Pain Management in Long-Term Care Facilities: Current Research Trends and Future Direction

Approximately 40 million Americans were aged 65 or older in 2010. By 2050, the number of people in that age group is expected to inflate to 88 million. Accordingly, there is a growing need to address the health care of older adults, including individuals residing in long-term care (LTC) facilities around the United States. LTC is an umbrella term that includes facilities providing varying degrees of daily living assistance and medical care. These include adult day service centers, home health agencies, hospices, skilled nursing facilities (SNFs), assisted living, and similar residential care communities. Data from the National Study of Long-Term Care Providers, 2013-2014, indicated that there were roughly 67,000 paid and regulated LTC service providers, which served about 9 million people in the United States. This included roughly 15,600 SNFs and 30,200 assisted living facilities and similar residential care communities. These numbers were considerably increased from estimates taken in 2012, when there were roughly 58,500 paid and regulated LTC services providers that served approximately 8 million people in the United States. These included 15,700 SNFs and 22,200 assisted living facilities.^1,2 

With the aging population and the growing number of people entering these facilities, obtaining the knowledge, skills, and resources necessary to address the mental and physical health needs of residents is of great importance. AMDA - The Society for Post-Acute and Long-Term Care Medicine’s 2012 clinical practice guideline Pain Management in the Long-Term Care Setting also highlights the importance of addressing health care issues specific to the LTC setting and provides recommendations to guide staff and practitioner practices. A variety of psychiatric and physical health conditions are present in residents at these facilities, including chronic pain and physical disorders involving marked levels of pain such as fibromyalgia, for example. According to the American Geriatrics Society, estimates of people affected by pain in SNFs range between 45% and 80%.³ Given the immense number of residents affected by pain, the current outbreak of opioid use disorders, and recent legislation regarding the provision of opioid medications,⁴ a renewed focus on the assessment and treatment of pain and pain-related disorders is warranted.

This literature review is designed to analyze and organize current research trends in the area of pain management within LTC facilities, to determine the current trends related to mental health interventions aimed at dealing with pain management within such facilities, and to evaluate the gaps in order to guide future studies. 

This review does not include the large body of literature pertaining to pain management in the general geriatric population but is specific to current research trends in LTC for several reasons. First, the large body of pain management literature pertaining to the general geriatric population is already well established. Second, it cannot be assumed that residents of LTC facilities are receiving a similar quality of health care as older adults living in the community. There are likely key differences, not only between the population living in LTC facilities and the general geriatric population, but also among various venues under the umbrella of LTC. A study by Zimmerman et al underscored differences in the provision of health care services between SNFs and assisted living facilities.⁵ Through this review, the authors aim to reach the scientific community studying LTC, providers of health care within LTC facilities, administrators, and those implementing policies and procedures within such facilities.

Search Criteria

The authors conducted a review of various databases and included search terms in the title of the articles such as long-term care, nursing home, or assisted living and pain management, pain relief, pain control, or pain reduction. The search was limited to studies conducted between 2012 and current day. The generated list of literature included mostly peer-reviewed journal articles. The list was reviewed and analyzed for trends and themes. Topics included pain assessment, pain management, knowledge and attitudes of staff in LTC toward pain management, and pain management intervention. This review will include a breakdown of the literature into the types of LTC facilities as well as their locations. Finally, the need for nonpharmacologic interventions, including those of a psychological nature, will be discussed.

Results

Pain Assessment

A discussion of current research trends in the area of pain assessment practices in LTC facilities should begin with a brief mention of what is already enforced in the United States. The Centers for Medicare & Medicaid Services has mandated guidelines regarding the clinical assessment of common, often unrecognized conditions (including pain) in residents of nursing homes (NHs) accepting federal insurance through the Minimum Data Set. These guidelines do not specifically address the needs of residents within other LTC facilities.⁶ 

The remainder of this section will focus on current research trends of pain assessment practices within all LTC facilities. A qualitative study administered in Quebec analyzed the educational and training needs of health care providers working in LTC facilities in the area of pain management. It revealed that the highest educational need for these providers pertains to assessment of pain.⁷ Similarly, Hadjistavropoulos et al conducted a study in two LTC facilities in Canada and, using a case series methodology, revealed that implementing interventions geared toward increasing and sustaining best practices in pain assessment can be effective.⁸ Thus, instructing providers in the area of assessment should be heavily emphasized when generating pain management curriculums in LTC.

