ASSESSING PAIN IN THE ELDERLY

NONVERBAL CLUES TO PAIN KEY POINTS

Assessment of Pain
Multidimensional pain assessment is the key to adequate treatment of pain.
A comprehensive pain assessment should consist of a thorough evaluation of all physical and
emotional symptoms.
All older persons should be screened for persistent pain on initial evaluation, on admission to any
health care service, and periodically thereafter. Any persistent pain that has an impact on physical
function, psychological function, or quality of life should be considered a significant problem.
Consider pain as a fifth vital sign and assess patients for pain when checking pulse,
blood pressure, core temperature, and respiration.
The patients self-report of pain is the most reliable indicator of pain.
Pain can occur when there is no physiological etiology but it is nonetheless real to the patient.
Older patients are less likely to complain about pain due to the misconception that pain is
normal or expected with age.
For those with moderate to severe cognitive impairment, assessment of behaviors and family or
caregivers observations are essential.
The verbally administered zero to ten scale is a good first choice for assessment of pain intensity;
however, other scales such as word descriptor scales, faces scales, or pain thermometers may be
more appropriate for some patients.
Document the pain assessment in a paper record or computerized entry.
Observe patient during care, activities, and treatments to detect whether pain is present and to
identify its location and the limitations it places on the patient.
Per F-Tag 309 of CMS State Operations Manual, Appendix PP Interpretive Guidelines for
Long-Term Care Facilities:
Completion of the pain questions on the Minimum Data Set (MDS) does not remove the
facilitys responsibility to document a more detailed pain assessment
Information to collect during assessment:
History of pain and its treatment
Intensity of pain (e.g., as measured on a standardized pain scale)
Descriptors of pain (e.g., burning, stabbing, tingling, aching)
Pattern of pain (e.g., constant or intermittent)
Location and radiation of pain
Frequency, timing and duration of pain
Impact of pain on quality of life (e.g., sleeping, functioning, appetite, and mood)
Factors that precipitate or exacerbate pain (e.g., activities, care, or treatment)
Strategies and factors that reduce pain
Additional symptoms associated with pain (e.g., nausea, anxiety)
Physical examination
Current medical conditions and medications
Residents goals for pain management and his or her satisfaction with the current
level of pain control
Metabolic
Decreased insulin production
Increased glucose intolerance
Increased muscle breakdown
Gastrointestinal
Decreased appetite
Decreased gastric/bowel motility
Increased nausea
Genitourinary
Decreased urinary output
Increased fluid retention
Increased fluid overload
Musculoskeletal
Decreased muscle function
Increased fatigue
Increased immobility
Increased osteoporosis
Gait or mobility changes
Changes in Activity Patterns or
Routines
Refusing food; appetite change
Sleep, rest pattern changes
Sudden cessation of common routines
Increased wandering
Mental Status Changes
Crying or tears
Increased confusion
Irritability or distress
Cardiovascular
Increased heart rate
Increased blood pressure
Respiratory
Decreased respiratory flow
and volume
Decreased cough
Increased sputum retention
Increased infection
Facial Expressions
Slight frown; sad, frightened face
Grimacing, wrinkled forehead
Closed or tightened eyes
Any distorted expression
Rapid blinking
Verbalizations/Vocalizations
Sighing, moaning, groaning
Grunting, chanting, calling out
Noisy breathing
Asking for help
Verbally abusive
Body Movements
Rigid, tense body posture; guarding
Fidgeting
Increased pacing, rocking
Restricted movement
Changes in Interpersonal
Interactions
Aggressive, combative
Resisting care
Decreased social interactions
Socially inappropriate, disruptive
Withdrawn
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ASSESSING PAIN IN THE ELDERLY
References:
Ruger T, Cunnighan M, Thorpe D. Strategies for Pain Management. Newtown, PA: Associates in Medical Marketing Co.; 1998.
MD Anderson Cancer Center Nursing Reports.
AGS Panel on Persistent Pain in Older Persons. The Management of Persistent Pain in Older Persons.
J Am Geriatr Soc.2002;50:S205-24.
Morrison LJ and Morrison RS. Palliative Care and Pain Management. Med Clin N Am 90(2006)983-1004
Centers for Medicare and Medicaid Services (CMS) Survey and Certification Memo S&C-09-22; F-Tag 309, Appendix PP, CMS
State Operations Manual
F-TAG 309:
GUIDANCE TO SURVEYORS ON PAIN MANAGEMENT IN NURSING FACILITIES
Intent of new guidance:
In order to help a resident attain or maintain his or her highest practicable level of well-being and to prevent or manage pain, the facility, to
the extent possible:
Recognizes when the resident is experiencing pain and identifies circumstances when pain can be anticipated;
Evaluates the existing pain and the cause(s), and
Manages or prevents pain, consistent with the comprehensive assessment and plan of care, current clinical standards of practice, and the
residents goals and preferences.
