MDS Alert

Don't underestimate the pain associated with these conditions.

Nurses who want to be good pain sleuths should get out the magnifying glass and think out of the box when viewing Section I (diagnoses).

While everyone recognizes cancer, hip fractures and arthritis as painful, other conditions can escape the pain radar screen - especially in residents with dementia and those who can't communicate pain verbally.

Be on the lookout for these often painful conditions:

1. Parkinson's disease (coded at I1y). "The rigidity and muscle stiffness seen in this disease can be quite painful," says Kathleen Thimsen, RN, ET, MSN, principal of RARE Consulting Group in Bella Vista, AR. "Yet the person with Parkinson's has facial freezing, so you may not see facial flinching or expressions that signal discomfort."

Pain in Parkinson's can also include burning-type pain or paresthesias that travel along the spinal roots - or painful muscle cramping during "off states" when the anti-Parkinson's medication wears off between doses, says Daniel Weintraub, MD, a psychiatrist and neurologist at Philadelphia Veterans Administration.

Solution: Before treating Parkinson's-related pain with pain medication, see if a neurologist can adjust the person's anti-Parkinson's medication to relieve the painful symptoms, suggests Weintraub. "For example, Sinemet (carbidopa and levodopa) comes in a long-acting version that can decrease off periods, and Comtan inhibits levodopa metabolism, which can also smooth out the person's blood dopamine levels."

2. Multiple sclerosis. People with MS (coded at I1w) can also experience significant pain. "Pain in MS is often related to paresthesias, spasticity, tic douloureux and postural problems," according to "Nursing Home Care of Individuals With Multiple Sclerosis: Guidelines and Recommendations for Quality Care," published by the National Multiple Sclerosis Society.

3. Various conditions causing neuropathic pain. Neuropathic pain can be caused by HIV infection (coded at I2d), post-herpetic shingles (code in I3), injuries, certain drugs (including antiviral drugs used to treat HIV or anti-neoplastic agents) and diabetic neuropathy.

Tip: Code diabetic neuropathy in I3 with two codes in combination: type 1 or 2 diabetes (250.61 or 250.60) and 357.2 (polyneuropathy in diabetes), advises Ann Zeisset, RHIT, CCS, CCS-P, practice manager for the American Health Information Management Association.

Don't be fooled: Because neuropathy may result in decreased sensation, healthcare providers sometimes underestimate how painful it can be, cautions Pam Campbell, RNC, CRNAC, MDS operations director for LTC Solutions in Camdenton, MO.  "Yet the person with neuropathy can experience electrical-type sensations and aching pain in the affected extremities," she notes.

Pain management tip: There are two large families of neuropathic pain, which dictate treatment approaches: constant static burning, stinging, numbness descriptors; and the lance-like descriptors of sharp, stabbing, electric shocks, lightening bolts, says Rhonda Nichols, RN, MSN, CNS, a pain specialist in Los Angeles.

"Tricyclic antidepressants seem to be effective in treating the former type of pain descriptors but are less successful in the latter," says Nichols. "The lancinating version is treated with membrane stabilizing agents such as anticonvulsants and antiarrhythmics ... that reduce the sensitivity of the cell membrane to generating a pain impulse.

"Shingles or post-herpetic pain is a type of neuropathic pain often helped by topical lidocaine patches," she adds.

4. Pressure ulcers. Some practitioners still believe stage 3 or 4 pressure ulcers are relatively painless due to damage to the nerves. Not true, say experts. "Approximately half of people will rate their stage 3 or 4 pressure ulcer as being a 3 out of 10 on a pain scale when the wound is covered and not being disturbed," says Karl Steinberg, MD, CMD, with Stone Mountain Medical Associates Inc. in Oceanside, CA.  "But when someone touches the wound, that pain level goes up."

Tip: Code pressure ulcers in I3 based on the wound's location on the body (for details, see the April 2005 MDS Alert). Also code the location of wound-related pain in J3h of the MDS (soft tissue pain, e.g., lesion or muscle).

Editor's Note: For strategies to manage pressure ulcer pain, see the March 2005 issue of Long-Term Care Survey Alert, p. 26. For subscription information, call 1-800-874-9180.