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Graduate Theses and Capstones


January 2017

Implementing a Care Bundle for Persistent Pain in Older Adults 75 years Old and Older Residing in a Nursing Home

Student Name




United States University, studentpersonalemailaddress@gmail.com

Implementing a Care Bundle for Persistent Pain in Older Adults

75 Years Old and Older Residing in a Nursing Home


Student Name

A capstone submitted in partial fulfillment of the requirements for the degree of

Master of Science in Nursing

United States University

San Diego, California

January 2017

Capstone committee:

George Peraza-Smith

Capstone Chair

Renee P. McLeod



Dean, College of Nursing


[Optional – Insert your acknowledgements]

Table of Contents Page

Title Page 1

Acknowledgement 2

Table of Contents 3

Abstract 4

Background & Significance 6

Problem Description 8

Literature Review & Supporting Evidence 8

Untreated Persistent Pain 10

Persistent Pain and Non-Opioids 11

Persistent Pain and Opioids 12

Consequences of Opioid Use and Aging 15

Risk of Opioids and Aging 16

Providers’ Persistent Pain Management Practices 16

Gaps in the Literature 18

Theoretical Framework 18

Specific Aims 19

PICOt Questions 20

Methods 20

Design 20

Setting and Sample 20

Human Subjects Protection 20

Proposed Interventions 22

Stakeholders 22

Outcome Measurements 23

Possible Limitations 24

Expected Outcomes 25

Implications for Practice 26

References 28

Appendix A: United States University IRB Application 37

Appendix B: Informed Consent 46

Appendix C: Capstone Poster 48


Background & Significance: Pharmacological management of persistent pain in older adults continues to evolve. Even though persistent pain is highest among older adults, they have been insufficiently represented in clinical trials and studies on the management of persistent pain. Past clinical practice guidelines addressing pain in older adults primarily recommended non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) selective inhibitors as analgesics of choice after acetaminophen. Evidence has emerged indicating serious risk for cardiovascular, gastrointestinal and renal dysfunction with consistent use of NSAIDs and COX-2 analgesics. Other evidence supports the efficacious use of opioid analgesic in the treatment of moderate-to-severe persistent pain in older adults. Updated clinical practice guidelines recommend more reliance on opioid analgesic for the treatment and management of persistent pain in older adults.

PICOt Question:

Population/Problem Older adults 75 years and older who experience persistent pain and who reside in a nursing home.

Intervention The implementation of the Persistent Pain Management Care Bundle.

Comparison Traditional Care.

Outcome – Decreased self-reported pain ratings, improved patient satisfaction, improved health-related quality of life.

Time Three months.

Methods/Design: The methods for this study will be a quality improvement project with an interventional design comparing outcomes from prior to implementation of an intervention care bundle with outcomes from post implementation of the intervention care bundle. The SQUIRE guidelines will be used to guide the study (SQUIRE, 2008). The setting for this project will be on a 46-bed skilled nursing and custodial unit. The sample will be 50 older adults 75 years and older with persistent pain.

Proposed Intervention: Five interventions will be used in a care bundle. The interventions are derived from the American Geriatrics Society (2009) guideline titled Pharmacological Management of Persistent Pain in Older Persons focused recommendations on an older population 75 years and older.

Expected Outcomes: The expected outcomes of the proposed quality improvement study included improved recognition and management of persistent pain in older adults 75 years and older residing in XYZ Nursing Home. Three specific outcomes will be evaluated in this study: 1) decreased self-reported pain ratings (NRS); 2) improved patient satisfaction (Care and Pain Management); and 3) improved quality of life (SF-36). An additional expected outcome would be that providers and staff will have a deeper understanding of pain management with this population and will translate pain management improvements to other patient and resident populations.

long-term care, older adult, opioid, persistent pain, practice guidelines

Implementing a Care Bundle for Persistent Pain in Older Adults

75 Years Old and Older Residing in a Nursing Home

Background & Significance

Over the past two decades pain has garnered more attention with the intro-duction of pain as the fifth vital sign (Curtiss, 2001; Walid, Donahue, Darmohrary, Hyer, & Robinson, 2008). As the fifth vital sign, pain is regarded as equally important as the assessments of temperature, blood pressure, heart rate and respiratory rate. With increasing age likely come physical illnesses that can lead to significant pain for older adults (Baumann, 2009). The management of pain presents several unique challenges in older adults due to ageist beliefs by both the older adult and the provider. Many believe pain to be a part of aging and accept pain as normal (Jones & Macfarlane, 2005). In addition, many older adults do not want to be a “bother” and may become discouraged from making unacknowledged requests for treatment of their pain (Jones, et al., 2006; Malanga & Paster, 2007).

