Pain Management for Older Adults in Disadvantaged Communities.

Pain Management in Older Adults

Associations Between Cognitive Performance and Self-Efficacy for Pain Management in Older Adults With Chronic Pain

Emergency Department Pain Management in the Older Adult

ABSTRACTBackground: The undermanagement of pain in older adults has been identified as a problem worldwide.Aims: The purpose of this research is to identify priority areas in education and research for future development with the aim of improving pain management in older persons. In addition, barriers to addressing these priorities are identified.Methods: This mixed methods study, based on a modified Delphi approach, included three distinct components: (1) a qualitative component using focus groups with key informants or experts in the field of pain management in older adults (n = 17), (2) a scoping review of the literature, and (3) a survey of ranked responses completed by the same key informants who attended the focus groups. Thematic analysis was used to identify the initial list of issues and descriptive statistics were used for ranking them.Results: A number of concerns related to both education and research were frequently endorsed by participants. For education, they identified the need for more content in both undergraduate and continuing education programs related to documenting about pain; assessing pain, and learning about the complexities of pain. Research priorities included the need to explore successful practice models; costs of untreated pain; effects of mobility on pain; and patient preferences for pain management. Key barriers to addressing these barriers included lack of staff time and resources and unfamiliarity with pain assessment tools.Conclusion: These findings highlight priority issues related to pain management in older adults from a nationwide perspective.

Acute Pain Assessment and Pharmacological Management Practices for the Older Adult With a Hip Fracture: Review of ED Trends

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.

