Crit Care Nurs Q Vol. 38, No. 3, pp. 237–244 c 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
Pain Assessment and Management in Critically Ill Older Adults Kenn M. Kirksey, PhD, RN, ACNS-BC, FAAN; Gayle McGlory, PhD, RN, CCRN, RN-BC; Elizabeth F. Sefcik, PhD, RN, GNP-BC Older adults comprise approximately 50% of patients admitted to critical care units in the United States. This population is particularly susceptible to multiple morbidities that can be exacerbated by confounding factors like age-related safety risks, polypharmacy, poor nutrition, and social isolation. The elderly are particularly vulnerable to health conditions (heart disease, stroke, and diabetes) that put them at greater risk of morbidity and mortality. When an older adult presents to the emergency department with 1 or more of these life-altering diagnoses, an admission to the intensive care unit is often inevitable. Pain is one of the most pervasive manifestations exhibited by intensive care unit patients. There are myriad challenges for critical care nurses in caring for patients experiencing pain—inadequate communication (cognitively impaired or intubated patients), addressing the concerns of family members, or gaps in patients’ knowledge. The purpose of this article was to discuss the multidimensional nature of pain and identify concepts innate to pain homeostenosis for elderly patients in the critical care setting. Evidence-based strategies, including an interprofessional team approach and best practice recommendations regarding pharmacological and nonpharmacological pain management, are presented. Key words: assessment, critical care, elderly, pain, pain management
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HE NATIONAL INSTITUTE on Aging and the World Health Organization (WHO)’s report on Global Health and Aging estimated that 8% of the global population was 65 years of age or older in 2010. There are predictions that this percentage will double by 2050.
Author Affiliations: Ben Taub and Quentin Mease Hospitals, Harris Health System, Houston, Texas (Dr Kirksey); Lyndon B. Johnson Hospital, Harris Health System, Houston, Texas (Dr McGlory); and College of Nursing & Health Sciences, Texas A&M University—Corpus Christi, Corpus Christi, Texas (Dr Sefcik). The authors of this manuscript declare no conflicts of interest. Correspondence: Kenn M. Kirksey, PhD, RN, ACNSBC, FAAN, Ben Taub and Quentin Mease Hospitals, Harris Health System, Nursing Administration, 2nd Floor, 1504 Taub Loop, Houston, TX 77030 ([email protected]). DOI: 10.1097/CNQ.0000000000000071
Those born in 1900 seldom lived beyond 50 years of age; however, it is now fairly commonplace for Americans to live into their seventh decade and beyond.1 In fact, the average life expectancy among Americans was 78.8 years in 2012.2 Despite efforts aimed at promoting exercise and healthier food choices, early screening for diseases, and preventative measures like smoking cessation, older adults remain particularly susceptible to health conditions that can result in significant incidences of morbidity and mortality. Nearly 75% of deaths in the elderly can be attributed to heart disease, cancer, stroke, diabetes, influenza, pneumonia, kidney disease, Alzheimer disease, chronic lower respiratory diseases, unintentional injuries, and suicide.2 These conditions can quickly escalate from fairly manageable chronic states to life-altering situations. This is especially true in the elderly who have multiple morbidities and other 237
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confounding factors (eg, social isolation, safety risks, polypharmacy, and poor nutrition). Patients who present to the emergency department with these life-challenging events are often admitted to the intensive care unit. There are estimates that individuals older than 65 years of age make up approximately one-half of admissions to intensive care units.3 Although this vulnerable patient population may experience the gamut of untoward manifestations, one of the most pervasive complaints is pain. The focus of this article was to describe an evidence-based, interprofessional team approach to the assessment and management of pain in critically ill older adults. CASE STUDY Sarah (pseudonym) is a 77-year-old widow who lives alone and spends as much time as possible gardening and walking her dog. During an afternoon walk, her foot was caught in a crack in the sidewalk and caused her to fall. She hit her head and landed hard on her left hip and leg. A neighbor who witnessed the fall immediately called an ambulance and stayed with Sarah until paramedics arrived. Upon arrival in the level 1 trauma center, Sarah was assessed from head-to-toe, extensive blood work was done, and radiography (including a computed tomographic scan of the head) ordered. Following stabilization, she was transferred to the surgical intensive care unit. Although she had a mild concussion, the computed tomographic scan ruled out a skull fracture. Additional x-rays revealed a fractured hip and femur. She was deemed hemodynamically stable enough to go for immediate surgical repair of both fractures. Upon return to the surgical intensive care unit, she remained intubated and sedated for several more hours. Her son and daughter-in-law provided additional information about her status prior to her injuries. Sarah’s husband died 6 months before her injury. Her son noted that she complained of not sleeping well, having frequent nightmares, a diminished appetite, feeling depressed, and she had “really gone down.”
