Clinicians’ perspectives of pain in older adults with heart failure

Abstract

Pain is one of the common heart failure (HF)-related symptoms and is often ignored by older adults, who consider it to be a natural process of aging. Little is known about the pain experiences and management of clinicians who are specialized in HF. We conducted semi-structured interviews to obtain qualitative data and sought to describe clinicians’ experiences with pain assessment and pain management among older patients with HF using a descriptive approach with 20 interviews. Participants’ mean age was 45 ± 10.7 years; 90% identified as White. The majority (85%) of participants had more than five years of clinical experience caring for persons with HF. Some participants expressed that pain management is not their routine even though they assess pain as part of the physical exam. Most participants highlighted the lack of specific guidelines or educational materials for managing pain in older adults with HF. Some participants stated that family caregivers could play an important role in HF patient pain assessment and management. Our findings show that non-pharmacologic treatments play a pivotal role in improving care for individuals with HF and pain symptoms.

Introduction

Pain is one of the common heart failure (HF)-related symptom and is often ignored by older adults, who consider it to be a natural process of aging.^1,2 It has been estimated that 23% to 85% of patients with HF across different clinical settings experience pain routinely, even though pain is not listed as a hallmark symptom of HF.^3–5 Studies have identified that confounding factors, such as dyspnea, depression, limitations in daily activities, and poor quality of life have all been associated with an increase in pain levels.^4–6 Despite an increasing awareness of pain issues in patients with HF, few studies have focused on pain among older adults with HF.^2,4 Poorly characterized pain experiences in older adults may challenge healthcare providers’ ability to recognize, assess and intervene on pain in a timely manner.^3,7,8 Research has further demonstrated that optimal pain assessment methods in older adults differ from those in younger adults.^7,9 For example, risk factors for back pain in younger adults are commonly due to certain occupational exposures, but it is difficult to identify risk factors for back pain in older adults because they are retired and have more comorbidities.⁹ However, the issue of pain continues to be under-recognized by HF patients and clinicians.²

Patients with HF commonly present with both acute and chronic pain symptoms arising from multiple factors.^10,11 Patients with HF frequently have a prior history of myocardial infarction, which is a principal etiologic contributor to their commonly reported symptom of chest pain.^10–12 Other reported areas of pain include abdominal pain, back pain, extremity pain, joint pain and generalized pain. ^2,12,13 Pain in HF patients is modulated by a combination of bio-logical factors such as age, disease stage and demographic variables, including gender, race, health literacy, and social support, Additional contributors to pain in HF patients include neurohormonal dysregulation, such as elevated proinflammatory cytokines, compromised hemodynamics, affective disorders like anxiety and depression, and limitations in physical functioning.^2,12,14,15 Also, the multifaceted nature of pain in HF may include its anatomical distribution, underlying etiologies, and contributing mechanisms as influenced in part by the presence of comorbid conditions, overlapping symptomatology, the use of implantable medical devices, and prior cardiac interventions.¹⁰

Clinicians are trained to consider pain as a “fifth vital sign”.¹⁶ Because pain is a subjective experience and cannot be directly quantified through diagnostic tests like biomarkers, it is essential to assess it using validated tools and to tailor interventions based on those assessments.^16,17 If pain is under-reported or not assessed correctly, clinicians are unable to treat pain appropriately.^3,17 Inadequate pain assessment can result in suboptimal pain management, potentially worsening other symptoms associated with HF.^3,17 Our previous qualitative study of older adults with HF in the home healthcare setting revealed some degree of patient dissatisfaction with healthcare providers’ assessment and management of pain.² However, little is known about clinicians’ perspectives of pain, pain assessment, and pain management among older adults with HF.² To address these gaps, we conducted a qualitative study of healthcare providers who provided routine care to patients with HF in order to characterize their experiences assessing and managing pain in this vulnerable population.