Other researchers studied the use of pain assessment tools. Chow et al conducted a review of the literature regarding the use of pain assessment tools in LTC facilities and found that self-report should be the primary method of obtaining information about the nature of residents’ pain, followed secondarily by the use of observational instruments.⁹ Similarly, Osterbrink et al reviewed the use of assessment tools specific to SNFs using survey data in Germany and discovered that observational instruments designed to assess pain in residents with severe cognitive impairment were deficient, but most SNFs in their study had limiting policies governing practices in pain assessment.¹⁰ However, the implementation, enforcement, and effectiveness of such policies remains in question and could be the focus of future studies.

Assessing the experience of pain of residents in LTC facilities involves an understanding of the key factors and variables associated with pain. Lukas et al used multivariate logistic regression in a cross-sectional study to analyze the variables associated with pain in European SNFs.¹¹ They discovered pain was positively correlated with female gender, fractures, pressure ulcers, falls, sleeping disorders, cancer, unstable health conditions, a number of drugs, and depression. The authors also found that a high number of NH residents experience pain (48.8%). A continued analysis into the nature of the connection between pain and these other variables may provide helpful insight into the management of pain. 

When assessing pain in LTC residents, it is often necessary to consider the barriers to pain management and assessment. A study conducted in Ireland by Egan and Cornally compared patient-related barriers to pain management to barriers within organizations and caregivers.¹² Results suggested that patient-related barriers interfered the most with effective pain management. Patient-related barriers may include such phenomena as fearing medications, concealing pain, and thoughts of bothering the nurses. Researchers conducting future studies may consider analyzing the effectiveness of assessing the prevalence of these barriers within LTC facilities and identifying methods for overcoming them.

Each of the aforementioned studies was conducted either under the umbrella term LTC facility or within SNFs. There was no specific mention of assisted living facilities within these articles, suggesting a need for pain assessment research within that setting. Also, none of these studies were conducted within the United States. Many were in Europe, and one took place in Canada. It seems reasonable that further pain assessment research is needed specific to the United States, as there are likely key differences in the provision of health care among LTC facilities in other countries given nuances in the political, social, and economic landscapes. 

Pain Management

When analyzing the effectiveness of interventions used to manage pain experienced by residents in LTC facilities, it is necessary to discuss pharmacologic practices, as medication management is generally the most common method of treating pain. However, LTC facilities are not always effective and efficient in identifying those in pain and scheduling analgesic medications. Moreover, often these medications are offered on an as-needed basis, but patients with cognitive limitations or other deficits may not be able to adequately articulate such needs.

Lapane et al employed a logistic regression analysis of 2508 residents from 185 SNFs using data from a proprietary database in the United States to evaluate the use of analgesic medication as well as identify the factors related to scheduled analgesic medication use.¹³ The authors discovered that 23% of SNF residents in pain had no scheduled analgesic medications prescribed to them, but those who reported experiencing excruciating pain or moderate pain were more likely to have analgesics prescribed. Common analgesics prescribed to the residents included hydrocodone (41.7%), short-acting oxycodone (16.6%), and fentanyl (9.4%). The factors related to decreased odds of scheduled analgesic medications included severe cognitive impairment, age older than 85 years, and a diagnosis of Parkinson disease. The factors related to increased odds included a fracture in the resident’s history, a diagnosis of diabetes, and increased scores on a measure used to evaluate mood. A similar study by Pimentel et al examined the prevalence of pain and the use of analgesic medication in NH residents with cancer.¹⁴ It revealed that more than 65% of NH residents with cancer had documented pain in general (regardless of severity or frequency), and more than 17% of residents reporting daily pain did not receive analgesic medications.

