UF Research Highlights Importance Of Managing Pain In Nursing Home Residents

March 16, 2001

GAINESVILLE, Fla. — Deteriorating bones, worn-out disks and grinding joints: These are some of the problems that can pack a painful punch to the experience of growing older.

But pain often goes undetected in nursing home residents, potentially causing depression and lowering their feelings of well-being, according to a University of Florida researcher.

In a recent study, nursing home caregivers were able to accurately spot pain in their patients only about a third of the time. And depression was highest among those whose pain went undetected, according to a study in the March edition of the Journal of Gerontological Nursing.

“The findings of this study illustrate the complexities of pain assessment, demonstrating how difficult it is to detect pain and pointing to the need for more education in this area,” said Ann Horgas, an associate professor in the UF College of Nursing who conducted the study while at Wayne State University in Detroit.

“By properly assessing and managing pain, we can positively affect the quality of people’s lives. That’s particularly true for nursing home residents, 80 percent of whom live with chronic pain,” said Horgas, who is affiliated with UF’s Institute on Aging.

Gauging pain is a tricky business.

In recent years, more attention has been paid to pain assessment in hospitals and other acute-care settings. In January, the agency that accredits U.S. hospitals — the Joint Commission on Accreditation of Health Care Organizations — began requiring caregivers to monitor and document pain as a fifth vital sign along with blood pressure, pulse, respiration and temperature.

The problem has largely been overlooked in nursing homes, however, where detection is even more complex because of the frail condition of many residents and the pervasive myth that pain is a natural part of aging.

“Older adults often think, ‘I’m old, of course I can expect to hurt,’ so they may underreport their pain to care providers, try to minimize it or believe there’s nothing that can be done to treat it,” Horgas said. “And those are the things that can have serious consequences for quality of life.”

Pain accompanies some of the diseases that are common as people age, like arthritis, but that doesn’t mean people must live with unrelieved pain. The first step in helping to manage pain, however, is proper assessment.

For those reasons, Horgas wanted to know how accurately and consistently primary caregivers in nursing homes were able to gauge their patients’ pain.

In her study, 45 residents in a private nursing home were asked if they had experienced any pain during the past week. Sixteen nursing assistants also were asked if any of the residents they had cared for in the previous week had been in pain. While nursing assistants do not administer pain medication, they are the primary caregivers in this setting, providing 90 percent of the direct care in nursing homes.

The study found residents and caregivers disagreed in their pain assessments 62 percent of the time. In most of those instances, residents said they had experienced pain during the week even though nursing assistants had not detected it. But in others, the assistants attributed pain during the week when the residents denied having had it.

“The primary caregiver, who works most closely with the residents helping them do all the activities of daily living, should be able to identify when someone is in pain,” Horgas said. “But if that first line of detection isn’t there because they aren’t identifying residents in pain, there is a breakdown in the system of being able to manage pain effectively. This can have serious consequences for the physical and mental health of older adults.”

Depression was found to be highest among nursing home residents whose pain went undetected, the study also showed. And ratings of well-being were highest among those inaccurately judged to be in pain. That may be because those residents felt they were getting more attention from the caregivers so they felt more satisfied or positive, Horgas speculated.

“This isn’t an indictment of nursing assistants,” Horgas said. “Pain assessment is difficult for all health professionals no matter their level of training. It comes down to a need for education about pain detection for all staff, including nursing assistants, who are typically the least well-trained.”

Although the study was small and conducted in only a single nursing home, the results point to a need for better education about pain and more standardized ways of evaluating pain within nursing homes so that all health-care professionals are making assessments based on the same measurements, Horgas said.

In addition, Horgas said, family members and friends of nursing home residents can help caregivers by providing information about how their loved one shows signs of pain.

“There’s no blood test for pain, and people respond very differently to it,” Horgas said, “so providing information specific to that individual can significantly help caregivers.”

Horgas’ research addresses a number of important issues related not only to pain in the elderly, but chronic pain in general, according to Robert Yezierski, director and founder of the Pain Program in the Miami Project at the University of Miami who will be the director of the Center for Pain Research at UF starting late next month.

“In our society today we are living longer and therefore it is likely that chronic pain associated with a variety of neurological conditions or just the aging process will challenge a large number of us,” Yezierski said. “Studies like the one of Dr. Horgas are important as they provide a much-needed perspective on current practices and point out what we need to address in the future in order to ensure the elderly pain patient a quality of life they are entitled to.”