Review question/objective The objectives of the review are to determine the best available evidence on strategies to improve pain management and factors affecting pain management in emergency departments. More specifically, the review questions are to identify: What are the best strategies to improve pain management in emergency departments? What are the factors improving pain management in emergency departments? What are the factors hindering pain management in emergency departments? Background Pain is the most common reason for seeking medical attention in the emergency department.1,2 Although it accounts for up to 78% of visits to the emergency department3,4, management of pain has not received sufficient attention from many emergency department team members.5 Unfortunately, pain may be viewed as consequence of illness and injury that must be tolerated or even in some instances as a punishment for inappropriate behavior.6 Oligoanalgesia refers to the under treatment of pain and in the emergency department is thought to be common; despite the expectation that pain relief is considered to be the emergency department top priority.2, 7-10 A study conducted by Fosnocht and colleagues revealed only 45 % of the emergency department patients received pain medication prescriptions and 70% of those who received medication reported decreased pain that met with their needs.8 Despite the fact that intravenous opioid is the drug of choice recommended for treatment of severe pain, 11 less than one third of patients with severe pain were given the medication in one study.5 Up to 74% of patients who presented at an emergency department were discharged while they were suffering from moderate to severe pain.2,7 Unrelieved pain is a major, yet avoidable, significant health problem.12 Optimal management of pain in emergency department is challenging. Untreated and undertreated pain can have serious physiological and psychological consequences. Unrelieved acute pain stimulates sympathetic activity which can cause tachycardia, hypertension and sweating.6 It may exacerbate myocardial ischemia by increased myocardial work and oxygen consumption, may impair immune function by activation of the metabolic stress response, and can cause reduction in cognitive function.6,13 In addition, untreated and undertreated pain can aggravate the patients’ discomfort and exacerbate an already-stressful situation in the emergency department.5 Pain management is truly an essential nursing and medical responsibility. In application of the ethical principles of beneficence (duty to benefit another) and non-malfeasance (duty to do no harm), health personnel have a role and obligation in providing effective pain management and comfort to all patients. Hospitals are required to inform the patients regarding their rights related to pain management as stated in the Joint Commission on Accreditation of Hospital Organization 2001 Guideline.6,12 Timely and appropriate pain management is an important quality indicator of emergency department performance.14 Meeting the patients’ needs for pain relief certainly influences their satisfaction with emergency department care. Efforts to improve patients’ pain management in all health care settings are supported by the collaboration between the American Society for Pain Management Nursing (ASPMN), the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) and the American Pain Society (APS). Over 25 years of research on pain management conducted in the United States of America, Canada, and Australia, multiple standards/guidelines on pain management and regulatory statutes on pain management have been developed.2 Despite significant efforts to enhance pain management, oligoanalgesia in emergency departments still remains an important problem for emergency professions.2 After the release of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards for pain management for accredited health care organizations, pain assessment and management practices in the emergency departments showed some improvements over time.15 This notion was reflected in the study by Herr and Titler.15 Medical records from hospitalised older adult patients with hip fractures admitted through the emergency department of 12 acute care hospitals (N = 1454) were reviewed. Records were categorised into 3 different periods between 2000 and 2002. Pain assessment practices and pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults were reviewed. Results from this study revealed improvements in pain assessment practices over time (99% of patients had pain documentation in 2002). However, up to 34% of patients in this study had no objective assessment of pain (numeric rating scale) documented. Moreover, the mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 time periods. By the end of the study (2002) only 60% of patients had any analgesic ordered and of these 59% had an opioid ordered. Oligoanalgesia still needs to be explored in order to be able to manage pain in a more timely and more appropriate manner. A number of studies have been conducted to elucidate factors affecting pain management in emergency departments.10,16-18 Yet, such information is still inconclusive. Berben and colleagues suggested possible barriers in current pain management in the emergency department could arise from workload, attitudes of staff, knowledge deficits and misconceptions on the need of effective pain management.10 A cross-sectional analysis of documented emergency department visits by elderly patients from the National Hospital Ambulatory Medical Care Survey16 suggested a potential influence of attitudes toward analgesic prescribing, and the recognition of ethnic, racial, and age differences in patients with pain on the effective pain management in the emergency department. Additionally, patients' clinical condition instability may affect the pain management of the injured patients who often experience considerable pain in the emergency department.17 Lack of communication between the patient and healthcare professional, as well as organisational limitations have also been associated with pain management.18 Despite these concerns, strategies to enhance pain management have long been developed in response to the awareness of inadequate emergency department pain management.19-24 Those strategies reported in the literature include, but are not limited to, innovative use of guidelines 22, 25, use of pain protocol 26, nurse-initiated pain management 18, 21, and staff educational interventions.24 Nevertheless, we have not reached agreement on the best strategy to enhance pain management. Improving inadequate pain control is a critical goal in emergency health care. As patients’ primary health care advocators, emergency health personnel play a vital role in resolving under-treated pain in their patients.27 Up till now, the literature shows an unresolved issue of under optimal pain management in the emergency departments, which deserves serious consideration. The Cochrane Library of Systematic Reviews, Joanna Briggs Institute (JBI) Library of Systematic Reviews and CINAHL databases have been searched and no previous systematic reviews on this specific topic were identified as being published or underway. It is anticipated that this systematic review will uncover literature encompassing factors affecting and the strategies to enhance pain management in the emergency department. The aim of this systematic review is to synthesise the best available research evidence on factors that influence pain management in the emergency department, with the aim of providing timely and appropriate emergency department pain management in order to fulfil the needs for pain relief of the patients and increase their satisfaction. Inclusion criteria Types of participants This review will consider both qualitative and quantitative publications that include patients, their family members, physicians, or nurses in emergency departments. Types of intervention(s)/phenomena of interest The quantitative component of the review will consider studies that evaluate the strategies to improve pain management and factors affecting pain management in emergency departments. The qualitative component of this review will consider studies that explore the experiences of patients, family members, physicians or nurses in emergency departments regarding the pain management. Types of outcomes Quantitative: The quantitative component of this review will consider studies that include, but not limited to, the following outcome measures: patient satisfaction, relief or reduction of pain, and time to first analgesia. Types of studies The quantitative component of the review will consider any randomised controlled trials, pseudo-randomised controlled trials, before and after studies, observational analytical studies, and descriptive studies such as surveys to enable the identification of current best evidence regarding the strategies to enhance pain management and factors affecting pain management in emergency departments. The qualitative component of the review will consider qualitative studies that draw on the experiences on pain management and factors that affect pain management including, but not limited to, designs such as phenomenology, grounded theory and ethnography. Search strategy The search strategy aims to find both published and unpublished studies. The search will be limited to English language reports and will be not be limited by year of publication. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. The databases to be searched include: Academic Search Elite CINAHL ProQuest Health and Medical Complete PubMed Science Direct Scopus SpringerLink Wiley InterScience The search for unpublished studies will include: Mednar, ProQuest Dissertations & Theses, Dissertations Full Text, and conference proceedings. Initial keywords to be used will be: pain, pain management, strategy, strategies, factors, barriers, emergency, emergency department, emergency room, satisfaction, and pain reduction. Assessment of methodological quality Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix II). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the JBI-QARI (Appendix III). Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix IV). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Qualitative research findings will, where possible be pooled using the JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rated according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. Quantitative papers will, where possible be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form. Conflicts of interest There are no conflicts of interest in this review.

