Karen S. Feldt

Treatment of Pain in Cognitively Impaired Compared with Cognitively Intact Older Patients with Hip-Fracture

OBJECTIVE: To compare the experience of pain and treatment of pain in cognitively impaired and cognitively intact older adults after surgical repair of a hip fracture.

AGGRESSIVE BEHAVIOR: Educating Nursing Assistants

Caring for cognitively impaired aggressive residents presents a challenge to nursing assistants in long-term care facilities. Nursing assistants participated in an educational program that included content about cognitive losses, precipitants of aggression, communication techniques, strategies for preventing aggressive behavior, and managing personal feelings. Following the educational intervention in this study, nursing assistants reported that caring for cognitively impaired residents was significantly more rewarding and less frustrating. The use of the clinical nurse specialist to teach and assist in role modeling direct care of residents was effective in improving nursing assistant skill in working with aggressive cognitively impaired residents.

Pain and hip fracture outcomes for older adults.

Purpose: To determine if postoperative pain is a predictor of functional outcomes for elderly hip fracture patients who were previously independent ambulators (with or without assistive device). Design: Prospective comparative survey design. Sample: Convenience sample. 85 hip fracture patients age 65 years or older from two Midwestern urban hospital orthopaedic units. Methods: Subjects were interviewed between day 2 and 5 (M = 2.6) postoperatively and again 2 months postoperatively. Independent variables of cognitive status and pain status were measured using the Folstein Mini Mental State Exam (MMSE) and two pain measures, the Verbal Descriptor Scale (VDS) and Ferrells Pain Experience Interview (FPEI). The dependent variable, functional outcome, was measured using the degree of assistance required for basic ADLs from Jettes Functional Status Index (FSI). Findings: Pain with movement was significantly higher than pain at rest (p < .0001). Mental status, pain report with movement (during hospital interview), illness severity, and age accounted for 51% of the variance in functional outcomes 2 months postoperatively. Conclusions: Undertreated postoperative pain contributes to poor functional outcomes. Implications for Nursing Practice: Pain assessment of postoperative older patients should be conducted during movement. Efforts to reduce postoperative pain severity in the immediate postoperative period may yield better functional outcomes months later.

GOAL-DIRECTED CARE: Caring for Aggressive Nursing Home Residents With Dementia

1. Aggressive behavior in elders with dementia occurs most often during personal care. It is often a response to invasion of private space and may be prevented or reduced by interpersonal approaches that reflect a set of individualized goals for the resident. 2. Five resident goals for preventing or reducing aggressive behavior are to feel safe, to feel physically comfortable, to experience a sense of control, to experience optimal stress, and to experience pleasure. 3. These goals provide a framework for humane care that respects the personhood of the individual and minimizes the need for psychotropic medications and physical restraints.

Relationships between aggressive behavior in cognitively impaired nursing home residents and use of restraints, psychoactive drugs, and secured units

This study examined relationships between aggressive behavior in cognitively impaired nursing home residents and physical restraints, psychoactive drugs, and placement on a secured unit. Data were obtained from 116 residents who were consistently aggressive as measured by the Ryden Aggression Scale 2. Subjects averaged 9.5 aggressive behaviors per day. Forty-seven percent of subjects were restrained, and 62% were regularly receiving psychoactive drugs. Use of restraints, antipsychotics, and placement on a secured unit were all significantly related to increased physical aggression scores. Four variables accounted for 23% of the variance in physical aggression scores: location on a secured unit, not receiving an antidepressant, being restrained, and number of psychotropic and/or anxiolytic medications administered. Significantly lower physical aggression scores were noted for subjects receiving antidepressants.

The relationship between social interaction and characteristics of aggressive, cognitively impaired nursing home residents

The extent of social interaction of aggressive, cognitively impaired nursing home residents and the relationship between social interaction and selected resident characteristics were explored in this study, which was part of a larger experimental study of the effect of dementia education for staff on the aggressive behavior of cognitively impaired residents. Staff rated residents using the Social Interaction Scale (SIS),which has two subscales: Institutional Interaction and Family/Community Interaction. Mean SIS scores were low; institutional interaction scores were higher than family/community scores. Marital status, morale, degree of cognitive impairment, dependency, and sexual aggression were significantly associated with social interaction, but gender and age were not.

Frail older patient care by interdisciplinary teams: a primer for generalists.

ABSTRACT Frail older patients-unlike younger persons in the health care system or even well elders-require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved. This paper describes the roles of the participating team members in the context of interdisciplinary care for frail older adults. In addition, the challenges that occur when Geriatric Interdisciplinary (ID) Teams involved in providing care to frail older patients are identified and discussed.

Older adults with hip fractures. Treatment of pain following hospitalization.

This study examined pain experiences and treatment for older adults in long-term care or rehabilitation settings 3 week after surgical repair of a hip fracture. Pain report and pain treatment for cognitively intact residents were compared with cognitively impaired residents. Two thirds of all participants reported pain. Most rated pain as slight or mild in severity. Pain report was similar for cognitively impaired and intact participants. Pain was reported as severe or worse by 17% of the residents. Nursing care plans documented comfort as a goal for fewer than half the participants. Almost 40% (n = 23) of the participants were receiving no pain medication 3 weeks postoperatively, five of these rated their pain as moderate or severe. Pain documentation, including effective non-pharmacological treatments, needs to be improved for cognitively impaired and intact older adults who are recovering from hip fracture surgery.