The family also stated that their mother had severe “bone problems and arthritis” and, consequently, had trouble walking at times and experienced moderate pain in her lower extremities. Pain assessment in older adults Assessing blood pressure, heart and respiratory rates, temperature, and oxygen saturation is essential data routinely used by nurses to monitor patients’ status and to detect early, and often, subtle signs of deterioration.4,5 As patient acuity increases, additional surveillance measures are warranted. Adding the appraisal of pain, urinary output, and level of consciousness to the mix of standard patient assessments has been proposed to yield 8 “vital signs.”6 It has been posited that patients experiencing pain is inevitable (particularly in postoperative situations), but having them linger with the discomfort unabated is unacceptable. Nurses should closely monitor patients and administer analgesics quickly to alleviate their discomfort.6 Researchers have conjectured that adequate pain management can improve patient outcomes and potentially reduce the patient’s length of stay.7 Multidimensional nature of pain The next 4 sections of the article address the phenomenon of homeostenosis and the multidimensional nature of pain (physical, psychosocial, and communication needs that the patient may be experiencing).3 The section on physical aspects focuses on differentiating between subjective and objective pain since critically ill patients may have an impaired ability to communicate (cognitively impaired, mechanically ventilated, and sedated). Physical aspects Age-related physiological changes can include an increase in fat mass, decrease in muscle mass, diminished renal and liver function, and decrease in the cerebral vascular flow.8 These physiological disruptions can impact the patient’s perception of pain and response to analgesics. Promptly relieving pain is particularly important in critically ill older patients
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Pain Assessment and Management in Critically Ill Older Adults like Sarah to promote comfort, rest, and healing. Reports from 1 qualitative study noted that pain can be the result of surgical wounds, intubation, disease processes, and even some nurse-initiated care. The study supported the assumption that relieving pain and discomfort and promoting rest are essential in elderly patients.3 As previously noted, appraising the newly admitted patient for pain should be considered a fundamental vital sign.6 Accurate assessment is an essential first step in managing pain.9 The patient’s subjective rating of pain is preferred, although there can be variations in self-report that may make the assessment more difficult for the nurse.10 Although Sarah was eventually able to verbalize her pain needs, frequent and accurate assessments by her critical care nurse were essential while she remained intubated. When assessing a patient like Sarah, both subjective and objective data should be considered. There are several instruments that facilitate pain assessment in both realms. Factors that need to be considered when selecting an instrument for pain assessment include well-established psychometric properties and practicality for use in an elderly patient population.11 There are a number of scales that can facilitate subjective reporting by the patient. Two commonly used instruments include the 0 to 10 Numeric Pain Rating Scale12 and the Brief Pain Inventory (BPI).13 The 0 to 10 Numeric Pain Rating Scale has 11 anchors ranging from 0 (no pain) to 10 (worst possible pain). The BPI can be used for either self-report or interview. The BPI has reported the Cronbach α reliability indexes ranging from 0.77 to 0.91.13 It is not uncommon for critically ill patients to be unable to communicate verbally, whether the cause is physiological or iatrogenic. Several scales are available for the nurse to use in assessing pain levels in these patients. The Wong-Baker FACES Pain Rating Scale provides pictures of 6 faces, with facial expressions ranging from a happy face (no hurt) to a sad face where the individual is crying (hurts worst).14 The Abbey Pain Scale
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can be used to measure pain in patients diagnosed with dementia and unable to speak. The nurse observes for behaviors like vocalization (groaning and crying), nonverbal body language, facial cues (frowning), and physiological changes (vital signs).15 Another instrument that has applicability for pain assessment in patients with dementia is the Pain Assessment in Advanced Dementia.16 The categories of observations are very similar to those described in the Abbey Pain Scale. An additional commonly used instrument is the CriticalCare Pain Observation Tool (CPOT).17 Development of the CPOT was based on retrospective chart reviews to determine common pain notations and findings with focus groups of critical care clinicians. This instrument is designed for use in both intubated and nonintubated critical care patients.18 Four domains— facial expressions, movements, muscle tension, and ventilator compliance—are scored from 0 to 2; total scores range from 0 (no pain) to 8 (most pain). The researchers used pre- and posttest methodology to evaluate the interrater reliability of critical care nurses’ use of the CPOT and found the instrument to be beneficial in the evaluation of pharmacological interventions.18 In another study, the alpha reliability coefficients for the Pain Assessment in Advanced Dementia and CPOT scales were determined to be 0.80 and 0.72, respectively.17 The Behavioral Pain Scale (BPS) can be used to assess pain in unconscious, sedated, or ventilated patients.19 The BPS is composed of 3 observational subscales (facial expression, upper limbs, and compliance with ventilation) that are scored from 1 to 4, with higher numbers indicating greater levels of discomfort. The total BPS score can range from 3 (no pain) to 12 (most pain). The use of the BPS is recommended in critical care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions.19 The BPS was used to assess Sarah’s pain while she remained intubated during the first few hours of her postoperative recovery.
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Psychosocial aspects The literature is replete with citations about psychosocial aspects of pain. Researchers from 1 study noted that elderly participants wanted caring behavior from the critical care staff, flexible visiting hours for those who had visitors, an increase in patient control ability, and especially open communication lines with staff.3 Having an endotracheal tube seemed to cause nervousness and anxiety because the older patient was unable to communicate. One of the study participants who was female and near Sarah’s age reported that the inability to talk due to intubation was very frustrating. Several participants expressed a desire to be better informed about their disease or situation. It is not uncommon for critically ill elderly patients to experience cognitively or iatrogenically induced difficulties with communication, which can further diminish their abilities to self-report level and intensity of pain.3 This makes it even more imperative that the nurse objectively assess the patient for pain and become the voice for those patients who cannot verbalize their own comfort needs. Communication needs When the patient is elderly, lethargic due to the illness, injuries, or medications, appears confused, or is unable to communicate verbally, some health care providers may opt to communicate with the patient’s family members rather than directly with the patient. Communicating directly with patients facilitates comprehension about what is happening to them and diminishes the sense of uncertainty and fear.20 Being diligent in providing information about the progression of their disease, prognosis, and plan of care trajectory is imperative to enhance elderly patients’ understanding.3 Pain homeostenosis There are a number of data-based reports citing the multidimensional nature of pain in older patients.21,22 Older adults can experience various chronic conditions (osteoporosis, osteoarthritis, and postherpetic neuropa-