Achterberg provided an editorial review of pain management research in Europe. The article primarily addressed the use of analgesic prescription pain medication and strong opioids.¹⁵ The author deduced that the management of pain in older adults with cognitive impairment has been inadequate and suggested that deficiency in pain management is likely a function of low physician involvement, ineffective assessment of pain-related problems, and subpar training and implementation of adequate pain assessment and management strategies. A paper by Hallenbeck provided another editorial review of pain management specific to American SNFs.¹⁶ The author provided statistics on the large number of residents in SNFs experiencing some level of pain and noted a significant number had cancer. He highlighted inconsistencies within pain management research in the last decade, with some studies suggesting improvements in pain management, while others suggest continued problems in this area. Future studies could address these inconsistencies and ascertain the variables related to the nuances within these studies that may account for the discrepancies.

Similarly, Hunnicutt et al administered a study using stratified analyses to determine statistics pertinent to pain of residents in American SNFs.¹⁷ The prevalence of persistent pain was 19.5%, whereas intermittent pain was 19.2%. Within the group of people experiencing persistent pain, 6.4% were untreated while 32% were undertreated. The same study found that racial/ethnic minorities and residents who were significantly cognitively impaired had increased rates of untreated and undertreated pain. Overall, one of five NH residents has persistent pain, according to this study.

A study by Vaismoradi et al synthesized international pain research findings specific to SNFs to better understand older people’s experiences of pain and how they manage their pain.¹⁸ The authors integrated the data into a theoretical model using themes of pain identity, pain recognition, and response to pain. The metaphor normalizing suffering was generated as a reflection of how older people experience and manage pain. The authors concluded that older people can find increased pain relief if they are encouraged to report their pain. 

Finally, a study by Liu explored the role of nursing assistants in managing the pain of residents within SNFs in Hong Kong.¹⁹ This was an exploratory qualitative study in which the authors concluded that, while nursing assistants carry on several important functions within the scope of residents’ pain management, their services were largely undervalued by other health care professionals. The implications and the applications of this particular study seem important to the adequate provision of pain management services and the overall culture within LTC facilities. A replication of a study of this nature within the United States may be helpful.

Together, the studies referenced within this subsection highlight the great need for continued research in the area of pain management within LTC facilities, given the large number of people who experience pain within these facilities and the ineffectiveness of many efforts to manage pain. While the statistics denoting this need are helpful, many of these studies discussed pain management in general terms without involving a more detailed analysis of why a person’s pain was not managed. Future research could explore these topics using both quantitative and qualitative methods. It is important to note that, while seemingly more research was conducted in the United States in the area of pain management relative to pain assessment, the studies within this subsection primarily reflected the management of pain specific to SNFs with little or no mention of assisted living facilities. This concern was discussed in the previous section; more research of this nature is needed within this specific setting.

Knowledge and Attitudes of Staff

This next area of the literature review examines the attitudes, knowledge, and beliefs of LTC facility staff in the realm of pain management. This area blends partially with the subsequent area of the literature review (ie, intervention), as a few of the articles cited within this section also address the use of interventions. However, given the amount of studies in this subject area, knowledge and attitudes warrant a separate category. 

Barry et al conducted a questionnaire study in Northern Ireland assessing the knowledge, attitudes, and beliefs of NH managers in regard to pain assessment and pain management of residents with dementia.²⁰ Results indicated NH managers generally were knowledgeable about pain in residents with dementia and were aware of the challenges regarding pain assessment. However, many were unaware of how to manage pain in those residents and noted concerns with administering opioid medications. Similarly, Cho and Kwon conducted a cross-sectional survey study that analyzed the knowledge and attitudes of pain management by nurses in a LTC hospital in Korea.²¹ Results reflected a poor level of knowledge and negative attitudes toward pain management among the nurses, which the authors surmised would likely negatively impact the practice of pain management.