In the literature the terms chronic pain and persistent pain are used interchangeably with persistent pain being preferred because it is less likely to be associated with the negative attitudes and stereotypes that clinicians and patients often associate with the chronic pain label (American Geriatric Society [AGS], 2002, Woo, et al., 2008). Persistent pain affects just over 76 million Americans—more than diabetes (20.8 million), heart disease (18.7 million), and cancer (1.4 million) combined (American Pain Society, 2011; Walid, et al., 2008). It is estimated that 25-50% of older adults living in the community experience significant pain at least some of the time (Sawyer, Bodner, Ritchie, & Allman, 2006) while 44-80% of nursing home residents experience persistent pain (AGS, 2002; Jones, Vojir, Hutt, & Fink, 2007). Older persons are more likely to experience persistent pain than younger persons (McLennon, Adams, & Titler, 2007) and there is an increased incidence of persistent pain with age (Hager & Brockopp, 2009). It is predicted that 80-85% of individuals will experience a significant health problem that predisposes them to pain after the age of 65 years (AGS, 2009) and 80% of older persons with cancer report pain (Miaskowski, 2010).

There is an emergent focus and evidence on effective pain assessment and management strategies. However, this increased focus on pain assessment and management has not necessarily improved adequate management of pain in the elderly. Evidence has emerged on the serious cardiovascular and gastrointestinal tract risk associated with the consistent use of nonsteroidal anti-inflammatory drugs (NSAIDs) and Cyclooxygenase-2 (COX-2) inhibitors (AGS, 2009; Auret & Schug, 2005; Hanlon, Backonja, Weiner & Argoff, 2009). NSAIDs have also been associated with a wide range of renal dysfunctions (Pratt, Roughead, Ryan, & Gilbert, 2009). Other evidence has revealed that these drugs may complicate the treatment of common medical conditions in older adults, such as hypertension and congestive heart failure (Kuehn, 2009). Data is emerging on the efficacy of the use of opioid analgesics for the treatment of moderate to severe persistent pain in older adults (Auret & Schug, 2005; AGS, 2009; Planton & Edlund, 2010).

Remaining aware and knowledgeable of the latest evidence and practice guideline recommendations can pose a significant challenge for the provider practicing in long-term care. The plethora of information available for implementing evidence-based practice can be overwhelming (Kent & Fineout-Overholt, 2007). Several national associations have published clinical guidelines on persistent pain management. The American Society of Anesthesiologist Task Force on Pain Management (2010), the American Medical Directors Association (2009) and the AGS (1998, 2002, 2009) have developed practice guidelines on managing persistent pain. AGS’s (2009) guideline titled Pharmacological Management of Persistent Pain in Older Persons focused recommendations on an older population 75 years and older. Since the guideline was first published in 1998, it has been reviewed and revised with some minor updates in 2002 and significant updates in the current 2009 edition. The primary evolution in the development of the AGS’ guidelines have been a shift away from NSAIDs and Cox-2 inhibitors as the primary recommendations of pharmacological management of persistent pain in older adults to the use of opioid analgesics for moderate to severe persistent pain in older adults (Smith, 2011).

Problem Description

Managing persistent pain in older adults residing in nursing homes offers several challenges from the resistance of older adults to opioid therapy to the ageist beliefs on pain in the elderly of facility staff to providers’ ignorance to evidence-based pain management strategies. This problem was first identified at the XYZ Nursing Home when resident’s request for pain relief was being minimized and ignored by staff and providers. This phenomenon was especially significant in residents over the age of 75 years old with persistent pain where the persistent pain was being under-recognized, under-assessed and under-treated. The nursing home administration identified the following areas for improvement: inaccurate staff and provider knowledge, inadequate assessment and management of pain, and insufficient documentation systems. A quality improvement team was convened to explore and implement revised systems to improve the assessment and management of persistent pain in nursing home residents over the age of 75 years.

Literature Review & Supporting Evidence

Literature searches were conducted using following databases: Academic Search Premier, CINAHL, EBSCO host, ProQuest, Google Scholar, and PubMed. Primarily full text, peer reviewed journals published in English from 20010-2017 were examined. Terms and phrases used in the search included older adult, pain, persistent pain, non-cancerous pain, pain assessment, pain management, adverse events with pain management, pain management outcomes. Over 53,532 publications were identified in the initial search. The search was narrowed to assessment and management of pain in older adults in nursing home narrowed the identified publications to 832 documents. Each document was scanned for inclusion and 132 were identified for review.

