MDS Alert

Study sheds light on conditions most likely to cause pain.

The nursing home resident who complains about pain is the one most likely to achieve relief, whereas those who can't communicate their discomfort in words oftentimes go without any pain treatment at all.

Break the silence: By knowing the factors and conditions likely to cause pain, your clinical team can home in on residents with dementia who have them to see if they display behavioral signs of pain.

The evidence is in: Based on data from 650-plus nursing facilities in New York state, Christie Teigland, PhD, and researchers at the New York State Association of Homes & Services for the Aging identified conditions and factors associated with pain in a cognitively intact population of residents who could report they were having pain. And they found that Alzheimer's and dementia residents showed roughly the same number of pain-related conditions as the cognitively intact residents. In fact, the residents with dementia may actually have a few more of those because they tend to be older residents, said Teigland, who presented the study findings at the American Medical Directors Association annual meeting in March 2008. However, residents with dementia reported far less pain than their cognitively intact counterparts with the same pain-related conditions.

A major quality-of-care shortfall: Failure to identify and treat pain leads to more behavioral symptoms, aggression, depression, weight loss and faster functional decline, Teigland warns. In other words, the MDS may be screaming at you that a resident with dementia is in pain.

Some of the factors linked to whether a person is likely to be in pain or report it include:

• Having a high body mass index. Residents who are obese are 30 percent more likely to have pain compared to those who are not obese, Teigland tells Eli.

• Being male or older. Men are less likely to be coded with pain because they are less likely to report it. Older residents are less likely to report pain.

• Continence programs. If someone is on a scheduled toileting plan, he is less likely to have pain. Some of the factors that show up to be significant in terms of predicting unreported pain are proxy variables for something else, Teigland says. For example, a resident on a toileting schedule might have less constipation (another risk factor for pain) or may be moving more, which helps him feel more comfortable.

A resident on a bladder retraining program is more likely to have pain, the study showed. One explanation could be that residents on a bladder retraining program have to actually hold their urine to void, Teigland says. That approach could produce some discomfort and mild pain, although not necessarily. Also, bladder retraining is usually done to help control bladder problems related to unstable conditions that flare up periodically. Thus, it may be the unstable conditions that cause the pain and not the bladder retraining program itself. The item is a good proxy indicator for pain nevertheless, Teigland says.

Other conditions and factors that increase or decrease the likelihood of someone having pain include:

• Conditions in Section J, such as edema, falls, fever and vomiting, increase the likelihood of pain.

• Stability of conditions indicators in J5 increase the likelihood of pain, especially end-stage disease (70 percent more likely).

• Stage 2-4 pressure ulcers and stasis ulcers cause pain.

• Skin conditions (burns, open lesions due to cancer and surgical wounds) are painful, especially surgical wounds.

• Skin treatments can cause pain (turning/repositioning, surgical wound care and applying dressings). Preventive/protective skin and foot care lowers the risk for pain.

• Many diseases/conditions are associated with pain (arthritis, hip fracture, other fractures, osteoarthritis, pathological bone fracture, asthma, allergies) and infections (urinary tract infection, wound infection, viral hepatitis).

• Residents receiving physical therapy are 1.5 times more likely to experience pain.

• Urinary catheters, including an external catheter, increase the likelihood of pain by more than 25 percent.

In addition to evaluating the resident with behavioral symptoms in the usual ways, physicians should consider giving the person two Tylenol every four to six hours for a day or two to see if his behaviors change, said Conn Foley, MD, a medical director who co-presented with Teigland at the AMDA meeting. That's certainly a reasonable strategy before starting the person on psychoactive medication, he cautioned conferees.

Assessment tips: Make housekeeping part of the team in evaluating pain in people with dementia, as these staff members are often in the resident's room, suggests Cheryl Boldt, RN, a consultant with Maun Lemke in Omaha, NE. Also, "hold up the pain assessment sheet with signs of pain for residents with cognitive impairment and see how many of the indicators for pain the staff, physician and family can identify."