Key Components of Pain Management
Mentioned in F-Tag 309:
Care Process for Pain Management
Pain Recognition
Assessment
Management of Pain
Non-Pharmacological Interventions
Pharmacological Interventions
Monitoring, Reassessment, and Care Plan Revision
The Pain Management Investigative Protocol is to be
used by surveyors for any resident:
Who states he/she has pain or discomfort;
Who displays possible indicators of pain that cannot be readily attributed
to another cause;
Who has a disease or condition or who receives treatments that cause or
can reasonably be anticipated to cause pain;
Whose assessment indicates that he/she experiences pain;
Who receives or has orders for treatment for pain; and/or
Who has elected a hospice benefit for pain management.
References: VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain; Version 2.0 2010. Available at:
http://www.healthquality.va.gov/cot/cot_310_full.pdf. Accessed December, 2010.
AGS Panel on Persistent Pain in Older Persons. The Management of Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50:S205-24.
SIDE ONE
A99010RCK (Rev. 03/11) Reorder From: MED-PASS, Inc. 800-438-8884 / 937-438-8884 2009 American Society of Consultant Pharmacists
SIDE TWO
Presence of pain behavior
during movement?
(e.g., grimacing, guarding, groaning
during personal care, ambulation,
or transfers)
Presence of non-movement
specific behavior suggestive
of pain?
(e.g., agitation, reclusiveness, insomnia,
diminished appetite)
Consider:
Premedication prior to provocative movement
Strategies to alter pain-inducing movement
Providing reassurance for fear-related behavior
Treat causative pathology
Continue to be vigilant for behavioral
changes that indicate pain
Ensure that basic comfort
needs are being met
Consider using analgesic medications
or nonpharmacologic management
Are basic comfort needs
being met?
(toileting, thirst, hunger,
visual/hearing impairment)
Is there evidence of pathology
that may be causative?
(e.g., infection, constipation)
Yes
Yes
Yes
No
No
No
No
Yes
Wong-Baker FACES Pain Rating Scale Verbal Descriptor
Scale
Mild
Moderate
Severe
Very severe,
horrible
Unable to
answer
PAIN SCALE - This scale can be helpful upon initial assessment in addition to evaluating effectiveness of interventions.
Reference: AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-24.
References:
AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-24.
Herr K, Decker S. Assessment of pain in older adults with sever cognitive impairment. Annals of Long-Term Care. 2004;12:46-52.
From Hockenberry MJ, Wilson D: Wongs essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby.
ASSESSMENT OF PAIN ALGORITHM FOR SENIORS WITH SEVERE COGNITIVE IMPAIRMENT
www.med-pass.com
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Content edited and updated by Charlie Waters, PharmD, BCPS, CGP, FASCP
SAMPLE QUESTIONS IN A PAIN INTERVIEW
1. How strong is your pain right now?
What was the worst pain over the past week?
What was the average pain over the past week?
2. How many days over the past week have you been unable
to do what you would like to do because of your pain?
3. Over the past week, how often has pain interfered with
your ability to take care of yourself, such as bathing,
eating, dressing, and going to the toilet?
4. Over the past week, how often has pain interfered with
your ability to take care of your home-related chores,
such as going grocery shopping, preparing meals,
paying bills, and driving?
5. How often do you participate in pleasurable activities such
as hobbies, socializing with friends, travel? Over the past
week, how often has pain interfered with these activities?
6. How often do you do some type of exercise?
Over the past week, how often has pain interfered
with your ability to exercise?
7. How often does pain interfere with your ability
to think clearly?
8. How often does pain interfere with your appetite?
Have you lost weight?
9. How often does pain interfere with your sleep?
How often over the past week?
10. Has pain interfered with your energy, mood,
personality, or relationships with other people?
11. Over the past week, how often have you taken
pain medication?
12. How would you rate your health at the present time?
Reference: AGS Panel on Persistent Pain in Older Persons. The management of
persistent pain in older persons. J Am Geriatr Soc. 2002;50:S205-24.
Also Available - Treating Pain in the Elderly clinical reference card (item # A99020RCK) provides a valuable complementary pain management information resource. Contact MED-PASS at 800-438-8884 for more information.
www.ascp.com
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