Persistent pain is a personal emotional and physical experience. This pain experience is an unpleasant, subjective, and multifaceted ranging from mild to severe agony with periodic episodes to persistent and always present. Fox (2009) describes persistent pain as pain that continues beyond the anticipated healing time of an acute injury or disease and lasting for three months or more. Persistent pain is an unpleasant, subjective, personal and multidimensional experience that is constantly present (Oware-Gyekye, 2008). The American Geriatrics Society [AGS] (1998) defines persistent pain as ”pain that exists beyond an expected time frame for healing” that “is understood as persistent pain that is not amenable to routine pain control methods” (p. 636). The International Association for the Study of Pain defines persistent pain as “continuous or intermittent pain or discomfort that has persisted for at least three months” (Elliott, Smith, Penny, Smith, & Chambers, 1999, p. 1249). The American Society of Anesthesiologist Task Force on Chronic Pain Management (2010) stated that the elderly experience a significant burden of persistent pain with persistent pain being defined as “persistent or episodic pain of a duration or intensity that adversely affects the function or well-being of the patient” (p. 812). The common threads to these definitions are that persistent pain is a personal, multifaceted experience that last beyond an expected time frame, usually three or more months, and negatively affects the older persons function and diminishes quality of life.

Untreated Persistent Pain

Persistent pain is under-recognized and under-treated in older adults in many settings (AGS, 2002; Collett, O’Mahoney, Schofield, Closs, & Potter, 2007). Elderly persons residing in nursing homes are at an increased risk for inadequate pain relief due to providers’ under-prescribing practices. Won and her colleagues (2004) conducted a cross-sectional study of 10,372 nursing home residents from geographically diverse States who were over the age of 65 years and who experienced persistent pain. The researchers used the Minimum Data Set (MDS) which includes assessments of functional status, as well as, assessments of pain and analgesic use. The MDS has been shown to have strong validity and reliability. Findings revealed suboptimal compliance with current practice guidelines by providers on geriatric prescribing recommendations. The most common analgesics prescribed were acetaminophen (37.2%), propoxyphene (18.2%), hydrocodone (6.8%) and tramadol (5.4%) with 25% of participants receiving no analgesics. Evidence has not demonstrated that propoxyphene is superior to acetaminophen. Propoxyphene use by older adults has been linked to increased hip fractures in community elderly (Mort & Schroeder, 2009), as well as increased risk for hospitalization, emergency visits and death (Kamal-Bahl, Stuart, & Beers, 2005). Geriatric prescribing practices recommend that propoxyphene should be avoided in older adults (Terrell, Heard, & Miller, 2006). This soundly designed study has implications on the underutilization of appropriate pain management analgesics for older adults experiencing persistent pain. The study results provide strong evidence for support toward improving provider prescribing patterns and the need for further education on appropriate analgesic selection for persistent pain in older persons.

Community-dwelling older persons with dementia have a greater risk for inappropriate and inadequate treatment of persistent pain. Shega and colleagues (2006) found that elderly persons with cognitive impairment and persistent pain were at greatest risk for insufficient analgesia. A cross-sectional design was used for this study by observing a convenience sample of 115 dyads of community-dwelling elders and their caregivers. Both the older adult and their caregiver determined pain assessment. Over half of the participants (54%) who experienced daily pain reported no use of any analgesic. The majority of caregivers who administered an analgesic used NSAIDs. No participant was prescribed a strong opioid, such as morphine. Forty-six percent were reported to have had insufficient pain relief. Insufficient pain relief was 1.07 times as likely for each additional year of age (95% confidence interval (CI) = 1.01-1.14), 3.0 times as likely with advanced cognitive impairment (95% CI = 1.05-9.10), and 2.5 times as likely for older adults with impairment in daily functioning (95% CI = 1.01-6.25). Limitations of this study include a sample of convenience and reliance on caregivers’ report of pain. The study design was unclear on the distinction between provider prescribing practices and caregiver administration practices. This vagueness in reviewing provider prescribing patterns of opioids makes interpretation of the data uncertain. The results suggest that older adults with dementia and persistent pain may not be prescribed or given adequate analgesic. Further study is required to examine the impact of cognitive impairment and adequacy of persistent pain management in this population.

