Abstract
Objectives
Pain is very common among older persons living in nursing home, affecting 45% to 80% of residents, interfering with daily activities and quality of life. Aims of the study are: 1) to measure the analgesics non-prescription in nursing home residents who present pain symptoms; 2) to identify the main determinants of analgesics non-prescription.
Design
Retrospective cross-sectional analysis.
Setting
Data from an observational study (‘Incidence of pNeumonia and related ConseqUences in nursing home Residents' [INCUR] study).
Participants
800 older persons living in 13 French nursing homes.
Measurments
Pain symptoms were definied by one of the following criteria: i) Presence of pain affecting the individual's function in the Activities of Daily Living; ii) Presence of daily pain, and/or; iii) Severe pain measured with a visual analogue scale.
Results
Among the patients originally included in the study, 288 (36%) reported pain symptomatology (mean age 86.9 [SD 7.2] years, 220 (76%) participants women). Amongst these, 138 (47.9%) were treated with non-opioid analgesic drugs, 52 (18.1%) with opioids, and 98 (34%) did not receive any analgesic prescription. An adjusted logistic regression analysis found that the strongest determinant of analgesics non-prescription was the number of concomitantly prescribed drugs (p<0.001). Age, education, and frailty were not associated with prescription of analgesic drugs.
Conclusions
Pain undertreatment is very common among older persons living in nursing homes. The number of prescribed medications represents the most relevant risk factor for the analgesics non-prescription. Our findings document the importance of reviewing prescriptions in nursing home residents.
Key words: Older Persons, pain, analgesics, drug prescription, nursing homes
Introduction
The number of people using nursing facilities, alternative residential care places or home care services is projected to steadily increase (1). Most of this increase is explained by the growth of the older population. It has been estimated that among people who reach 65 years of age, more than two-thirds will need long-term care services during their lifetime (1). Nearly one out of 8 Americans aged 85 years and older resides in an institutional setting (2).
Reporting of pain is very common among nursing home residents. It can be caused by a variety of conditions, with musculoskeletal disorders (e.g., osteoarthritis), neoplastic pain, neuropathies among the most common causes in later life (3). Pain is also common in the advanced stages of many chronic diseases, including congestive heart failure, end stage renal disease, and chronic obstructive pulmonary disease (4). Although varying according to the patient's characteristics and assessment instruments, it has been estimated that 45% to 80% of nursing home residents complaints about pain (5). Daily pain is associated with impaired physical performance and muscle strength, and this association gets stronger as pain severity increases. Pain also interferes with daily activities causing depression and emotional distress (6). Furthermore, the presence of pain is of major concern for public health as well, since pain has been associated with increased healthcare costs (although data from nursing homes are still scarces (7)).
Despite these considerations, physicians often overlook and undertreat pain, particularly when reported by older adults (8). It has been shown that about one-quarter of community-dwelling older adults with pain does not receive any analgesic drugs, independently of clinical diagnoses (8). Persons aged 85 years and older are particularly exposed to the risk of not receiving any treatment (8). Notwithstanding, data about analgesics prescription in older adults in nursing home are scarce (5).
In the present cross-sectional study, we hypothesize that the pain management in nursing home residents could be suboptimal. Specific factors, as age, dementia, frailty, and number of medications, may affect the attempt to control the pain symptoms. Our aim is, thus, to measure the prevalence of nursing home residents presenting pain symptoms and not receiving any analgesics. Analyses will also be conducted for identifying the main determinants of the analgesics nonprescription.
Methods
The data used in these analyses are from the assessment conducted at the baseline visit of the “Incidence of pNeumonia and related ConseqUences in nursing home Residents” (INCUR) project, a multicentre observational cohort study. A detailed description of the INCUR methodology and study design was previously published (9). Briefly, the aim of the INCUR study was to estimate the incidence of pneumonia events in older persons living in nursing homes over a period of 12 months. A total of 800 nursing home residents aged 60 and older were recruited in 13 nursing homes randomly selected in the Midi-Pyrenees region, South-Western France, between 2012 and 2013. Information about sociodemographic and lifestyle characteristics, chronic diseases, and functional status of residents were collected.
The study was approved by the Ethical Committee of the study coordinating centre. No formal written informed consent was needed, as the data collected was part of daily standard care activities, nonetheless all participants were informed about the on going research.
Study sample
For the purpose of the present study, a subgroup residents with pain in the INCUR cohort was identified by meeting at least one of the following inclusion criteria:
-
*
Presence of pain affecting the individual's capacity to perform the Activities of Daily Living (ADL) (10). This information was self-reported by the patient during the clinical assessment at the baseline visit;
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*
Presence of self-reported daily pain at the baseline visit, as evaluated according to the case report form clinical examination section;
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*
Severe pain measured with a visual analogue scale (i.e., equal to or more than 70% of the possible spectrum) at the baseline visit (11).