thy), each of which can exacerbate the person’s propensity for persistent pain. There are estimates that more than 40% of the older population experience some level of chronic pain.23 Persistent pain is often linked with physical dysfunction, sleep disturbance, and diminished socialization. These physical and psychosocial disruptions can result in anxiety, depressive symptoms, and feelings of isolation. Elderly patients may also have a greater tendency for becoming frail, with factors like impaired mobility, depression, inadequate nutrition, and comorbidities cited as precipitating elements.24 Shega and colleagues22 coined the term “pain homeostenosis” to describe these stressors. Disruptions in nutrition or sleep, personal losses (eg, death of a loved one), starting new medications, experiencing multiple comorbidities, and environmental changes all place the older person at higher risk of “cognitive dysfunction, falls, and disability with minor perturbations.”22(p113) When an older patient who has a history of persistent pain caused by one of the precipitating factors previously described is admitted to the critical care area with an acute condition, the predisposition for homeostenosis increases exponentially. Researchers conducted a cross-sectional study to explore associations between frailty and self-reported pain.22 Although causality could not be established, the findings suggested a clear link between persistent pain and frailty. Participants reported varying degrees of pain relief when taking pharmacological agents ranging from over-thecounter analgesics to opioids. The study team suggested that nonpharmacological measures (complementary/alternative therapies, physical or occupational therapy, application of heat or cold compresses) may assist in tempering the effects of chronic pain.22 Evidence-based pain management strategies Interprofessional team approach Interprofessional care has been conceptualized as a team partnering in an integrated
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Pain Assessment and Management in Critically Ill Older Adults and interdependent way.25 Researchers from the United Kingdom used grounded theory methodology to conduct semistructured interviews (both individually and in focus groups) to determine the perspectives of interprofessional team members in providing person-centered pain management.26 Factors like “collective efficacy, negotiated space and team maturity” were identified as essential components in person-centered interprofessional care.26(p493) Collective efficacy (a phrase originally coined by Bandura) refers to the teams’ beliefs in their abilities for successful performance.27 In other words, it is imperative that the team have respect for other members’ professional competencies. Team maturity resulted from working with other members over time. They were able to develop stronger relationships because they had witnessed team members’ credibility over time. Negotiated space referred to physical proximity. When nurses, physicians, and other professionals worked in juxtaposition, there were more opportunities for team members to discuss patient care in person and to expedite development of collegial and congenial relationships.26 Individualizing the plan of care There are reports that pain is managed poorly in elderly persons.8,28 When the individual has a limited ability to communicate, addressing pain issues becomes even more difficult.29 McLiesh and colleagues8 posited that using a multidisciplinary team approach can enhance the care for this vulnerable patient population. The old adage “one size fits all” is certainly not applicable when designing a pain management plan of care for critically ill older adults. Because of the previously described multidimensional nature of pain in the elderly, staff needs specific knowledge and skills as well as appropriate systems to address the comfort needs in this particular patient group. The following sections of the article describe both pharmacological and nonpharmacological considerations regarding pain management needs in critically ill older adults.
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Pharmacological management An interprofessional approach that includes the physician, geriatrician, nurse, pharmacist, physiotherapist, and pain specialist should be used to implement strategies for pain management.8 There is a lack of in-depth knowledge regarding effective management of pain in the elderly population.8 Pharmacological pain management of the critically ill patient may be complicated due to physiological changes in the patient such as age, decreased organ function, or body mass.30 These factors must be taken into consideration when prescribing and administering medications. Use of multimodal tactics to address pain etiology and select medications that target particular kinds of pain (chronic, acute, postoperative) have demonstrated efficacy in reducing side effects because providers are able to choose the optimal medication and dosage.31 The WHO divided analgesics into categories for use in patients with varying levels of pain. Although the classification system was developed for patients experiencing cancer-related pain, there is certainly applicability for patients with discomfort that is the result of other conditions. The first category includes nonopioids like aspirin, acetaminophen, and nonsteroidal antiinflammatory drugs. Examples of nonsteroidal anti-inflammatory drugs include diclofenac, etodolac, ibuprofen, indomethacin, ketorolac, meloxicam, nabumetone, and naproxen. Hydrocodone, combined with ibuprofen, aspirin, or acetaminophen; oxycodone, combined with aspirin or acetaminophen; and tramadol are used for complaints of mild or moderate pain. When the patient is able to take oral medications, it is preferable to start with nonopioids. If these medications are ineffective, adding an oral opioid may relieve the patient’s pain. Using an atypical opioid like tramadol may be preferred in patients like Sarah who have a history of chronic pain due to conditions like arthritis. Critically ill patients often experience more intense pain that requires single-entity opioids like hydromorphone, fentanyl, oxycodone, or morphine. The WHO guidelines offer some
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key points to consider when selecting and administering analgesics. The guidelines recommend starting at a low dosage and slowly increasing (especially in older adults), using what has worked in the past to control pain, premedicating before initiating procedures (eg, dressing change) that may cause pain, and reassessing the patient to ensure that adequate pain control has been achieved. It also provides an essential opportunity to note any unwanted changes in respiratory status or oversedation.31 Some researchers believe that a low-dose, short-acting, opioid regimen may be optimal in nonverbal patients.32 In 1 study, researchers initiated a low-dose trial of hydromorphone to older adults.30 Hydromorphone 0.5 mg was administered intravenously and was titrated at 15 minutes or 1 hour intervals based on reassessment results. Another group of researchers implemented a strategy where an analgesic trial was implemented to manage suspected pain. Low doses of nonsteroidal anti-inflammatory medications, nonopioid epidural medications, and fentanyl were deemed effective in managing pain.33
touch, acupuncture, and tai chi.34 Since analgesics sometimes need to be administered sparingly in older, critically ill adults, incorporating nonpharmacological therapies may have significant benefits in adequately managing their pain. The author noted that “nurses are in an ideal position to integrate multidimensional pain assessment.”34(p51) As Sarah continued to improve, the critical care nurses caring for her partnered with other members of the interprofessional health care team in providing therapeutic touch and meditation. She responded well to these alternative therapies and required fewer analgesics when pharmacologic and nonpharmacologic measures were used in combination.