Methods

Study design

This was a qualitative descriptive study. We used semi-structured interviews with HF clinicians to address the evidence gap surrounding pain assessment and management among older adults with HF. In pain research, qualitative study designs are increasingly utilized for their strength in elucidating and representing subjective experiences. Verbal or written informed consent was obtained from all participants.

Sample

The following criteria determined potential participants’ eligibility for inclusion: Physicians/Nurse Practitioners/Clinical Specialists/Physician Assistants with >1 year of experience taking care of patients with HF in the acute care setting and at the clinic. Individuals were excluded if they were not currently practicing in a clinical setting. In qualitative studies, sample size is usually not determined a priori, but rather enrollment is closed when data saturation occurs (i.e., additional interviews no longer reveal new themes). We used data saturation to determine our sample in this study.

Recruitment

Potential participants were recruited through the listservs of the healthcare systems across different locations in the United States and the Heart Failure Society of America. Potential participants that were interested in participating contacted the research team to learn more about the study procedures and to be screened for eligibility. If the potential participant was eligible and willing to participate, the research team set up an appointment to review the consent documents, obtain consent, and conduct semi-structured interviews (see Table 1) either by video call (Zoom) or over the phone. Interview guide is in Table 1. At the end of study interview, participants were remunerated for their time with a $40 gift card.

Table 1.

Interview guide.

Tell me about your older adults with heart failure and their pain.	a. What kinds of pain your patients experience? b. In your clinical experience, what have you learned about pain in older adults with heart failure? c. What is your practice with pain in older adults with heart failure (i.e. following pain guidelines)?
Pain assessment	a. How do you assess for the presence of pain? How often do you assess pain? b. What kind of pain assessment tools do you use? What do you think using different assessment tools for older adults with heart failure? c. What are some of your greatest challenges or frustrations in assessing pain symptoms in older adults with heart failure? d. What do you think about assessing other symptoms when you assess pain symptoms? e. From your experiences, how is pain assessment different for younger adult patients compared to older adult patients? f. What triggers you to do a pain assessment in older adults with heart failure? g. If you need comprehensive pain assessment, how comprehensive is it? What method or tools do you use? h. If you were the one in charge of designing pain assessment tools for older adults with heart failure, what would you include and why?
Pain management	a. Can you tell me what you know about pain management in patients with heart failure? b. What is your typical strategy for pain management in older adults with heart failure? c. From your experiences, how is pain management different for younger adult patients compared to older adult patients? d. How do you help older adult patients manage their pain at home? What educational materials or guidelines for pain management do you provide? e. What types of pain management tools would be helpful to you in your day-to-day clinical work to help plan interventions? f. If you were the one in charge of designing pain management tools for older adults with heart failure, what would you include and why?

Data management procedures

Interviews were conducted in-person or by video call (Zoom) and audio-recorded by one interviewer. Audio-recordings were transcribed within 24 h of the interview in order to ensure accuracy in capturing the interview data. During transcription, any participant personal information was removed and the data was de-identified (given a study identifier). The de-identified interview data were then transferred into password-protected NVivo software used for data management, coding, and analytical reports of the qualitative data. Three study team members independently applied codes to the 20 transcripts from 20 interviews. Differences in coding were discussed and resolved across coders. Once consensus was reached, final codes were entered into the coding database and were analyzed with sub-sequent direct quotations.

Data analysis

Qualitative data analysis consists of the identification, coding, and categorization of themes.¹⁸ We used Crabtree and Miller’s editing organizing style and a hermeneutic editing approach for the analyses.¹⁹ After each interview was transcribed, open coding was conducted with a line-by-line approach using the transcripts until the overarching themes and subcategories were identified, and previous codes were saturated. All coding was completed using NVivo software. Codes were assigned to find connections between main themes and subcategories. Each theme was defined and then described using a data dictionary. Confusing or duplicate themes were eliminated through research team discussions to reduce the risk of bias. Data analysis was iterative and involved regular meetings throughout the entire data analysis process to define and refine codes, main themes, and subcategories. The team generated a series of main themes grouped into separate categories of codes; the team performed pattern coding and assessed the relationship between different a priori and emergent main themes; the different themes were collapsed into broad themes.

