Study finds persistent and severe pain among nursing home residents

The first national look at pain among the frailest nursing home residents uncovers “woe-fully inadequate pain management,” say its Brown Medical School authors. Their study appears in the April 25 issue of the Journal of the American Medical Association.

PROVIDENCE, R.I. — A new nationwide study shows that severe pain among elderly nursing home residents is prevalent, persistent and poorly treated.

The authors of the first national look at pain management among this frail population say that the findings underrate the true pain burden experienced by the patients. They call untreated pain in nursing homes “an important national public health problem.”

The study reports the rate of persistent severe pain, using data gathered through the federally required Minimum Data Set (MDS). The MDS is used to collect details on individuals admitted to U.S. nursing homes, including information on the frequency and severity of pain.

“We believe the findings underestimate the actual pain burden,” said lead author Joan Teno M.D. “MDS data is collected by nursing home staff. It is based on staff perception, and staff routinely underestimate the pain burden of patients.”

The study appears in the April 25 issue of the Journal of the American Medical Association. The authors used the MDS to examine the pain experience of more than 2.2 million people residing in U.S. nursing homes on or about April 1, 1999.

They found that 41.2 percent of elderly nursing home residents who were in pain around April 1, 1999, still experienced moderate daily pain or excruciating pain 60 to 180 days later. Of individuals in a nursing home between 2 and 6 months, one in seven had persistent pain. Nationwide, rates of persistent pain varied, with most states between 39.5 percent and 49.5 percent.

Editors: To support localized stories, the researchers have published state-by-state data at a temporary pre-embargo address: www.chcr.brown.edu/dying/factsondying2001.htm. After 4 p.m. EDT on Tuesday, April 24, the data will reside at the study’s permanent Web address: www.chcr.brown.edu/dying/factsondying.htm.

“Our findings demonstrate woefully inadequate pain management among a frail, old and vulnerable population of Americans,” said co-author Vince Mor, director of the Department of Community Health, Brown Medical School. “Important ground has been gained in the last decade in pain management, but these results highlight the urgent work yet to be done.”

There is an urgent need for balance in public policy on pain management given that recent public attention and policy have focused on the dangers of opiate prescription abuse, said Teno, associate director of the Brown University Center for Gerontology and Health Care Research. “Recent media coverage has fed fears about opiate drug prescription abuse,” she said, “but that should not be a reason for leaving a vulnerable population in persistent severe pain. The focus must be on quality medical care that provides competent, compassionate and coordinated medical care for frail, older Americans residing in nursing homes and treats drug abuse as well.”

The high rate of persistent severe pain has important policy ramifications, said Karen Kaplan, National Program Director for Last Acts, a coalition of more than 600 organizations united to improve end of life care. “Current regulations need to change to make pain a focus at all state and federal inspections of nursing homes to comport with the new standard of the Joint Commission on the Accreditation of Healthcare Organizations,” she said. That standard says hospitals and nursing homes must recognize the right of patients to the appropriate assessment and management of pain.

Teno agrees. “Persistent pain in nursing homes should be considered by regulators as an indicator of quality and reported publicly along with other indicators,” she said. “Federal and state nursing home surveyors should assess the quality of pain management at the time of annual inspection of nursing homes. We call on local Peer Review Organizations of the Health Care Financing Agency to work with nursing homes to improve pain management in the next decade.”

In addition, there is a need to enhance education of nursing home staff to give people the in-formation and tools to improve their behaviors concerning pain management, Teno said.

She suggests that patients and family members ask a nursing home about its pain-treatment policy. “Ask if it regularly assesses pain as the ‘fifth vital sign.’ Also ask what efforts has the home taken to be more aware of and to improve pain management.”

The study’s other authors are Sherry Weitzen, a Brown doctoral student, and Terrie Wetle, associate dean of medicine for public health and public policy, at the Brown Medical School. The study was funded by a grant from the Robert Wood Johnson Foundation.