pain in older adults with all stages of dementia.

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.

Evaluation of Multidimensional Pain Measures for Older Adults: A Scoping Review.

A Paradigm Shift for Movement-based Pain Assessment in Older Adults: Practice, Policy and Regulatory Drivers

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.

To report data on current nurse practice behaviors related to evidence-based assessment of acute pain in older adults, perceived stage of adoption of pain assessment practices, and perceptions of barriers to optimal assessment in this population. Medical records from 709 older adult patients hospitalized with hip fractures from 12 acute care settings were abstracted for nurse assessment practices during the first 72 hours after admission. Questionnaires sent to nurses on study units regarding perceived stage of adoption and barriers to assessment in older adults. Data revealed several areas in which pain assessment practices were not optimal. Pain was not routinely assessed every 4 hours, and pain location was assessed even less frequently. Pain behaviors were assessed more in patients with a diagnosis of dementia compared to those without dementia, but the frequency of pain behavior assessments was low. Pain was not routinely assessed within 60 minutes of administering an analgesic. Nurses reported not using optimal pain assessment practices even when they were aware of and persuaded that those practices were desirable. In addition, nurses reported that difficulty communicating with patients created the greatest challenge in managing pain. Our data suggest that pain is not being assessed and reassessed in a manner that is consistent with current practice recommendations in older adult patients with pathologic processes that highly suggest the presence of acute pain.

PurposeCognitive impairment is correlated with physical function. However, the results in the literature are inconsistent with cognitive and physical performance measures. Thus, the aim of this study was to determine the association between cognitive performance and physical function among older adults.MethodsA total of 164 older adults aged ≥60 years and residing in low-cost housing areas in Kuala Lumpur, Malaysia participated in this study. Cognitive performance was measured using the Mini Mental State Examination, clock drawing test, Rey auditory verbal learning test, digit symbol test, digit span test, matrix reasoning test, and block design test. Physical performance measures were assessed using the ten step test for agility, short physical performance battery test for an overall physical function, static balance test using a Pro.Balance board, and dynamic balance using the functional reach test.ResultsThere was a negative and significant correlation between agility and the digit symbol test (r=−0.355), clock drawing test (r=−0.441), matrix reasoning test (r=−0.315), and block design test (r=−0.045). A significant positive correlation was found between dynamic balance, digit symbol test (r=0.301), and matrix reasoning test (r=0.251). The agility test appeared as a significant (R2=0.183, R2=0.407, R2=0.299, P<0.05) predictor of some cognitive performance measures, including the digit span test, clock drawing test, and Mini Mental State Examination.ConclusionThese results suggest that a decline in most cognitive performance measures can be predicted by poor execution of a more demanding physical performance measure such as the ten step test for agility. It is imperative to use a more complex and cognitively demanding physical performance measure to identify the presence of an overall cognitive impairment among community-dwelling older adults. It may also be beneficial to promote more complex and cognitively challenging exercises and activities among older adults for optimal physical and cognitive function.

Objective:The aim is to map out and describe, through a scoping review, the current evidence on immersive virtual reality (IVR) for postoperative pain management in surgical older adults.Background:Managing postoperative pain in older adults through pharmacological interventions poses inherent complexity and risk to the patient. There is a growing interest in nonpharmacological interventions, including IVR, to address postoperative pain in older adults. However, IVR use for postoperative pain across a spectrum of surgical procedures remains largely unknown in the older adult demographic.Methods:A comprehensive literature search of 5 databases was conducted through April 2024. Inclusion criteria were: (1) mean/median age greater than 65; (2) patients underwent surgical procedures; (3) the intervention group received IVR before, during, or after surgery; and (4) numerical postoperative pain scores were collected. Study titles/abstracts underwent initial screening against inclusion/exclusion criteria, followed by full-text screening. A narrative report was compiled with the identified studies.Results:This scoping review yielded 10 studies. Three main findings emerged: (1) IVR for postoperative pain occurred predominantly in total joint replacement surgery; (2) while over half of the studies in this review indicated that IVR could improve postoperative pain management, weak to moderate study designs and small sample sizes limited the ability to draw firm conclusions about IVR use in older adults; and (3) there was significant heterogeneity in IVR administration and program content offered.Conclusions:Despite common misconceptions that older adults are averse to new technology, this scoping review suggests that IVR for postoperative pain in older surgical adults holds potential as an acceptable and feasible intervention. This review highlights the need for more rigorous randomized clinical trials on IVR efficacy in older adults across a more diverse spectrum of surgical procedures and older adult subgroups (eg, underrepresented minority groups or those with physical/cognitive limitations).

In 2011, an Institute of Medicine report, Relieving Pain in America, called for a cultural transformation of pain care.1 The report concluded that “healthcare providers should increasingly aim at tailoring pain care to each person's experience, and self-management of pain should be promoted.”1(p1) Medical treatments are often less than adequate for patients with chronic musculoskeletal pain. Ordering more diagnostic tests of uncertain value, prescribing more prescription analgesics with poorly understood risks and benefits, and providing more surgical procedures, nerve blocks, and epidural injections will not achieve the aims of improved patient outcomes, increased patient satisfaction, and more prudent use of finite health care resources.2,3 Rather, we need to help patients with chronic pain resume valued life activities by placing more emphasis on improving quality of life and less on interventions that afford only short-term pain relief with appreciable risks and costs.

Negative pain beliefs are associated with adverse pain outcomes; however, less is known regarding how positive, adaptive factors influence pain and functioning. These relationships are especially important to examine in older adults with pain, given increased disability and functional limitations in this population. We investigated whether pain resilience moderated the relationships between negative pain beliefs (fear-avoidance, pain catastrophizing) and pain outcomes (functional performance, movement-evoked pain) in sixty older adults with low back pain. Higher pain resilience was associated with lower fear-avoidance (p < .05) and pain catastrophizing (p = .05). After controlling for demographic variables, higher fear-avoidance (p = .03) and catastrophizing (p = .03) were associated with greater movement-evoked pain in individuals with low pain resilience, but not among those high in resilience. No significant moderation effects were observed for functional performance. Resilience may attenuate the relationship between negative psychological processes and pain-related disability, highlighting the need for interventions that enhance pain resilience in older adults.