Nonpharmacological management
Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage . . . The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.36(p1)
Administration of appropriate analgesics is usually imperative for adequately managing pain in older adults in a critical care setting, although they may only be 1 part of the optimal solution. Sarah’s family reported that she had a history of using complementary and alternative therapies to manage her chronic pain needs before her hospitalization. Although Tobon34 specifically outlined complementary and alternative medicine (CAM) therapies for older adults experiencing vascular leg pain, these modalities potentially have applications in managing pain associated with myriad physical conditions. The National Center for Complementary and Alternative Medicine defined CAM as “the array of health care approaches with a history of use or origins outside of mainstream medicine.”35(para1) Some of the most commonly used CAM modalities are nutritional supplements, spiritual healing, herbal therapies, therapeutic
Person-centered care Communicating with a patient who cannot communicate verbally Managing pain with critical care patients who cannot communicate verbally can present a challenge for critical care nurses.8,17 The International Association for the Study of Pain defined pain as:
Further assessment is required and the keen observational skills of a good critical care nurse are priceless in this instance. The challenge is that a critical care patient is unable to communicate, and other options for assessment are required prior to pain management.11 Addressing the concerns of family members Pain control is a cardinal point to health care providers and patients’ family members.37 Although it is important to communicate directly with the patient, involving designated family members in the patient’s plan of care
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Pain Assessment and Management in Critically Ill Older Adults is a critical part of person-centric care. Proxy reporting from family members is advocated. Family members are “encouraged to actively participate in the assessment of pain.”33(p231) Loved ones can assist nurses with identifying the critically ill patient’s pain indicators and response to interventions. Sarah’s son and daughter-in-law became actively engaged in her care, even requesting that nurses administer pain medications while their mother was still intubated and unable to voice her own needs. Educating the patient about pain management modalities Prior to educating the patient about pain management modalities, critical care nurses must be educated on the difficulties in pain assessment and management of the critically ill patients who are unable to communicate.8 Although nurses are responsible for educating the patient about pain management, sometimes this option is unavailable when the patient is unable to expressively or receptively communicate with nurses. Despite the patient’s inability to communicate, the nurse should still talk to the patient about pain management when possible, educate the patient’s family about pain management modalities,33 and consult with
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the family member in reference to the patient’s behavior to interpret possible signs of pain.38 CONCLUSIONS When older patients like Sarah are admitted to the critical care unit, there are agerelated physiological and psychosocial factors that may place them at greater risk for morbidity and mortality than might be experienced by younger patients with the same illness or injuries. Critical care nurses are particularly adept at monitoring airway, breathing, hemodynamic function, and other vital parameters. Assessing and managing pain is another imperative that should be similarly addressed. The multidimensional nature of pain experienced by older patients can present critical care nurses with myriad challenges in providing their care. Addressing the needs of critically ill patients from any age who have impaired verbal communication (whether due to some physiologic reason like dementia or an iatrogenic cause like intubation) can be perplexing for the nurse. When the patient is elderly and may have multimorbidities or other challenges associated with homeostenosis, the nurse’s job becomes exponentially more complex.
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6. Elliott M, Coventry A. Critical care: the eight vital signs of patient monitoring. Br J Nurs. 2012;21: 621-625. 7. Klassen B, Liu L, Warren S. Pain management best practice with older adults: effects of training on staff knowledge, attitudes, and patient outcomes. Phys Occup Ther Geriatr. 2009;27:173-196. 8. McLiesh P, Mungall D, Wiechula R. Are we providing the best possible pain management for our elderly patients in the acute-care setting? Int J Evid Based Healthc. 2009;7:173-180. 9. Spillman SK, Baumhover LA, Lillegraven CL, et al. Infrequent assessment of pain in elderly trauma patients. J Trauma Nurs. 2014;21:229-237. 10. Barr J, Fraser G, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306.
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11. Cade CH. Clinical tools for the assessment of pain in sedated critically ill adults. Nurs Crit Care. 2008; 13:288-297. 12. McCaffery M, Pasero C. 0-10 numeric pain rating scale. In: Wong D, ed. Pain: Clinical Manual. 5th ed. St Louis, MO: Mosby, Inc; 1999:1215-1216. 13. MD Anderson Cancer Center. The Brief Pain Inventory (BPI). http://www.mdanderson.org/educationand-research/departments-programs-and-labs/ departments-and-divisions/symptom-research/ symptom-assessment-tools/brief-pain-inventory.html. Accessed November 1, 2014. 14. Wong DL, Hackenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P. Wong-Baker FACES rating scale. In: Wong D, ed. Wong’s Essentials of Pediatric Nursing. 6th ed. St Louis, MO: Mosby Inc; 2001: 1301. 15. Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a 1 minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004;10: 6-13. 16. University of Iowa. Pain Assessment in Advanced Dementia Scale (PAINAD). https://www.healthcare .uiowa.edu/igec/tools/pain/PAINAD.pdf. Accessed December 2, 2014. 17. Paulson-Conger M, Leske J, Maidl C, Hanson A, Dziadulenicz L. Comparison of two pain assessment tools in nonverbal critical care patients. Pain Manag Nurs. 2011;12:218-224. 18. Gelinas C, Arbour C, Michaud C, et al. Implementation of the critical-care pain observation tool on pain assessment/management nursing practices in an intensive care unit with nonverbal critically ill adults: a before and after study. Int J Nurs Stud. 2011;48:14951504. 19. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a Behavioural Pain Scale to assess pain in ventilated unconscious and/or sedated patients. Intensive Crit Care Nurs. 2006;22:32-39. 20. Hofhuis J, Spronk P, van Stel H, Schrijvers AJ, Rommes JH, Bakker J. Experiences of critically ill patients in the ICU. Intensive Crit Care Nurs. 2008;24:300-313. 21. Karp JF, Shega JW, Morone N, Weiner DK. Advances in understanding the mechanisms and management of persistent pain in older adults: the critical role of descending inhibition. Br J Anaesth. 2008;101:111120. 22. Shega J, Dale W, Andrew M, Paice J, Rockwood K, Weiner D. Persistent pain and frailty: a case for homeostenosis. J Am Geriatr Soc. 2012;60:113-117. 23. Maxwell CJ, Dalby DM, Slater M, et al. The prevalence and management of current daily pain among older home care clients. Pain. 2008;138:208-216. 24. Rudy TE, Weiner DK, Lieber SJ, Slaboda J, Boston JR. The impact of low back pain on older adults: a comparative study of patients and controls. Pain. 2007;131:293-301.