Moreover, two quasi-experimental studies conducted by the same authors in Hong Kong evaluated the effects of a pain management program (one integrated) on the knowledge and attitudes of various NH health care workers toward pain management.^22,23 In both studies, implementation of the program was associated with an increase in knowledge and improved attitudes among staff toward pain management, and, in the 2013 study, residents in the experimental arm of the study had significantly lowered pain scores along with an increase in scores on measures of overall well-being. However, the 2013 study implemented an integrated intervention by providing education on pain to the staff while also providing residents with opportunities such as gardening and physiotherapy activities. In contrast, the 2014 study only included the pain education intervention with staff. A 2012 study by Tse et al ascertained similar results to the 2013 study by Tse and Ho.²⁴ 

Taken together, the results suggest a great need for pain management education among staff members and that implementation of a program geared toward educating staff on pain and managing pain can be helpful when used correctly. However, it should be noted that information regarding the long-term sustainability of such a program was absent from these studies, and future research replicating these studies should include follow-up data. None of these studies appeared to incorporate the calculation of an effect size, specifically in regard to the implementation of pain management programs. Significant differences between experimental and control groups within these studies, in general, is a source of promising news. But without effect sizes, it is difficult to conclude whether the results of these programs alone are objectively worth the resources required to implement and sustain the programs or if those resources would be better used for other methods of pain education, intervention, and management. 

Furthermore, none of the articles within this section mentioned assisted living facilities as a specific setting of study. Finally, as was discussed in an earlier section, none of the studies in this section took place within the United States. Generalizability, implication, and application of results from studies in other countries cannot reliably be assumed within the United States.

Pain Management Intervention

The final category of articles from this literature review surrounds specific interventions made to improve pain management practices and the overall management of pain in LTC facilities. This topic had the most abundant amount of research within the review.

Dräger et al conducted a cluster-randomized controlled experiment in Germany assessing NH staff and physicians to determine the effects of pain intensity and pain interference in residents at 12 SNFs in Berlin.²⁵ The intervention consisted of a training measure provided to nursing staff and physicians using various delivery methods. Results indicated that a percentage of those residents with pain scores greater than zero decreased significantly following the intervention but found insignificant reductions in pain 6 months later. A similar randomized controlled study conducted within SNFs in the Puget Sound area of Washington measured the effects of a pain assessment and management algorithm intervention on pain intensity of residents in a SNF and found that neither the intervention group nor the control group demonstrated any change in pain intensity from baseline.²⁶ Also, a study by Könner et al using a cluster-randomized controlled trial of NH residents in Berlin discovered education programs directed at general care practitioners and SNF staff did not significantly improve pain severity, nor did they help lessen use of inappropriate medications.²⁷ However, Li and Osborne did find significant outcomes in improving pain management and life quality using a pain management quality and safety project specific to their residents.²⁸ Thus, results of these studies appear mixed in terms of whether pain education interventions with staff are useful.

The next series of articles evaluated the effects of various pain management teams within LTC facilities. Kaasalainen et al used a mixed-methods design in Canada to study the effects of a nurse practitioner-led pain management team on pain-related outcomes, clinical practice behaviors, and the quality of the practices prescribing medications within LTC facilities. Researchers discovered the program did significantly reduce residents’ pain.²⁹ Two other studies researched the effectiveness of peer-assisted or peer-led pain management teams on variables such as the experience of pain and other factors of well-being within SNFs in Hong Kong and found significant improvement in these areas.^30,31 The two studies used different quantitative designs but ascertained similar results. 

Another study addressed and evaluated the use of nonpharmacologic interventions in LTC facilities. Kalinowski et al employed a cluster randomized controlled trial of NH residents in Germany and ascertained the effects of a nonpharmacologic intervention with nurses and physicians on subsequent nonpharmacologic therapies used by these health care providers.³² The intervention resulted in an increase of nonpharmacologic therapies administered by physicians but not by nurses. 

The results of these studies offer some promise in the area of peer-assisted or peer-led pain management programs. Further research in this area is warranted, and replication studies of Tse et al 2015 and Tse et al 2016 within the United States would be beneficial.^30,31 As mentioned, the implementation of specific pain-education program interventions with staff and health care professionals in LTC facilities yielded mixed results. Researchers of future studies may consider comparing the methodologies of these studies and the differences within the interventions themselves to determine the variables that accounted for the mixed results. Finally, as congruent with prior sections, the studies inherent within the interventions section of this paper illustrate a general need for more studies within the United States and specific to assisted living facilities, as the majority of these studies were international and conducted under the umbrella LTC or NH.

