Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents

AUTHORS:

Aida B. Won, MD; Kate L. Lapane, PhD; Sue Vallow, RPH, MBA; Jeff Schein, DrPH, MPH; John N. Morris, PhD; Lewis A. Lipsitz, MD

Pain is a common problem in elderly persons living in nursing homes, with a prevalence of persistent pain between 49% and 84%. About one-quarter have pain daily, and 41.2% continue to experience moderate daily pain or excruciating pain (at any frequency) at assessments 6 months later.

The morbidity of persistent pain is high. It is associated with decreased involvement in recreational activities, increased dependency in activities of daily living (ADLs), and an increased prevalence of depression and anxiety. There is evidence that pain is often inadequately treated. About 40% of cancer patients and 25% of noncancer patients in nursing homes do not receive analgesics despite experiencing pain daily. Older persons, men, cognitively impaired persons, and racial minorities are at greater risk for undertreatment. In addition, analgesics are most often prescribed on an as-needed (prn) basis even though guidelines suggest they should be given as a standing dose.

To improve appropriate analgesic prescribing and administration, it is important to understand current analgesic prescribing patterns and their effect on outcomes. Therefore, the objectives of this study were to characterize individuals with and without persistent pain; identify the characteristics of individuals using long-acting opioids, short-acting opioids, nonopioids, and no analgesics; determine the prevalence of specific analgesic use, prescribing patterns, and analgesic doses; and determine the extent to which different analgesic classes are associated with particular adverse events or diagnoses.

OBJECTIVES:

To determine the prevalence of analgesics used, their prescribing patterns, and associations with particular diagnoses and medications in patients with persistent pain.

DESIGN:

Cross-sectional study.

SETTING:

Nursing homes from 10 U.S. states.

PARTICIPANTS:

A total of 21,380 nursing home residents aged 65 and older with persistent pain.

MAIN OUTCOME MEASURE:

Minimum Data Set (MDS) assessments on pain, analgesics, cognitive, functional, and emotional status were summarized. Logistic regression models identified diagnoses associated with different analgesic classes.

RESULTS:

Persistent pain as determined using the MDS was identified in 49% of residents with an average age of 83; 83% were female. Persistent pain was prevalent in patients with a history of fractures (62.9%) or surgery (63.6%) in the past 6 months. One-quarter received no analgesics. The most common analgesics were acetaminophen (37.2%), propoxyphene (18.2%), hydrocodone (6.8%), and tramadol (5.4%). Only 46.9% of all analgesics were given as standing doses. Acetaminophen was usually prescribed as needed (65.6%), at doses less than 1,300 mg per day. Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed as a standing dose more than 70% of the time, and one-third of NSAIDs were prescribed at high doses.

CONCLUSIONS:

In nursing home residents, persistent pain is highly prevalent, there is suboptimal compliance with geriatric prescribing recommendations, and acute pain may be an important contributing source of persistent pain. More effective provider education and research is needed to determine whether treatment of acute pain could prevent persistent pain.

Pain is a common problem in elderly persons living in nursing homes, with a prevalence of persistent pain between 49% and 84%. About one-quarter have pain daily, and 41.2% continue to experience moderate daily pain or excruciating pain (at any frequency) at assessments 6 months later.

The morbidity of persistent pain is high. It is associated with decreased involvement in recreational activities, increased dependency in activities of daily living (ADLs), and an increased prevalence of depression and anxiety. There is evidence that pain is often inadequately treated. About 40% of cancer patients and 25% of noncancer patients in nursing homes do not receive analgesics despite experiencing pain daily. Older persons, men, cognitively impaired persons, and racial minorities are at greater risk for undertreatment. In addition, analgesics are most often prescribed on an as-needed (prn) basis even though guidelines suggest they should be given as a standing dose.

To improve appropriate analgesic prescribing and administration, it is important to understand current analgesic prescribing patterns and their effect on outcomes. Therefore, the objectives of this study were to characterize individuals with and without persistent pain; identify the characteristics of individuals using long-acting opioids, short-acting opioids, nonopioids, and no analgesics; determine the prevalence of specific analgesic use, prescribing patterns, and analgesic doses; and determine the extent to which different analgesic classes are associated with particular adverse events or diagnoses.

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