Persistent Pain and Non-Opioids

A growing body of evidence demonstrating that NSAIDs and COX-2 inhibitors may result in serious and life-threatening gastrointestinal and cardiovascular adverse events or gastrointestinal bleeding has shifted provider perspective toward the use of opioids, especially with older adults (AGS, 2009). A small study of 29 older adults with rheumatoid arthritis (RA) suffering from moderate to severe persistent pain found that the use of strong opioid analgesia (oxycodone) was effective in pain relief without adverse effects (Raffaeli et al., 2010). Forty-two percent of participants reported effective pain relief with oxycodone and 50% achieve improved outcomes. The study used a valid and reliable instrument to measure functional outcome from RA by the American College of Rheumatology. Although the limitations of this study prevent generalizing the results, the data calls for more study to evaluate the use of opioids over NSAIDs and COX-2 inhibitors that have a higher incidence of adverse effects over opioids.

Persistent Pain and Opioids

Use of analgesic medications has been the most commonly reported pain management approach used by older adults (Fitzcharles, Lussier, & Shir, 2010). There has been an increased use of opioid analgesia in the medication management of non-cancerous pain for older adults. Evolving evidence has been in support of a distinct role for opioids in management of persistent pain in many settings (AGS, 1998; Auret & Schug, 2005; D’Arcy, 2008a). Low dose opioids have been shown to be an effective treatment for moderate to severe persistent pain unrelieved by other analgesics (Burks, 2005). Evidence exist that opioids are most justified for persistent pain that has a nociceptive origin, such as osteoarthritis (Burks 2005) or a neuropathic origin, such as radiculopathy (D’Arcy, 2008a).

Furlan, Sandoval, Mailis-Gagnon, and Tunks (2006) conducted a meta-analysis of 41 randomized clinical trials involving a combined sample of 6019. The researchers rated 87% of the studies reviewed of high methodological quality. The systematic review demonstrated several significant results that have implications for persistent pain management. A limitation to this study is a lack of analysis between age groups. The study analysis revealed opioids were effective in the treatment and management of non-cancer persistent pain with more effectiveness shown for both nociceptive and neuropathic pain syndromes. Strong opioids of oxycodone and morphine were significantly superior to naproxen and nortriptyline in managing persistent pain. Propoxyphene, tramadol and codeine, which are weak opioids, did not significantly outperform NSAIDs for either pain relief or functional outcomes. A weakness of this meta-analysis for the purposes of this literature review is that the authors did not provide age ranges from their analysis. A random review by this author of four of the studies from the meta-analysis showed that although persons over the age 65 were included in the clinical trails they were not well represented. The meta-analysis did not seem to find outcome differences between age groups. Age was not cited in the results or the discussion and may have been an oversight. Clinical trials that do not have a specific focus on older adults have historically underrepresented and even excluded adults 65 years and older (Payne & Hendrix, 2010).

Prescribing practices of opioids for persistent pain management in older adults have been mixed. Even with mounting evidence supporting use of opioids in the elderly, prescribing of opioids for older adults with arthritis or low back pain have not significantly changed over the past few decades. Researchers from Brigham and Women’s Hospital found that continuous opioid use for the management of persistent pain is relatively uncommon for older adults suffering from arthritis or low back pain (Solomon et al., 2006). The study was comprised of 14,410 Medicare beneficiaries who were enrolled over a six-year period in a drug benefit program for low-to-moderate income Pennsylvania residents with rheumatoid arthritis, osteoarthritis and low back pain. Only four percent of subjects with rheumatoid arthritis used opioids consistently compared to less than one percent for older adults with osteoarthritis and low back pain. There was no increase in opioid use over the six-year period. Low potent opioids were the most commonly prescribed to this group of participants. A major limitation of this study was that the sample consisted of low income elderly who may have been prescribed opioids but may not have filled their prescription due to unaffordable out-of-pocket costs. This study would have made opioid use patterns clearer by surveying participants and providers to discern decision making practices in their selection of analgesic pain relief. This study does lend additional evidence to the underutilization of opioids in the management of persistent pain for this population of older adults.