The cognitive status of participants was measured using the Abbreviated Mental Test Score (AMTS) (12). The presence of depressive symptoms was defined by the 10-item Geriatric Depression scale (GDS). Physical function was measured using the Activities of Daily Living (ADL) scale and a modified (4-item) Instrumental ADL scale (given the non-applicability of some original items to institutionalized persons) (13). All scales have been evaluated as continouos variables. A 36-item Frailty Index (FI) was computed according to the model proposed by Rockwood and Mitnitski (14) and the standardization criteria described by Searle and colleagues (15) (Table S1 in Supplementary Materials). Given the nature of the analyses, variables describing pain were not considered in the computation of the FI. For each patient, the number of prescribed medications (coded according to the Anatomical Therapeutic Chemical [ATC] system) was calculated (medications related to ATC codes used to operationalize the dependent variable were not included in this calculation).
Dependent variable
The outcome of interest for the present analyses was the nonprescription of analgesic medications. Analgesic medications were defined according to the following ATC codes: M01A*, M01B*, M02A*, N02A*, N02B*.
Statistical Analysis
Descriptive statistics were presented as mean and SD, or absolute numbers and percentage, as appropriate. Unadjusted and adjusted logistic regression models were performed to predict the non-prescription of analgesic drugs (dependent variable). A two-sided p value <0.05 was considered as statistically significant. Statistical analyses were performed using SPSS v24 software.
Results
Among the 800 patients originally enrolled in the INCUR study, 288 (36%) met the inclusion criteria for severe pain symptoms, and were considered for the present analyses. The mean age of the study sample was 86.9 (standard deviation, SD 7.2) years. The majority of the sample (n=220, 76%) was composed by women. Baseline characteristics are reported in Table 1.
Table 1.
Baseline Characteristics of Patients included in the Study
| N= 288 | |
|---|---|
| Age, years mean (SD) | 86.9 (7.2) |
| Female Sex, n (%) 286 | 220 (76.4) |
| Education, years mean (SD) 223 | 7.8 (3.2) |
| AMTS, mean (SD) 285 | 6.8 (2.9) |
| GDS, mean (SD) 264 | 3.2 (2.4) |
| ADL, mean (SD) | 3.5 (1.8) |
| IADL, mean (SD) | 3.2 (0.8) |
| Drugs, n mean (SD) | 9.5 (4.2) |
| Frailty Index, mean (SD) 285 | 0.40 (0.10) |
Legend: Italic numbers are referred to the non-missing values for each variable; ADL= Activities of Daily Living; AMTS= Abbreviated Mental Test Score; GDS= Geriatric Depression Scale; IADL= Instrumental Activities of Daily Living; SD= standard deviation.
Among the 288 patients, 138 (47.9%) were treated with non-opioid analgesic drugs, and 52 (18.1%) with opioids; 98 (34%) residents did not receive any analgesic prescription.
A logistic regression analysis was performed to explore the relationship between the independent variables of interest and the non-prescription of analgesic drugs (Table 2). Age, gender, education, and FI were not found to be associated with the pharmacological management of pain (Table 2). On the other hand, the only variable negatively affecting the prescription of analgesics was the number of concomitantly prescribed drugs, even after potential confounders were considered (multivariate adjusted model: OR 0.82; 95%CI 0.75– 0.90; p<0.001) (Table 2).
Table 2.
Logistic regression analysis exploring the predictors for non-prescription of analgesic drugs (dependent variable) in nursing home residents with pain symptomatology (n=288)
| Univariate Analysis | Multivariate Analysis | |||
|---|---|---|---|---|
| OR (95% CI) | p | OR (95% CI) | p | |
| Age (per year) | 0.98 (0.95–1.01) | 0.353 | 0.99 (0.95–1.04) | 0.776 |
| Female Sex | 1.61 (0.91–2.85) | 0.098 | 1.85 (0.92–3.70) | 0.084 |
| Education (per year) | 0.93 (0.85–1.02) | 0.125 | 0.84(0.85–1.04) | 0.227 |
| Frailty Index (continuous) | 0.42 (0.04–4.38) | 0.464 | 0.88 (0.04–17.62) | 0.935 |
| Drugs (per each) | 0.84 (0.78–0.90) | <0.001 | 0.82 (0.75–0.90) | <0.001 |
Legend: CI= confidence interval; OR= odds ratio.