Results

Study sample characteristics

Participants’ sociodemographic characteristics are presented in Table 2. Participants (N=20) had a mean age 45 years and the majority (80%) identified as female and White (90%). Most (n=14, 70%) were nurse practitioners, and the remainder were physicians (n=4, 20%) or physician assistants (n=2, 10%). The majority (n=17, 85%) of participants had more than five years of clinical experience caring for persons with HF. Most participants reported that they felt confident or very confident assessing pain (n=16, 80%) as well as managing pain (n=15, 75%) in older adults with HF.

Table 2.

Participant characteristics (N=20).

Demographic/clinical characteristics	Mean(SD) or Count (%)
Age (Mean(SD))	45 (10.68)
Gender
Male	4(20)
Female	16(80)
Race
White	18(90)
Asian	2(10)
Length of Practice
1–2 years	2(10)
3 years	1(5)
4 years	0(0)
More than 5 years	17(85)
Job Title
Medical Doctor	4(20)
Nurse Practitioner	14(70)
Physician Assistant	2(10)
Confidence of pain assessment
Very Confident	5 (25)
Confident	11 (55)
Not Sure	3(15)
Not Confident	1(5)
Confidence of pain management
Very Confident	3(15)
Confident	12 (60)
Not Sure	4(20)
Not Confident	1(5)
Use of pain or symptom management guidelines
No	10 (50)
Yes	10 (50)
Confidence of pain management
Paper Format Without Pictures	3(15)
Paper Format With Pictures	1(5)
Web-based Format	10(50)
App-based Format	1(5)
Other	6(30)

Results from qualitative data

Three major categories and corresponding themes emerged regarding clinicians’ experiences with pain assessment and pain management practice as well as recommendations for pain assessment and management strategies.

1. Describing Pain Assessment Practice

Subtheme 1a. Various pain assessment methods

Although a majority of participants assessed pain alongside their general physical assessment, some of them focused mostly on pain or discomfort in the chest and did not ask any other questions related to pain. Two participants stated that they did not directly assess pain because it had already been done by a nurse or medical assistant at the time vital signs were taken. In terms of pain assessment modality, participants’ preferences varied. Some used a single Likert scale (1–10) response item, others asked for descriptions of pain, and still others used “FACES”-type scales. Most of them used the single-item Likert scale (1–10) approach because they thought it was something that patients could easily answer. Other participants preferred to elicit descriptions of discomfort, and still others preferred using “FACES”-type scales.²⁰

“Usually it’s a single Likert scale in clinic. It’s relatively uncommon for our patient population that it’s a major issue in clinic, honestly.” (P5) “I think both the 0 to 10 pain scale and the facial ones are good because a lot of times people will say, elderly people say, “Oh, I feel fine,” but then you look at their face and their expressions and you can see they hurt.” (P11)

Subtheme 1b. Underreporting of pain by older adults

Overall, participants reported experiencing challenges assessing pain in older adults in general, not specifically HF patients. They stated that the way older adults describe pain or report pain-related complaints is somewhat different from younger adults. Several participants reported that their older patients with HF do not usually complain of pain, and if they did endorse pain, it was sometimes attributed by the patient to other conditions such as arthritis or neuropathy. Overall, participants felt that it was more typical for their older patients with HF to complain of hallmark symptoms of HF (e.g., shortness of breath) during their clinical encounter. Interestingly, one participant noted that when a patient was accompanied by a family caregiver to the clinic that the patients’ accounts of their condition and pain severity were different from what the family caregiver reported.