25. Reeves S, Lewin S, Espin S, Zwarentsetin M. Interprofessional Teamwork for Health and Social Care. London, England: Wiley-Blackwell; 2010. 26. Howarth M, Warne T, Haigh C. Let’s stick together— a grounded theory exploration of interprofessional working used to provide person centered chronic back pain services. J Interprof Care. 2012;26:491496. 27. Bandura A. Self-sufficiency mechanism in human agency. Am Psychologist. 1982;37:122-147. 28. Royal College of Physicians British Geriatrics Society and British Pain Society. The Assessment of Pain in Older People: National Guidelines. London, England: RCP; 2007. 29. Hadjistravropoulos T, Voyer P, Sharpe D, Verreault R, Aubin M. Assessing pain in dementia patients with comorbid delirium and/or depression. Pain Manag Nurs. 2008;9:48-54. 30. Chang AK, Bijur PE, Davitt M, Gallagher J. Randomized clinical trial of an intravenous hydromorphone titration protocol versus usual care for management of acute pain in older emergency department patients. Drugs Aging. 2013;30:747-754. 31. Quinlan-Colwell A. What you should know about first-line pain medications. American Nurse Today. http://www.americannursetoday.com/what-youshould-know-about-first-line-pain-medications/?utm_ source=BenchmarkEmail&utm_campaign=AMNT_ Elec_DEC14_SW &utm_medium = email. Published December 2014. Accessed December 5, 2014. 32. Scherder E, Plooij B. Assessment and management of pain, with particular emphasis on central neuropathic pain, in moderate to severe dementia. Drugs Aging. 2012;29:701-706. 33. Herr K, Coyne P, McCaffery M, Manworren R, Merkel S. Pain assessment in the patient unable to self-report: position statement with clinical practice recommendations. Pain Manag Nurs. 2011;12:230-250. 34. Tobon J. Complementary and alternative medicine for older adults with venous leg ulcer pain. J Gerontol Nurs. 2010;36:46-53. 35. National Center for Complementary and Alternative Medicine (NCCAM). Complementary, alternative, or integrative health: what’s in a name? http://nccam. nih.gov/health/whatiscam. Published October 2008. Updated July 2014. Accessed December 4, 2014. 36. International Association for the Study of Pain. ISAP taxonomy. http://www.iasp-pain.org/Taxonomy? navItemNumber=576#Pain. Updated October 6, 2014. Accessed November 23, 2014. 37. Klein DG, Dumpe M, Katz E, Bena J. Pain assessment in the intensive care unit: development and psychometric testing of the nonverbal pain assessment tool. Heart Lung. 2010;39:521-528. 38. Symons F, Shinde S, Gilles E. Perspectives on pain and intellectual disability. J Intellect Disabil Res. 2008;52(part 4):275-286.
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Pain Assessment and Management in Critically Ill Older Adults Kenn M. Kirksey, PhD, RN, ACNS-BC, FAAN; Gayle McGlory, PhD, RN, CCRN, RN-BC; Elizabeth F. Sefcik, PhD, RN, GNP-BC Older adults comprise approximately 50% of patients admitted to critical care units in the United States. This population is particularly susceptible to multiple morbidities that can be exacerbated by confounding factors like age-related safety risks, polypharmacy, poor nutrition, and social isolation. The elderly are particularly vulnerable to health conditions (heart disease, stroke, and diabetes) that put them at greater risk of morbidity and mortality. When an older adult presents to the emergency department with 1 or more of these life-altering diagnoses, an admission to the intensive care unit is often inevitable. Pain is one of the most pervasive manifestations exhibited by intensive care unit patients. There are myriad challenges for critical care nurses in caring for patients experiencing pain—inadequate communication (cognitively impaired or intubated patients), addressing the concerns of family members, or gaps in patients’ knowledge. The purpose of this article was to discuss the multidimensional nature of pain and identify concepts innate to pain homeostenosis for elderly patients in the critical care setting. Evidence-based strategies, including an interprofessional team approach and best practice recommendations regarding pharmacological and nonpharmacological pain management, are presented. Key words: assessment, critical care, elderly, pain, pain management
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HE NATIONAL INSTITUTE on Aging and the World Health Organization (WHO)’s report on Global Health and Aging estimated that 8% of the global population was 65 years of age or older in 2010. There are predictions that this percentage will double by 2050.