Discussion

The scientific literature in the area of pain management in LTC facilities since 2012 has yielded helpful findings in many areas, but it seems clear that more research is needed within the United States and across other settings under the umbrella LTC. Given the abundance of assisted living facilities within the United States and the health care related nuances in these facilities that distinguish them from SNFs with their more intensive medical coverage, there is a great need for research specific to these sites and across all topics within pain management. 

Moreover, these studies highlighted the importance of thorough pain assessment prior to intervention and how many LTC facilities show a deficiency in this area. Thus, future studies dissecting this topic and the reasons for inadequate pain assessment practices seen in LTC facilities would be beneficial. The study, development, and validation of new brief pain assessment inventories or adaptation of current inventories applied to LTC facilities may be useful. This may be helpful in identifying residents with pain who would not otherwise disclose their pain because of cognitive deficits or other psychopathology.

This review accentuated the significant correlation of pain with other medical and nonmedical factors and variables (eg, female gender, fractures, falls, etc), which warrant further investigation into the nature of the relationships among these factors. In other words, can causation be implied between pain and some of these other factors, or are there other mediating variables that better explain the relationship? Furthermore, the review highlighted the need for more research addressing the pain management of LTC residents from ethnic minority groups as well as residents with cognitive deficits, as they often are underassessed and undertreated relative to other groups.

Another theme generated from this literature review was poor knowledge, skills, and attitudes related to pain and pain management frequently demonstrated by LTC staff members and health care providers. Researchers of future pain management studies could further examine this topic and appraise the challenges in this area as well as attempt to identify the reasons behind such challenges. Additionally, it seems plausible that poor knowledge, skills, and attitudes regarding pain management by staff members likely affect the overall management and pain intervention implementation by such staff. Thus, exploratory studies on this topic would be useful. Moreover, given the mixed results regarding the effectiveness of pain education program interventions, future researchers may consider comparing the methodologies of these studies and the differences within the interventions themselves to determine the variables that account for the mixed results.

In the area of methodology, another noteworthy mention is that few, if any, of the articles used effect sizes to determine the size of statistical differences generated from the studies. This was particularly true of the intervention outcome studies, in which a few resulted in statistically significant differences between the experimental and control groups. Without an effect size, it is difficult to discuss the applicability of such results to the everyday pain management curriculum of LTC facilities because it is uncertain whether implementing the programs would yield a positive cost/benefit analysis related to the time and resources needed. 

While the source of pain may originate from an organic physical ailment, pain also has psychological constructs that serve to increase, decrease, or perpetuate pain in those experiencing chronic pain conditions such as pain catastrophizing, passive coping, and external locus of control. The interventions discussed within this literature primarily addressed the physical components of pain but left out psychological components. Thus, it would appear that there were no mental health professionals involved in development and implementation of the interventions within these studies. Future mental health literature should include studies involving the prevalence and effectiveness of mental health professionals in treating pain and pain-related disorders with LTC facilities. Likewise, the involvement of specific evidenced-based interventions for pain such as cognitive behavioral therapy would be warranted, including how often they are used and their effectiveness.

How might clinicians, facility administrators, medical professionals, and support staff apply the aforementioned themes and findings to everyday processes in LTC facilities? While results are inconclusive in many areas, it is clear that some method of pain assessment practice should be implemented within the daily medical and psychological care procedures in LTC facilities, and the primary method of assessment should be self-report followed by observational instruments. Also, instructing providers on the importance of using pain assessment practices is essential. However, staff should take caution or completely avoid the use of observational instruments in residents with severe cognitive impairments. In general, older residents of LTC facilities should be encouraged to report their pain. Finally, the fostering of both knowledge and skills with staff in LTC facilities should be incorporated into facility trainings as well as policies and procedures.

Conclusion

This review highlights the importance of thorough pain assessment in LTC facilities prior to intervention. More research is needed within the United States and across other settings within LTC, particularly in assisted living facilities.

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