“I think older people do not express it [pain] as much as like younger do. I mean, they are not as willing to express it. Whereas I think the younger people are more apt to — you know, they are more in tune.” (P13)

“They tend to not tell you when they hurt and then they wait until it is so bad that we have a hard time getting on top of it.” (P11)

“I think they are more accustomed to having pain. So, a lot of times, they do not even mention it because it is just kind of a chronic condition that they are used to dealing with, and it is only when they are asked that they talk about it.” (P3)

“They don’t bring up pain that much, to be honest. They see us as their heart doctor. They don’t typically complain of pain too often. They’re really complaining more of shortness of breath and exertion, leg swelling, fatigue.” (P1)

“Because it would put it in the focus of heart failure, not — And it would be, like, are you short of breath today? It would put it in the focus of the visit and the heart failure.” (P20)

Subtheme 1c. Barriers to assess pain due to comorbidities

Some participants observed that heavy comorbidity burden in older adults with HF substantially and negatively impacted their ability to assess and manage patients’ pain. In some cases, this was due to difficulty in identifying the root cause of pain amidst multiple comorbidities, and in other cases difficulty in pain assessment and management was ascribed to general challenges of managing highly complex patients with multimorbidity.

“One of the biggest challenges if someone has a large number of comorbidities: it can be challenging to sort out which of the issues is the most likely culprit for the pain in a given situation.” (P4)

“It definitely tends to be different. Obviously, every case is unique, but typically with the younger patients their only problem most of the time is heart failure whereas most of our older adults with heart failure have many comorbidities.” (P1)

“Older adults tend to have multiple co-morbidities alongside heart failure. So, it’s trickier to manage older adults with heart failure because they have other co-morbidities.” (P12)

2. Describing pain management practices

Subtheme 2a. Common pain management practice

Because most participants prescribed pharmacologic treatments for pain in adults with HF, they routinely brought up the side effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and narcotics. For most, the first-line treatment was acetaminophen for non-cardiac related pain, and some of them would try transdermal patches (e.g., Lidoderm). If patients needed stronger or alternative medications, participants usually referred them to another provider for management, typically to primary care or a pain clinic. Only three participants mentioned recommending non-pharmacologic pain management strategies such as physical therapy, cardiac rehabilitation, or ice/heat. HF clinicians underscored the significance of considering alternative approaches to pain management.

“Yeah. I talk about other nonpharmacological treatments. They can do heat or ice. They can try to be more physically active so that they — if it is joint pain — things like that — like walking in a swimming pool or positive resistance kind of activities. I talk about even massage or other things that provide relief and not always stressing medications if that makes sense.” (P3)

“NSAIDs are, are terrible for people with heart failure because it messes up their kidneys and blood pressure. I do recommend Tylenol Arthritis a lot, because I do find that a lot of patients gain a little bit more benefit than just regular Tylenol.” (P7)

“Well, you know, you always want to start with the lowest dose or a non-narcotic step first. That would be my first line.” (P11)

“Physical therapy, cardiac rehab, different strategies that patients can use that are on — that are likely, not only to help their pain, but to improve their heart failure status too.” (P5)

Subtheme 2b. Pain management challenges related to lack of pain management guidelines targeting older adult patients with HF

Most participants utilized HF clinic guidelines in their care, and stated they were not aware of any specific pain management guidelines targeting patients with HF. For these participants, they felt that they would have used pain management tools targeting HF if they were readily available.

“I am not familiar with all the tools that are out there, and so I think that would be — I would just want to see what was available, and then see if it was applicable to our patient population.” (P4)

“if we had something like the first — something in our clinic like a — within the guidelines, something like the first level, just something — basic, and then if that does not work, then we refer them to pain clinic. That would be helpful.” (P13)

“No, I do not use a typical strategy for pain management, except, well, I guess I do in in what I tell them what not to do. Certainly I discourage nonsteroidals.” (P10)

Subtheme 2c. Pain management challenges related to co-morbidities

Participants reported challenges managing pain that were similar to the challenges they faced assessing pain. In general, older adults were viewed as being more complicated to treat due to having more comorbid conditions and a higher fall risk than younger adults. Although most participants connected challenges in pain assessment to general older adult patients, not particularly to older adults with HF, a few participants stated that they took patients’ conditions into consideration for pain management regardless of age. Another challenge reported by participants was that some older patients were reluctant to take pain medications. One participant mentioned about having caregiver support for pain management because older adults have more comorbidities and psychosocial issues around their care.