There is limited knowledge on whether and how health care access restrictions imposed by the coronavirus disease of 2019 pandemic have affected utilization of both opioid and nonpharmacological treatments among US older adults living with chronic pain. We compared prevalence of chronic pain and high impact chronic pain (ie, chronic pain limiting life or work activities on most days or every day in the past 6 months) between 2019 (pre-pandemic) and 2020 (first year of pandemic) and utilization of opioids and nonpharmacological pain treatments among adults aged ≥65 years enrolled in the National Health Interview Survey, a nationally representative sample of noninstitutionalized civilian U.S. adults. Of 12 027 survey participants aged ≥65 (representing 32.6 million noninstitutionalized older adults nationally), the prevalence of chronic pain was not significantly different from 2019 (30.8%; 95% confidence interval [CI], 29.7%-32.0%) to 2020 (32.1%; 95% CI, 31.0%-33.3%; p = .06). Among older adults with chronic pain, the prevalence of high impact chronic pain was also unchanged (38.3%; 95% CI, 36.1%-40.6% in 2019 versus 37.8%; 95% CI, 34.9%-40.8% in 2020; p = .79). Use of any nonpharmacological interventions for pain management decreased significantly from 61.2% (95 CI, 58.8%-63.5%) in 2019 to 42.1% (95% CI, 40.5%-43.8%) in 2020 (p < .001) among those with chronic pain, as did opioid use in the past 12 months from 20.2% (95% CI, 18.9%-21.6%) in 2019 to 17.9% (95% CI, 16.7%-19.1%) in 2020 (p = .006). Predictors of treatment utilization were similar in both chronic pain and high-impact chronic pain. Use of pain treatments among older adults with chronic pain declined in the first year of coronavirus disease of 2019 pandemic. Future research is needed to assess long-term effects of coronavirus disease of 2019 pandemic on pain management in older adults.

While pain is very common in older adults, the associated impact on daily life, including usage of medication and healthcare, varies considerably and often pain remains inadequately treated. It is not clear what is associated with this variation. Latent class analysis (LCA) is a model-based approach to identifying underlying subgroups in a population. In this study LCA was used to examine biopsychosocial risk classes of adults aged 50years and older, who were often troubled by pain, from The Irish Longitudinal Study on Ageing (TILDA), (n=2,896), and the associations with future medication and healthcare use. Four biopsychosocial risk classes (Low Biopsychosocial Risk, Physical Health Risk, Mental Health Risk, High Biopsychosocial Risk) were identified, with the 'High Biopsychosocial Risk' class accounting for 24% of older adults with pain. This class were much more likely to use medication and healthcare services when followed up across three waves of the TILDA study. In contrast, the Physical Health Risk and the Mental Health Risk classes reported lower usage of medication and healthcare at waves 2 and 3. Amongst the higher risk classes of older adults who are troubled by pain, there is considerable consumption of medication and healthcare services evident. Given our ageing population and significant number of adults in this high risk class, there is a need to optimize current pain management approaches among older adults. Intensive non-pharmacological approaches to pain management in older adults, tailored to individual biopsychosocial risk indicators for each individual class, may be worth exploring. While pain is very common in older adults, the usage of medication and healthcare varies considerably and often pain remains inadequately treated. Given our ageing population and the significant number of older adults reporting high biopsychosocial risk (24%), there is a need to optimize current pain management approaches. Intensive non-pharmacological approaches to pain management in older adults, tailored to individual biopsychosocial risk indicators for each individual class, may be worth exploring.

Population-Focused Approaches for Proactive Chronic Pain Management in Older Adults

Acute pain management in the older adult is both challenging and rewarding. This review addresses the difficulty with assessment of pain in the older adult, variations in the pain experience of older adults, physiological differences between the young and old, changes in pharmacokinetics and pharmacodynamics with age, and useful pharmacological treatments for acute pain in older adults. It then presents a few representative cases of pain management in older adults. The goal of this review is to provide relevant information that can be used to manage acute postoperative pain in the older adult.

Pain Management Among Older Farsi and Azeri Speaking Immigrant Adults With Limited English Proficiency (LEP): Interpretive Approach.

To identify the most appropriate outcome measures to determine the effectiveness of pain management plans in older adults with cancer. PubMed literature searches, medical and nursing textbooks, and clinical experience. Unrelieved chronic pain can have a significant impact on older adults' activity levels and their ability to function. Hence, effective pain management in older adults requires a comprehensive approach, including assessment of functional outcomes. Because the goals of pain management are broad, healthcare professionals should use an array of functional outcome measures along with pain intensity ratings to better assess the effectiveness of analgesic medications. Particularly in older adults, evaluation of functional outcomes provides a better indication of the effectiveness of pain management strategies than pain intensity ratings. Appropriate outcome measures for older adults in the outpatient setting include pain relief, physical functioning, emotional functioning, patients' ratings of global improvement and satisfaction with treatment, and symptoms and adverse effects associated with analgesic medications. Healthcare providers should manage pain in older adults with cancer in an interdisciplinary environment with pharmacologic and nonpharmacologic interventions. The primary goals are decreasing pain and improving function and quality of life.