Discussion
Our study shows that pain is a common condition among older adults living in long term care facilities. More than one-third of residents complained of severe pain symptomatology. At the same time, this condition is still largely undertreated as demonstrated by the 34% of residents who did not receive any analgesic treatment despite complaining about serious/frequent symptoms. To our knowledge, this is the first report showing that the number of prescribed drugs represents the main determinant for non-prescription of analgesics.
According to available evidence, the issue of pain management in older persons is particularly relevant. Consistently with our findings, it has been reported that between 20% and 30% of older patients with chronic pain do not receive any prescription for analgesic drugs (16). Moreover, the effective pain control is not always obtained. For example, our sample was entirely composed by individuals who were complaining of a severe pain symptomatology, daily occurring, and/or interfering with the daily functioning. In this group, 34% of patients did not receive any treatment. The non-prescription of analgesics in those patients reporting pain could represent a possible sign of malpractice, negatively affecting the quality of life of the person and potentially generating extra costs for the healthcare system.
When we explored the determinants of analgesics nonprescription, the number of concomitantly prescribed medications was found to be the only associated factor. Every prescribed drug concurs to an almost 20% reduction in the possibility of being treated for pain. Interestingly, previous data from the SHELTER study showed that previous falls, severe pressure ulcers and depression (all contributors to the fragilization of the individual) were the main predictors influencing the insufficient control of pain (5). However, the impact of polypharmacy was not taken into account. This finding is particularly frustrating if considering the severe lack of evidence for many pharmacological agents in nursing home residents, a population that is traditionally excluded by randomized controlled trials. In other words, the prescription of probably meaningless (if not harmful) drugs is here impacting on the control of a symptom critically interfering with the person's quality of life.
It is also noteworthy that our analyses do not show a significant role played by frailty on the prescription of analgesic drugs. This means that the use of medications is not really affected by the clinical complexity of the patient, but by the therapeutic confusion.
In this scenario, we could postulate that deprescribing would be the ideal solution to be implemented. This process is aimed at reducing medications use in order to safely meet the clinical priorities of the patient. It is the planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm. The goal is to reduce medication burden or harm while improving quality of life (17). Our findings document the importance of carefully and regularly reviewing prescriptions in nursing home. This might potentially help at finding room for prioritizing the treatment of a burdening symptom as pain.
Although we have no data to explore this aspect, we cannot exclude that among the non-biologically determined factors influencing the analgesic non-prescription there might be the stigma considering pain as a sort of “normal” manifestation of the ageing process. Both physicians, patients, and their relatives might erroneously consider pain as something that they have to “learn to live with” (18). It is thus important to educate patients (and caregivers) at reporting the symptom when present, in order to also raise awareness among healthcare professionals during the clinical assessment.
Our study has several limitations to be mentioned. First, INCUR was an observational study which was not designed to identify the determinants of the pain undertreatment. Thus, we cannot exclude that unmeasured residual confounders we could not consider in the present analyses might differently explain our results. Secondly, some missing data might have affected some of our analyses, in particular by reducing the statistical power. Third, the self-reporting of the pain symptoms could be affected by the cognitive status of the subjects included. Moreover, we cannot guarantee the generalizability of our results given the partial representativeness of our sample for the general population of nursing home residents.
Conclusions and implications
In conclusion, pain is very common among nursing home residents, but still largely left untreated. The strongest predictor of analgesics non-prescription in residents complaining pain symptomatology is represented by the number of concomintantly prescribed medications. Our findings document the importance of carefully and regularly reviewing prescriptions in nursing home. The periodic revision of treatment priorities may lead to a better management of older nursing home residents and potentially improve the treatment of such a burdening symptom as pain.
Acknowledgments
We thank Drs. Luca Mollo and Sedipeh Attal at Pfizer for their help and assistance. We also thank all the people who is making the INCUR project possible, in particular the clinical and administrative personnel of the participating nursing homes: Centre Hospitalier de Castelnaudary, De Vinci, Faux-Bourg Saint Adrien, Jean Loubès, Le Pastel, Domaine de Lasplanes, La Triade, Le Castelou, Le Garnagues, Maréchal Leclerc, Montréal, Saint Jacques, Saint Joseph.
Conflict of interest
None of the authors have any interest to disclose.
Funding sources
he INCUR study was originally funded by Pfizer. The funding agency had no role in the design and conduction of the study. No funding was used to prepare the current manuscript.
Electronic Supplementary Material
Supplementary material is available for this article at https://doi.org/10.1007/s12603-020-1513-2 and is accessible for authorized users.
Supplementary material, approximately 16 KB.
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