“Depending on the patient’s clinical history such as confusion or kidney issues. there is potential for more complications with the older adult, but our approach is going to be the same.” (P2)

“I think it is very individual to me. It is not about the age group as much as it is about the threshold for pain, their comorbidities, what they can handle, what they have tried before.” (P16)

“Depends on the situation, but there are some elderly people that say, ‘I do not need that drug. I have dealt with this. I have dealt with pain before, and I would rather just do without the drug.’” (P4)

“You have to be careful about polypharmacy in older adults that have more comorbid conditions.” (P6)

Subtheme 2d. Pain management challenges related to different specialty areas

Although a majority of participants routinely assessed pain, they tended to refer these patients to primary care or a pain clinic because the pain was not generally considered to be from the patient’s HF. Several participants stated that they were not specialized in pain in patients with HF. When they needed to provide interventions for pain management, they typically employed pharmacologic interventions. However, they mentioned concerns around polypharmacy, specifically that pain medications potentially could cause side effects or complicate their HF regimen.

“Chronic pain that is not related to the heart, specifically, we typically defer to a pain management team, because that is not our arena.” (P4)

“I tend to defer or — and help them set up with internal medicine or primary care. So, I do not routinely use any tools or give out any information for non-cardiac-related pains.” (P14)

3. Care Recommendations and Improvements

Participants provided several recommendations to enhance pain assessment and management strategies for older adults with HF. Their insights are organized into three subthemes.

Subtheme 3a: Need for specific pain assessment tools for older adults with HF

Clinicians identified unique challenges in assessing pain among older adults with HF, such as underreporting of pain, communication difficulties, and the complexity of distinguishing HF-related pain from pain due to other comorbid conditions like arthritis or neuropathy. They advocated for the development of specialized pain assessment tools tailored to this population to ensure accurate evaluation and effective management.

Such tools would enable clinicians to ask consistent and appropriate questions that consider the nuances of pain expression in older adults. Such tools could lead to better identification of pain issues and more targeted treatment plans. For instance, older adults may be less likely to voluntarily report pain or may describe their discomfort differently compared to younger patients. A tailored assessment tool could help bridge this communication gap.

Clinicians also emphasized the importance of including specific components in these tools, such as assessing the patient’s environment, understanding who is involved in their care, and considering factors like cognitive issues and level of social support. Some clinicians suggested involving caregivers in the assessment process to gain a more comprehensive understanding of the patient’s pain experience. However, other clinicians expressed concerns about the practicality of implementing additional assessment tools within busy clinical environments. They emphasized the need to balance thoroughness with efficiency to avoid overburdening both clinicians and patients. Time constraints and the potential for increased workload were cited as barriers to adopting new tools. Therefore, any new assessment instrument should be user-friendly and seamlessly integrate into existing workflows to be feasible for routine use.

“I think that would be excellent… It actually pinpoints exactly what to ask in a more consistent way.” (P13)

“I think it would be helpful… if there was some sort of study tool that proved to be effective for differentiating between symptoms that would be something that would, help in the assessment and maybe consideration of treatment to have a tool specifically developed for older adults with heart failure.” (P15)

“The more you make things complicated for busy clinicians, the harder it is to operationalize.” (P6)

“Having a survey or a tool will just make more work for me because I’m going to have to ask my questions and type the responses no matter what.” (P9)

“I think it would be very useful (to have a tool specific for older adults), if done right, I think sometimes in a busy clinical day it can be hard to — it depends how easy of access it is. I think that that is a very important think in clinical practice.” (P18)