Author Affiliations: Ben Taub and Quentin Mease Hospitals, Harris Health System, Houston, Texas (Dr Kirksey); Lyndon B. Johnson Hospital, Harris Health System, Houston, Texas (Dr McGlory); and College of Nursing & Health Sciences, Texas A&M University—Corpus Christi, Corpus Christi, Texas (Dr Sefcik). The authors of this manuscript declare no conflicts of interest. Correspondence: Kenn M. Kirksey, PhD, RN, ACNSBC, FAAN, Ben Taub and Quentin Mease Hospitals, Harris Health System, Nursing Administration, 2nd Floor, 1504 Taub Loop, Houston, TX 77030 ([email protected]). DOI: 10.1097/CNQ.0000000000000071
Those born in 1900 seldom lived beyond 50 years of age; however, it is now fairly commonplace for Americans to live into their seventh decade and beyond.1 In fact, the average life expectancy among Americans was 78.8 years in 2012.2 Despite efforts aimed at promoting exercise and healthier food choices, early screening for diseases, and preventative measures like smoking cessation, older adults remain particularly susceptible to health conditions that can result in significant incidences of morbidity and mortality. Nearly 75% of deaths in the elderly can be attributed to heart disease, cancer, stroke, diabetes, influenza, pneumonia, kidney disease, Alzheimer disease, chronic lower respiratory diseases, unintentional injuries, and suicide.2 These conditions can quickly escalate from fairly manageable chronic states to life-altering situations. This is especially true in the elderly who have multiple morbidities and other 237
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confounding factors (eg, social isolation, safety risks, polypharmacy, and poor nutrition). Patients who present to the emergency department with these life-challenging events are often admitted to the intensive care unit. There are estimates that individuals older than 65 years of age make up approximately one-half of admissions to intensive care units.3 Although this vulnerable patient population may experience the gamut of untoward manifestations, one of the most pervasive complaints is pain. The focus of this article was to describe an evidence-based, interprofessional team approach to the assessment and management of pain in critically ill older adults. CASE STUDY Sarah (pseudonym) is a 77-year-old widow who lives alone and spends as much time as possible gardening and walking her dog. During an afternoon walk, her foot was caught in a crack in the sidewalk and caused her to fall. She hit her head and landed hard on her left hip and leg. A neighbor who witnessed the fall immediately called an ambulance and stayed with Sarah until paramedics arrived. Upon arrival in the level 1 trauma center, Sarah was assessed from head-to-toe, extensive blood work was done, and radiography (including a computed tomographic scan of the head) ordered. Following stabilization, she was transferred to the surgical intensive care unit. Although she had a mild concussion, the computed tomographic scan ruled out a skull fracture. Additional x-rays revealed a fractured hip and femur. She was deemed hemodynamically stable enough to go for immediate surgical repair of both fractures. Upon return to the surgical intensive care unit, she remained intubated and sedated for several more hours. Her son and daughter-in-law provided additional information about her status prior to her injuries. Sarah’s husband died 6 months before her injury. Her son noted that she complained of not sleeping well, having frequent nightmares, a diminished appetite, feeling depressed, and she had “really gone down.”
The family also stated that their mother had severe “bone problems and arthritis” and, consequently, had trouble walking at times and experienced moderate pain in her lower extremities. Pain assessment in older adults Assessing blood pressure, heart and respiratory rates, temperature, and oxygen saturation is essential data routinely used by nurses to monitor patients’ status and to detect early, and often, subtle signs of deterioration.4,5 As patient acuity increases, additional surveillance measures are warranted. Adding the appraisal of pain, urinary output, and level of consciousness to the mix of standard patient assessments has been proposed to yield 8 “vital signs.”6 It has been posited that patients experiencing pain is inevitable (particularly in postoperative situations), but having them linger with the discomfort unabated is unacceptable. Nurses should closely monitor patients and administer analgesics quickly to alleviate their discomfort.6 Researchers have conjectured that adequate pain management can improve patient outcomes and potentially reduce the patient’s length of stay.7 Multidimensional nature of pain The next 4 sections of the article address the phenomenon of homeostenosis and the multidimensional nature of pain (physical, psychosocial, and communication needs that the patient may be experiencing).3 The section on physical aspects focuses on differentiating between subjective and objective pain since critically ill patients may have an impaired ability to communicate (cognitively impaired, mechanically ventilated, and sedated). Physical aspects Age-related physiological changes can include an increase in fat mass, decrease in muscle mass, diminished renal and liver function, and decrease in the cerebral vascular flow.8 These physiological disruptions can impact the patient’s perception of pain and response to analgesics. Promptly relieving pain is particularly important in critically ill older patients
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Pain Assessment and Management in Critically Ill Older Adults like Sarah to promote comfort, rest, and healing. Reports from 1 qualitative study noted that pain can be the result of surgical wounds, intubation, disease processes, and even some nurse-initiated care. The study supported the assumption that relieving pain and discomfort and promoting rest are essential in elderly patients.3 As previously noted, appraising the newly admitted patient for pain should be considered a fundamental vital sign.6 Accurate assessment is an essential first step in managing pain.9 The patient’s subjective rating of pain is preferred, although there can be variations in self-report that may make the assessment more difficult for the nurse.10 Although Sarah was eventually able to verbalize her pain needs, frequent and accurate assessments by her critical care nurse were essential while she remained intubated. When assessing a patient like Sarah, both subjective and objective data should be considered. There are several instruments that facilitate pain assessment in both realms. Factors that need to be considered when selecting an instrument for pain assessment include well-established psychometric properties and practicality for use in an elderly patient population.11 There are a number of scales that can facilitate subjective reporting by the patient. Two commonly used instruments include the 0 to 10 Numeric Pain Rating Scale12 and the Brief Pain Inventory (BPI).13 The 0 to 10 Numeric Pain Rating Scale has 11 anchors ranging from 0 (no pain) to 10 (worst possible pain). The BPI can be used for either self-report or interview. The BPI has reported the Cronbach α reliability indexes ranging from 0.77 to 0.91.13 It is not uncommon for critically ill patients to be unable to communicate verbally, whether the cause is physiological or iatrogenic. Several scales are available for the nurse to use in assessing pain levels in these patients. The Wong-Baker FACES Pain Rating Scale provides pictures of 6 faces, with facial expressions ranging from a happy face (no hurt) to a sad face where the individual is crying (hurts worst).14 The Abbey Pain Scale
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can be used to measure pain in patients diagnosed with dementia and unable to speak. The nurse observes for behaviors like vocalization (groaning and crying), nonverbal body language, facial cues (frowning), and physiological changes (vital signs).15 Another instrument that has applicability for pain assessment in patients with dementia is the Pain Assessment in Advanced Dementia.16 The categories of observations are very similar to those described in the Abbey Pain Scale. An additional commonly used instrument is the CriticalCare Pain Observation Tool (CPOT).17 Development of the CPOT was based on retrospective chart reviews to determine common pain notations and findings with focus groups of critical care clinicians. This instrument is designed for use in both intubated and nonintubated critical care patients.18 Four domains— facial expressions, movements, muscle tension, and ventilator compliance—are scored from 0 to 2; total scores range from 0 (no pain) to 8 (most pain). The researchers used pre- and posttest methodology to evaluate the interrater reliability of critical care nurses’ use of the CPOT and found the instrument to be beneficial in the evaluation of pharmacological interventions.18 In another study, the alpha reliability coefficients for the Pain Assessment in Advanced Dementia and CPOT scales were determined to be 0.80 and 0.72, respectively.17 The Behavioral Pain Scale (BPS) can be used to assess pain in unconscious, sedated, or ventilated patients.19 The BPS is composed of 3 observational subscales (facial expression, upper limbs, and compliance with ventilation) that are scored from 1 to 4, with higher numbers indicating greater levels of discomfort. The total BPS score can range from 3 (no pain) to 12 (most pain). The use of the BPS is recommended in critical care units and may improve the management of pain among sedated patients by providing a systematic and consistent approach to pain assessment to guide interventions.19 The BPS was used to assess Sarah’s pain while she remained intubated during the first few hours of her postoperative recovery.
