Non-pharmacological approaches to pain management in residential aged care: An evaluation
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Chronic pain is often under-recognised and undertreated in nursing home settings. Pharmacological interventions are often the first line treatment approach when dealing with chronic pain in older people. However, a combination of pharmacological and non-pharmacological approaches is encouraged and usually deemed more effective than using medications alone.
The aim of the current project was to evaluate the pain management program (PMP), utilising non-pharmacological approaches as an adjuvant to pharmacological intervention, conducted at five nursing homes.
The research questions were: Has the PMP:
1) Provided temporary relief from chronic pain as indicated on the Pain Numeric Rating Scale for residents who have received the PMP?
2) Decreased the use of PRN pain medications for residents with chronic pain?
Data collection occurred during the last four months of 2012 and the first four of 2013. Ninety-five participants were recruited, with an average age of 83 years.
The PMP involved an appointed physiotherapist implementing four sessions per week of non-pharmacological treatment (massage therapy, TENS, exercises and stretching , or combinations of these). Sessions were approximately 10 minutes long on average. The physiotherapist recorded residents’ levels of pain, using a 5-point scale, before and after the treatment. The intervention period for each participant was the first consecutive eight weeks in which they consistently received the intervention at least twice per week.
Data analyses focused on change in PRN pain medications and residents’ pain ratings.
The main message from the analyses of the data is that the intervention was clearly effective. Its effectiveness was shown in two ways:
a) Reductions in PRN medications from before to during the intervention period. The percentage of patients who received 7 or more PRN medications for their pain decreased from 9.5% pre intervention period to only 3.2% during the intervention period.
b) Reductions in pain ratings from pre to post each session. Average pain rating decreased from 2.4 (some to moderate pain) to 1.1 (a little pain).
The intervention seemed to be more effective for some groups than others: higher decreases in pain ratings were noted for residents without dementia, and for both those with neck/shoulder pain and knee pain. Larger decreases were also noted for residents who received TENS or exercise as well as massage.
Changes in pain ratings were also noted across the 8 weeks of the intervention period and within each week. Overall mean pre-session pain ratings decreased significantly from 2.7 in the first week to 2.5 in the 8th week.
Examining all 32 sessions, periodicity in ratings was noted, with higher pain ratings earlier than later in the week. When sessions were non-consecutive, pain ratings were much higher earlier in the week than when sessions were consecutive.
Some people with dementia provided their own pain ratings, but most were rated by the physiotherapist. Notably, people who had dementia were given lower pain ratings than those without dementia (who rated their own pain). It is possible that staff under-rate the pain of people with dementia, which is a clinical concern.
Recommendation 1: That the program be continued and extended to other residential aged care facilities.
Recommendation 2: That further research be undertaken to evaluate the intervention. Ideally, the evaluation should include use of a randomised control. Facilities could be randomised to implement PMP or not. Facilities allocated to the non-intervention group could trial two control conditions: one with no intervention and one with an active control such as an opportunity to chat with a volunteer for 10 minutes.
Recommendation 3: That staff members in residential aged care undertake further education in recognition and management of pain in older people with dementia.
Recommendation 4: That where feasible, residents be offered a combination of treatments for their pain management.
Recommendation 5: That exercise (and stretching) be included as a standard component of pain management whenever this is feasible.
The PMP was shown to be valuable, with reductions in both reliance on PRN medications for pain and residents’ pain ratings. The intervention was most effective for residents who received more than one treatment in a session.
Of concern is that residents with dementia were consistently allocated lower pain ratings than residents who were able to rate their own pain. It is possible that therapists under-rate the pain experienced by people with dementia.
Our recommendations for improved practice cover further evaluation and both education and clinical practice.