Subtheme 3b: Development of comprehensive HF pain management resources

Participants highlighted the lack of specific guidelines or educational materials for managing pain in older adults with HF. They emphasized the need for comprehensive resources that encompass both pharmacologic and non-pharmacologic options, tailored to the unique needs and safety considerations of this patient population. Clinicians suggested that such resources should provide clear guidance on safe medication use, including dosing recommendations and cautions for patients with kidney or liver dysfunction. Considering potential contraindications and interactions with HF medications is crucial to prevent adverse effects. For example, NSAIDs are often contraindicated in HF patients due to the risk of worsening kidney function and fluid retention. Additionally, including non-pharmacologic interventions such as physical therapy, exercise programs, heat and cold therapy, and alternative treatments could offer holistic approaches to pain management. Providing information on when to refer patients to specialists like pain clinics or physical therapists would also be beneficial. Standardized algorithms or checklists could assist clinicians in decision-making and ensure consistent care across providers. Such tools would help streamline the management process, making it easier for clinicians to select appropriate interventions based on individual patient factors, including comorbidities and overall health status.

“It would be helpful to have one go-to resource, either on a pocket card or an app, um, of what are the options, pharmacological and non-pharmacological, for treating pain in older adults with heart failure.” (P17) “

“we have heart failure clinic guidelines for everything else. For diuretic management, for potassium supplement. It would be helpful to have, one for pain too.” (P13)

“ maybe an algorithm, for pain management in heart failure patients and specific modalities to try, although I think there are some pretty good recommendations for things to avoid. and I know that pain organizations out there at site can modify. I mean, one specific to heart failure would be helpful though..” (P15)

“Maybe like a standardized approach to pain assessment, like an algorithm, is this acute pain? Is this chronic pain? And it could contain specific questions, like, what other comorbidities they have. Does this person have heart failure? Then you are going to avoid NSAIDs. That would help people by standardizing an approach to pain assessment and how to deal with it.” (P16)

Subtheme 3c: Integration of technology in pain assessment and management

Clinicians recognized the potential of leveraging technology to enhance pain assessment and management for older adults with HF. Mobile health (mHealth) applications and other home-based technological solutions were discussed as tools to facilitate efficient data collection, enable remote monitoring, and prompt timely interventions. Clinicians suggested that technology could support symptom tracking by allowing patients to record their pain levels, symptoms, and any triggers or alleviating factors on a regular basis. These data could then be used to monitor trends over time and identify any concerning changes that require medical attention. Features such as alerts for significant changes in pain levels could improve communication between patients and providers, leading to more timely adjustments in treatment plans.

Understanding the patient’s home environment was also highlighted as an important factor that technology could help assess. Environmental factors such as air quality, climate, and access to resources can influence health outcomes and symptom management in HF patients. Incorporating assessments of these factors into technological tools could provide a more comprehensive picture of the patient’s condition. However, they emphasized the importance of designing user-friendly tools that consider the technological proficiency and health literacy of older adults. Ensuring accessibility and ease of use is crucial to maximize the benefits of technology in this context. Some older patients may have difficulty using electronic forms or apps, so providing alternative options like paper-based versions could enhance usability. Clinicians also stressed the importance of involving patients and caregivers in the design and implementation of technological tools to ensure they meet the users’ needs and preferences. Motivation and willingness to use such tools were noted as key factors for successful integration.

“I think it could be helpful if you had a tool… or an app, and it was titled ‘Pain Management in Heart Failure.’ And then if you broke it down by different types of pain… you could then have options for pain and specific things to look for.” (P4)

“… a tool that can give them enough details that would help put that pain in context, so that whoever the provider of care is, can see the findings and determine if the patient needs to see an expert or consultant, that is a specialist for those types of symptoms. Otherwise, again, I think it’s all about the context of pain and there are many tools out there that do not give you context. And without the context of pain, I don’t believe that it could be managed accurately and appropriately.” (P09)