The Complexity of Managing Pain for Frail Elders

Within the past decade, researchers have begun a careful examination of how clinicians assess and treat pain in frail elderly. Most of this research has been descriptive in nature, identifying the patient, provider, and system variables that create barriers to good pain management and the scope of current practice. Some studies have linked the deficiencies in care to patient outcomes. Almost all provide recommendations to improve comfort of older adults with chronic illnesses or those at the end of life. Two new descriptive studies appear in this issue of the Journal of the AmericanGeriatrics Society. They provide further evidence of shortcomings in the assessment and treatment of pain for the elderly in community and nursing home (NH) settings, but these authors offer little new insight regarding the testing of solutions to this serious problem. Chodosh et al. used the Assessing Care of Vulnerable Elders quality indicators to evaluate the quality of care provided to community-dwelling elders with chronic pain. Their study confirms that documentation of pain assessment and treatment for vulnerable elderly is far below acceptable standards, similar to findings by other investigators on pain management in the general medical population. Unfortunately, documentation during brief clinic encounters or recall by elderly or their proxies may not reflect actual care. Were the proxies even present during the examination and discussion? The research did not capture whether the relationship between the physician and patient was new or long-standing; whether the provider had previous attempts or failures to manage pain; and, finally, whether the lack of treatment reflected an uneasy agreement between patient and provider to simply live with the status quo. In another study, the elderly complained that their physicians did not view them as partners and that they did not feel that they could obtain answers to their questions about pain. Chodosh et al. found that nearly 25% of the elderly were prescribed the sometimes problematic treatments of nonsteroidal antiinflammatory drugs (NSAIDs) or cycloxygenese-2 inhibitors (which may reflect the funders of the study). There was no indication of how many elders in this study were recommended to take acetaminophen routinely, a safer treatment option. Even so, between 80% and 90% of these elderly were offered treatment of some sort (nonpharmacological or pharmacological). It may be that this is an improvement in pain management for the community-based population over the past few decades, although there are no similar studies of this vulnerable population from the 1980s for comparison. The Minimum Data Set (MDS) provides us with rich insight into the status of residents in NHs, but in its present form, the structure and guidelines of the MDS limit how MDS pain data can be interpreted. Nurses who complete the current format of the MDS (2.0) have four options for pain severity: no pain, mild pain, moderate pain, and horrible or excruciating pain (there is no category between moderate and excruciating). Raters are required to identify and document pain severity as the ‘‘highest it has been in the past 7 days.’’ Nurses who feel that ‘‘moderate’’ does not capture that worst episode must mark the MDS pain severity as ‘‘horrible or excruciating’’ even if the resident had only one really bad pain episode during the week. For example, if the resident had mild pain on 6 of the days, but sustained a fall and had severe pain 1 day, they are ranked into the highest category, ‘‘horrible or excruciating.’’ Frequency of pain is a separate variable (none, pain less than daily, and pain daily) on the MDS. This appropriately identifies residents with chronic aches or pains every day as having daily pain, but combining the two variables (frequency and severity) can mislead naı̈ve researchers to believe that residents with ‘‘daily’’ and ‘‘horrible and excruciating’’ checked on the MDS are residents in excruciating pain every day, when in fact they may have had pain once during the previous week that was more than moderate. Teno et al. found that 3.7% of NH residents had at least one episode of horrible or excruciating pain within the previous 7 days. This is much lower than the 28% of NH hospice residents reported to be in excruciating pain by a previous study. Teno et al.’s data may be an underestimate, given the known difficulty in quantifying severity of pain in nonverbal cognitively impaired elders or other elders who are not able to report using the common assessment tools. Perhaps the hospice-enrolled elders in the previous study were more cognitively intact elders or elders who had proxies to estimate pain severity. Or perhaps pain management had improved in the 3-year period between the studies. Research exposing inadequate treatment of pain does not always reveal the complexities of pain assessment and treatment for this frail population. Several researchers are developing and testing instruments to assess pain in cognitively impaired elders as a first step toward improving care. More consistent assessment may yield better treatment, although this needs to be studied further. Researchers often conclude that providers need more pain education, but research on efficacy of pain education is mixed. A study of hospital-based cardiovascular nurses demonstrated that nurses’ pain knowledge was not associated with their assigned patient’s pain ratings or the

Treatment of pain for older hip fracture patients across settings.

PURPOSE To examine the treatment of pain following hip fracture across settings (hospital to nursing home or rehabilitation facility). DESIGN This was a secondary data analysis of two survey design studies that collected data on hip fracture patients in the hospital and for posthospital days at an institutional setting. SAMPLE 115 subjects, 65 years or older, who had undergone surgical treatment of a hip fracture. METHODS Medical records were reviewed to compare the amount of pain medication administered to postoperative hip fracture elders during the last 24 hours in the hospital with that of the first 24 hours in the nursing home (NH). FINDINGS The mean length of stay following surgery was 4.8 days. Subjects received significantly less medication during the first 24 hours in the NH as compared with the last 24 hours of hospitalization. Over one third (37.4%) of the subjects received no opioid analgesic and 18.3% (n = 21) received no analgesic of any kind during the first 24 hours of NH stay. IMPLICATIONS Rather than simply listing medications orders, hospital nursing staff should communicate type, amount, frequency and efficacy of pain medication in transfer notes to nursing home staff. Nursing home staff would benefit from postoperative pain management education.