Objectives: This study aimed to reveal the prevalence, geographic variations, and determinants of pain among the Chinese older adult population and provide empirical strategies for pain management in older adults in China. Methods: A total of 21,346 Chinese residents aged ≥ 60 years from 31 provinces in mainland China participated in our survey. Standardized questionnaires were used to collect data on socioeconomic characteristics, lifestyle factors, and self-reported pain experiences. Multivariate logistic regression models were used to estimate the associations between individual socioeconomic status, chronic diseases, and pain. Results: The national prevalence of pain was 56.5% (95% CI: 55.9–57.1%), representing approximately 140 million Chinese older adults. The prevalence increased with aging and peaked at 80 years and older (61.00%, 95% CI: 59.30–62.70%). Women (62.36%, 95% CI: 61.47–63.25%), rural residents (61.27%, 95% CI: 60.34–62.20%), and those with no formal education (65.08%, 63.90–66.26%) had a higher prevalence than men (50.27%, 95% CI: 49.32–51.22%), urban residents (52.19%, 95% CI: 51.28–53.10%), and those with higher education levels, respectively. Provincial prevalence ranged from 38.98% in Shanghai to 72.75% in Gansu Province. The presence of chronic diseases significantly increased the odds of pain, with multimorbidity (three or more chronic diseases) showing the strongest association (OR = 11.380, 95% CI: 10.257–12.627). Conclusions and Implications: Pain was highly prevalent among older adults in China and varied geographically. Socioeconomic status, chronic diseases, and multimorbidity were strongly associated with pain prevalence. Our findings support prioritizing the reduction in gender and geographic disparities in China’s pain management strategies. An integrated approach addressing both pain and chronic diseases should be urgently established in China’s healthcare system for older adults.

BackgroundChronic pain management in older adults can be challenging for primary care clinicians due to comorbidities, side effects, and complicated guideline recommendations. Clinical decision support systems (CDSSs) may improve care by integrating guideline-based recommendations, synthesizing relevant patient data, and facilitating shared decision-making. I-COPE (Improving Chicago Older Adult Opioid and Pain Management through Patient-centered Clinical Decision Support and Project ECHO) is an electronic health record–based CDSS designed to gather patient-reported data and support primary care clinicians in managing chronic pain, opioid use, and opioid use disorder in older adults.ObjectiveThis study examined clinicians’ views on challenges in managing chronic pain and their opinions on I-COPE.MethodsWe conducted semi-structured interviews with 18 clinicians (16 physicians and 2 advanced practice nurses) from 2 University of Chicago Medicine primary care clinics (internal medicine and geriatrics) piloting the I-COPE CDSSs in 2021. The interview guide was informed by the Consolidated Framework for Implementation Research and explored current practices in chronic pain management, challenges, and feedback on I-COPE tools.ResultsOf the 18 participants, 12 (67%) identified as female, 13 (72%) as White, and 9 (50%) had practiced for 10 years or less. Participants stressed the importance of a comprehensive, patient-centered approach to chronic pain management and prioritized multimodal and nonpharmacological treatments. Major barriers to effective chronic pain management were comorbidities, limited visit time, insurance coverage restrictions, and opioid misuse concerns. Most clinicians found the CDSSs beneficial for standardizing multimodal care discussions, enhancing visit efficiency, eliciting patient goals, and facilitating shared decision-making conversations. Clinicians raised concerns about the complexity of the intervention, anticipated issues with clinic workflow, and desired more adaptability. The primary care clinicians in this study demonstrated strong alignment with current pain management guidelines, prioritizing patient-centered pain management using multimodal treatments. They identified I-COPE as a promising tool to reinforce evidence-based practices, increase efficiency, and strengthen patient-clinician communication. However, implementation challenges—particularly around accessibility for older adults, workflow integration, and tool complexity—highlight the need for further refinement and support.ConclusionsI-COPE offers a promising approach to support primary care clinicians in providing patient-centered guideline-based chronic pain and opioid management for older adults. Further efforts to improve usability and adaptability for real-world workflows and equitable access for older adults should be prioritized.