“I think for data collection technology is much easier because it provides, uh, much better analysis, um, but that has to be done by somebody savvy to use it and older adults with heart failure, if they had to fill it out themselves may have difficulty with that.” (P05)

“I think if I were to do an app regarding pain symptoms, or even a paper-scale version for those who are not tech-savvy or technologically-inclined, then I would make it simple to where, basically, it would trigger whether or not they should talk with you.” (P4)

Discussion

This study contributes to an understanding of the various ways clinicians assess and manage pain in older patients with HF. Interestingly, despite expressing relative confidence in pain assessment and management practices, a majority of the narratives in this study revealed key challenges and opportunities for providing better support for clinicians to meet their patients’ pain management needs. In this section, we discuss key challenges in pain assessment and pain management for clinicians that will be helpful for developing practical pain assessment and pain management tools for older adults with HF.

Difficulties in assessing/managing pain

From the qualitative data, participants reported various pain assessment methods and challenges in pain assessments and the ways older adult patients with HF report pain. In terms of challenges in pain assessment, the majority of participants focused on pain for general older adult patients, not specifically for older adult patients with HF. ^2,5,8,21The common challenge in pain assessment is that older adults in general tend to under-report pain for various reasons, including the fact that many older adults consider it a part of the natural physiologic decline of aging.⁵ Thus, they tend to report HF-related symptoms such as dyspnea to their HF clinicians. On the other hand, HF clinicians focus on HF-related symptoms such as dyspnea and fatigue even though awareness of the burden of pain is increasing in patients with HF. Although it is recommended that HF clinicians should not restrict pain management to only cardiac-related pain but to chronic pain, nonetheless, a lack of pain assessment tools is one of the main concerns in pain management for persons with HF. ^5,8

Challenge of adding “one more thing” to HF specialty care appointments

Older adults in general have more comorbidities than younger adults. When HF is accompanied by pain and other comorbidities, HF clinicians face unique pain assessment and management challenges because many medications for treating chronic pain and other comorbidities interfere with HF guideline-directed medical therapies.⁶ In particular, the side effects of NSAIDs, which are commonly used, are problematic in HF because NSAIDs cause sodium and water retention through the inhibition of prostaglandin synthesis.²² Pharmacologic management of pain in heart failure (HF) may involve the use of opioids and NSAIDs because the patients or healthcare providers who are not specialized in HF may not be aware of the physiological changes from taking them in HF.^2,13,14

Furthermore, pain in patients with HF has been associated with anxiety, depression, decreased functional status, and sleep disturbance as well as rehospitalization. ^2,4,5,8Additionally, confounding factors such as dyspnea, limitations in daily activities, and poor quality of life have been associated with an inadequate pain control.^4–6 Thus, while it is very important to assess HF-related symptoms such as dyspnea, clinicians should also assess routinely for multiple debilitating symptoms such as pain alongside typical HF-related symptoms.²³ Although the etiology of pain may not be the patient’s HF, pain management is crucial to improving patient outcomes such as quality of life or rehospitalization.^2,21

Aging and age-friendly approaches to pain assessment/management

Understanding how HF clinicians practice pain assessment and pain management for older adult patients with HF heightens awareness of the importance of care for pain in this population. However, to improve care, we need to gain a better understanding of precisely what type of pain assessment and pain management would be effective for older adult patients with HF. There are limited guidelines for the management of chronic pain in older adults with HF⁶, and among various interventions for HF, age-friendly interventions for chronic pain are limited. Most clinicians stated that non-pharmacologic treatments play a pivotal role in improving care for individuals with HF and pain symptoms. New approaches are needed to better identify pain characteristics in patients with HF and to develop scalable strategies to manage pain of different etiologies that are not contraindicated in HF or have adverse interactions with common HF medications.¹³

The role of caregivers in pain assessment and management for older adults with HF