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Psychosocial aspects The literature is replete with citations about psychosocial aspects of pain. Researchers from 1 study noted that elderly participants wanted caring behavior from the critical care staff, flexible visiting hours for those who had visitors, an increase in patient control ability, and especially open communication lines with staff.3 Having an endotracheal tube seemed to cause nervousness and anxiety because the older patient was unable to communicate. One of the study participants who was female and near Sarah’s age reported that the inability to talk due to intubation was very frustrating. Several participants expressed a desire to be better informed about their disease or situation. It is not uncommon for critically ill elderly patients to experience cognitively or iatrogenically induced difficulties with communication, which can further diminish their abilities to self-report level and intensity of pain.3 This makes it even more imperative that the nurse objectively assess the patient for pain and become the voice for those patients who cannot verbalize their own comfort needs. Communication needs When the patient is elderly, lethargic due to the illness, injuries, or medications, appears confused, or is unable to communicate verbally, some health care providers may opt to communicate with the patient’s family members rather than directly with the patient. Communicating directly with patients facilitates comprehension about what is happening to them and diminishes the sense of uncertainty and fear.20 Being diligent in providing information about the progression of their disease, prognosis, and plan of care trajectory is imperative to enhance elderly patients’ understanding.3 Pain homeostenosis There are a number of data-based reports citing the multidimensional nature of pain in older patients.21,22 Older adults can experience various chronic conditions (osteoporosis, osteoarthritis, and postherpetic neuropa-
thy), each of which can exacerbate the person’s propensity for persistent pain. There are estimates that more than 40% of the older population experience some level of chronic pain.23 Persistent pain is often linked with physical dysfunction, sleep disturbance, and diminished socialization. These physical and psychosocial disruptions can result in anxiety, depressive symptoms, and feelings of isolation. Elderly patients may also have a greater tendency for becoming frail, with factors like impaired mobility, depression, inadequate nutrition, and comorbidities cited as precipitating elements.24 Shega and colleagues22 coined the term “pain homeostenosis” to describe these stressors. Disruptions in nutrition or sleep, personal losses (eg, death of a loved one), starting new medications, experiencing multiple comorbidities, and environmental changes all place the older person at higher risk of “cognitive dysfunction, falls, and disability with minor perturbations.”22(p113) When an older patient who has a history of persistent pain caused by one of the precipitating factors previously described is admitted to the critical care area with an acute condition, the predisposition for homeostenosis increases exponentially. Researchers conducted a cross-sectional study to explore associations between frailty and self-reported pain.22 Although causality could not be established, the findings suggested a clear link between persistent pain and frailty. Participants reported varying degrees of pain relief when taking pharmacological agents ranging from over-thecounter analgesics to opioids. The study team suggested that nonpharmacological measures (complementary/alternative therapies, physical or occupational therapy, application of heat or cold compresses) may assist in tempering the effects of chronic pain.22 Evidence-based pain management strategies Interprofessional team approach Interprofessional care has been conceptualized as a team partnering in an integrated
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Pain Assessment and Management in Critically Ill Older Adults and interdependent way.25 Researchers from the United Kingdom used grounded theory methodology to conduct semistructured interviews (both individually and in focus groups) to determine the perspectives of interprofessional team members in providing person-centered pain management.26 Factors like “collective efficacy, negotiated space and team maturity” were identified as essential components in person-centered interprofessional care.26(p493) Collective efficacy (a phrase originally coined by Bandura) refers to the teams’ beliefs in their abilities for successful performance.27 In other words, it is imperative that the team have respect for other members’ professional competencies. Team maturity resulted from working with other members over time. They were able to develop stronger relationships because they had witnessed team members’ credibility over time. Negotiated space referred to physical proximity. When nurses, physicians, and other professionals worked in juxtaposition, there were more opportunities for team members to discuss patient care in person and to expedite development of collegial and congenial relationships.26 Individualizing the plan of care There are reports that pain is managed poorly in elderly persons.8,28 When the individual has a limited ability to communicate, addressing pain issues becomes even more difficult.29 McLiesh and colleagues8 posited that using a multidisciplinary team approach can enhance the care for this vulnerable patient population. The old adage “one size fits all” is certainly not applicable when designing a pain management plan of care for critically ill older adults. Because of the previously described multidimensional nature of pain in the elderly, staff needs specific knowledge and skills as well as appropriate systems to address the comfort needs in this particular patient group. The following sections of the article describe both pharmacological and nonpharmacological considerations regarding pain management needs in critically ill older adults.