Some participants felt that family caregivers could play an important role in HF patient pain assessment and management, and that it might be valuable to include them in future interventions. This is a reasonable assumption, given the evidence that adequate caregiver support has positive impacts on clinical and person-centered outcomes for HF patients.^24,25 Family caregivers in HF support patients not only with HF-specific management, but also with a variety of other tasks, including basic and instrumental activities of daily living, complex medical/nursing tasks, care coordination, multimorbidity management, safety monitoring, management of health-related technologies (e.g., telemonitoring systems), and providing emotional support.^25,26 Adding more care activities to this already substantial task list should be carefully considered, given the adverse physical and psychological health outcomes that some HF caregivers experience in response to caregiving.²⁵ However, evidence from the dyadic literature suggests that mitigating distressing symptoms — like pain — in HF patients may have positive benefits to caregivers, as it may reduce caregiver stress and anxiety related to exposure to suffering in their loved one (the patient).^27,28

Involving caregivers in pain assessment and management may also be a natural extension of caregivers’ existing contributions to HF symptom monitoring and response, although it should be noted that caregiver-patient assessments of pain may not always be concordant, and they may not necessarily be in agreement around how pain should be managed.^29,30 In addition to patient-caregiver education and training in pain assessment and management, referring patient and caregivers for relationship-based services or interventions that support relationship quality and communication within the care dyad may be beneficial in getting dyads on the same page with effectively managing both HF and pain. ³⁰

The potential role for technology

As participants identified, mobile health (mHealth) applications, telehealth services, and electronic monitoring tools hold significant potential for enhancing pain assessment and management in older adults with HF. These technologies can facilitate efficient data collection, enable remote symptom tracking, and prompt timely interventions, thereby supporting clinicians in delivering personalized care and empowering patients to manage their symptoms effectively.^31,32

Numerous studies have explored the use of mHealth interventions in HF management.³³ One systematic review of mHealth-based HF interventions found that while these technologies are increasingly utilized, their impact on HF outcomes remains inconclusive. ²⁷ The review highlighted that mHealth interventions often involve components such as remote monitoring of vital signs and symptom reporting, which could be extended to include pain assessment. However, limitations in study designs and inconsistent results suggest the need for further robust research to determine the effectiveness of mHealth interventions on clinical outcomes in HF patients.³³ One study discussed the expanding opportunities to deliver healthcare digitally for patients with cardiac conditions, including HF.³⁴ They noted that various forms of non-invasive digital health technology—such as teleconsultations, smartphone applications, wearables, and remote monitoring systems—are available to assist in optimal HF management.

Advanced technologies such as generative artificial intelligence tools, including chatbots and virtual health assistants, can simulate personalized interactions, support symptom reporting, and suggest tailored pain management strategies.^35,36 These technologies have the potential to enhance patient engagement and provide real-time support. However, the successful implementation of these technologies depends on addressing barriers such as limited technological proficiency among older adults, cognitive or sensory impairments, and skepticism about digital tools. Designing user-friendly interfaces with simplified navigation, larger fonts, and clear instructions can improve usability.³⁷ Involving patients and caregivers in the design process ensures that tools align with their needs and capabilities, fostering acceptance and effectiveness.³⁸

Strengths and limitations of the study

Our study has strengths. Most notably, the geographic diversity of our sample with its differences in clinical settings, types of healthcare providers, and ranges of age and length of practice contributed to rich data and robust themes. Some limitations should also be noted. First, certain findings may be inconsistently transferable due to variation in level of participants’ experiences and training in taking care of older adults with HF, as well as differences in location of practice. Additionally, certain questions may have been interpreted differently by different participants.

Conclusion

ur findings show that non-pharmacologic treatments can play a pivotal role in improving care for individuals with HF and pain symptoms. Also, family caregivers could play an important role in HF patient pain assessment and management. This might be valuable to include them in future interventions that are developed by using advanced technologies such as artificial intelligence tools. This study provided informative evidence regarding clinicians’ clinical practices in pain assessment and management for older adults with HF and will be helpful for improving care.