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Pharmacological management An interprofessional approach that includes the physician, geriatrician, nurse, pharmacist, physiotherapist, and pain specialist should be used to implement strategies for pain management.8 There is a lack of in-depth knowledge regarding effective management of pain in the elderly population.8 Pharmacological pain management of the critically ill patient may be complicated due to physiological changes in the patient such as age, decreased organ function, or body mass.30 These factors must be taken into consideration when prescribing and administering medications. Use of multimodal tactics to address pain etiology and select medications that target particular kinds of pain (chronic, acute, postoperative) have demonstrated efficacy in reducing side effects because providers are able to choose the optimal medication and dosage.31 The WHO divided analgesics into categories for use in patients with varying levels of pain. Although the classification system was developed for patients experiencing cancer-related pain, there is certainly applicability for patients with discomfort that is the result of other conditions. The first category includes nonopioids like aspirin, acetaminophen, and nonsteroidal antiinflammatory drugs. Examples of nonsteroidal anti-inflammatory drugs include diclofenac, etodolac, ibuprofen, indomethacin, ketorolac, meloxicam, nabumetone, and naproxen. Hydrocodone, combined with ibuprofen, aspirin, or acetaminophen; oxycodone, combined with aspirin or acetaminophen; and tramadol are used for complaints of mild or moderate pain. When the patient is able to take oral medications, it is preferable to start with nonopioids. If these medications are ineffective, adding an oral opioid may relieve the patient’s pain. Using an atypical opioid like tramadol may be preferred in patients like Sarah who have a history of chronic pain due to conditions like arthritis. Critically ill patients often experience more intense pain that requires single-entity opioids like hydromorphone, fentanyl, oxycodone, or morphine. The WHO guidelines offer some
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key points to consider when selecting and administering analgesics. The guidelines recommend starting at a low dosage and slowly increasing (especially in older adults), using what has worked in the past to control pain, premedicating before initiating procedures (eg, dressing change) that may cause pain, and reassessing the patient to ensure that adequate pain control has been achieved. It also provides an essential opportunity to note any unwanted changes in respiratory status or oversedation.31 Some researchers believe that a low-dose, short-acting, opioid regimen may be optimal in nonverbal patients.32 In 1 study, researchers initiated a low-dose trial of hydromorphone to older adults.30 Hydromorphone 0.5 mg was administered intravenously and was titrated at 15 minutes or 1 hour intervals based on reassessment results. Another group of researchers implemented a strategy where an analgesic trial was implemented to manage suspected pain. Low doses of nonsteroidal anti-inflammatory medications, nonopioid epidural medications, and fentanyl were deemed effective in managing pain.33
touch, acupuncture, and tai chi.34 Since analgesics sometimes need to be administered sparingly in older, critically ill adults, incorporating nonpharmacological therapies may have significant benefits in adequately managing their pain. The author noted that “nurses are in an ideal position to integrate multidimensional pain assessment.”34(p51) As Sarah continued to improve, the critical care nurses caring for her partnered with other members of the interprofessional health care team in providing therapeutic touch and meditation. She responded well to these alternative therapies and required fewer analgesics when pharmacologic and nonpharmacologic measures were used in combination.
Nonpharmacological management
Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage . . . The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment.36(p1)
Administration of appropriate analgesics is usually imperative for adequately managing pain in older adults in a critical care setting, although they may only be 1 part of the optimal solution. Sarah’s family reported that she had a history of using complementary and alternative therapies to manage her chronic pain needs before her hospitalization. Although Tobon34 specifically outlined complementary and alternative medicine (CAM) therapies for older adults experiencing vascular leg pain, these modalities potentially have applications in managing pain associated with myriad physical conditions. The National Center for Complementary and Alternative Medicine defined CAM as “the array of health care approaches with a history of use or origins outside of mainstream medicine.”35(para1) Some of the most commonly used CAM modalities are nutritional supplements, spiritual healing, herbal therapies, therapeutic
Person-centered care Communicating with a patient who cannot communicate verbally Managing pain with critical care patients who cannot communicate verbally can present a challenge for critical care nurses.8,17 The International Association for the Study of Pain defined pain as:
Further assessment is required and the keen observational skills of a good critical care nurse are priceless in this instance. The challenge is that a critical care patient is unable to communicate, and other options for assessment are required prior to pain management.11 Addressing the concerns of family members Pain control is a cardinal point to health care providers and patients’ family members.37 Although it is important to communicate directly with the patient, involving designated family members in the patient’s plan of care
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Pain Assessment and Management in Critically Ill Older Adults is a critical part of person-centric care. Proxy reporting from family members is advocated. Family members are “encouraged to actively participate in the assessment of pain.”33(p231) Loved ones can assist nurses with identifying the critically ill patient’s pain indicators and response to interventions. Sarah’s son and daughter-in-law became actively engaged in her care, even requesting that nurses administer pain medications while their mother was still intubated and unable to voice her own needs. Educating the patient about pain management modalities Prior to educating the patient about pain management modalities, critical care nurses must be educated on the difficulties in pain assessment and management of the critically ill patients who are unable to communicate.8 Although nurses are responsible for educating the patient about pain management, sometimes this option is unavailable when the patient is unable to expressively or receptively communicate with nurses. Despite the patient’s inability to communicate, the nurse should still talk to the patient about pain management when possible, educate the patient’s family about pain management modalities,33 and consult with
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the family member in reference to the patient’s behavior to interpret possible signs of pain.38 CONCLUSIONS When older patients like Sarah are admitted to the critical care unit, there are agerelated physiological and psychosocial factors that may place them at greater risk for morbidity and mortality than might be experienced by younger patients with the same illness or injuries. Critical care nurses are particularly adept at monitoring airway, breathing, hemodynamic function, and other vital parameters. Assessing and managing pain is another imperative that should be similarly addressed. The multidimensional nature of pain experienced by older patients can present critical care nurses with myriad challenges in providing their care. Addressing the needs of critically ill patients from any age who have impaired verbal communication (whether due to some physiologic reason like dementia or an iatrogenic cause like intubation) can be perplexing for the nurse. When the patient is elderly and may have multimorbidities or other challenges associated with homeostenosis, the nurse’s job becomes exponentially more complex.
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