Maxwell et al. (2008) examined prevalence and correlates of medication usage for community-dwelling older adults who experience persistent pain. This cross-sectional study of 2,779 older home care adults assessed analgesic management using the Resident Assessment Instrument-Home Care (RAI-HC) which has demonstrated validity and reliability. Among other data, the RAI-HC measures use of prescription drugs, functional status, and quality of care. Approximately 48% (n=1,329) of the sample reported daily pain with one-fifth (21.6%) of this group reporting taking no analgesia. Among those receiving at least one prescription or over-the-counter medication, NSAIDs were the most commonly used medication (56.4%), followed by acetaminophen (39.1%), weak opioids (27.7%) and strong opioids (14.6%). Multivariate analysis revealed older adults 75 years and older (odds ratio (OR) 0.64, 95% CI 0.43-0.94), and those with congestive heart failure (OR 0.52, 95% CI 0.33-0.83), diabetes (OR 0.59, 95% CI 0.40-0.88), other disease-related complications (OR 0.34, 95% CI 0.13-0.92), cognitive impairment (OR 0.58, 95% CI 0.38-0.89) and/or requiring an interpreter (OR 0.43, 95% CI 0.19-0.95) were significantly less likely to receive an opioid alone or in combination with a non-opioids. A limitation of this study is that participants were volunteers in the community program in Canada. The generalizability of the results is limited due to the lack of an in-depth discussion on the characteristics of the sample and how the sample reflected the general population. From the data available, the researchers were unable to determine what proportion of the sample with daily pain may have been undertreated because of inadequate assessment by providers or because participants did not adequately report their pain to providers. This study provides further information on the use or non-use of analgesics by community-dwelling older adults with persistent pain inducing conditions.

Consequences of Opioid Use and Aging

Delirium has been a frequent complication observed in older adults with hip fractures (Juliebo et al., 2009). Untreated pain has been shown as an individual risk factor for development of delirium (Furlaneto & Garcez-Leme, 2007). In a prospective cohort study of 541 patients with hip fractures from four New York metropolitan hospitals, researchers found that avoiding opioids or using low doses of opioids increased the risk of delirium (Morrison et al., 2003). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (relative risk (RR) 5.4, 95% CI 2.4-12.3). Administration of meperidine, a synthetic opioid, increased the development of delirium as compared with patients who received other opioid analgesics (RR 2.4, 95% CI 1.3-4.5). Geriatric practice guidelines recommend that meperidine not be used in older adults due to increased risk of adverse affects (AGS, 2009). Cognitively intact patients with inadequately treated severe pain also had a significant increased risk of delirium (RR 9.0, 95% CI 1.8-45.2). A limitation in this study was that researchers were unable to analyze pain data for cognitively impaired patients due to missing data and inability of dementia patients to self-report their pain. Therefore, researchers were unable to determine pain’s role in the development of delirium in cognitively impaired patients. The study results supported previous research that undertreated pain and inadequate analgesia appear to be a possible risk factor for delirium in older adults. The results of this study highlight the need for further research on development of delirium and the utility of opioid therapy in cognitively impaired older adults.

Risk of Opioids and Aging

However in a recent study, opioid use by older adults was linked to an increase risk of fractures. Saunders’ research group (2010) conducted a cohort study of 2,341 participants over the age of 60 who were enrolled in a group health care plan. As compared with participants not currently prescribed opioids, older persons taking opioids did slightly trend toward increased fracture rates (hazard ratio (HR) 1.28, 95% CI 0.99-1.64). Older adults prescribed opioid doses equal to or greater than the morphine equivalent of 50 mg/day had a twofold increase in risk for fracture (HR 2.00, 95% CI 1.24-3.24), as well as, a 9.95% annual fracture rate. Thirty-four percent of the fractures in the study cohort were hip or pelvis fractures and 37% of the fractures occurred while in an in-patient setting. Data was collected from an automated pharmacy file where enrollees reported obtaining over 90% of their medications. To account for variation in dosing over time, researchers collected data in 90-day intervals. Researchers provided strength to the study by verifying the data through medical chart review. However, the study did not clearly differentiate other risk factors participants may have had and did not clearly give information on provider choice in selecting analgesic type. Current guidelines are clear that strong opioid analgesic is appropriate for select older populations with moderate to severe pain (AGS, 2009). These results reinforce the need for providers to evaluate risk versus benefit in the selection of appropriate opioid therapy and achieving adequate pain relief in elderly persons.

Providers’ Persistent Pain Management Practices

There is a dearth of research on practice patterns of providers in the management of persistent pain in the elderly. Kaasalainen, DiCenso, Donald, and Staples (2007) examined 18 Ontario nurse practitioners practice patterns and pain management approaches in older adults residing in LTC. A cross-sectional survey resulted in sixteen (89%) of the NPs indicating 33 activities related to pain management and identified barriers to the fulfillment of their pain-management role in LTC. Most of the NPs (81.3%) reported utilizing pain-assessment tools with less than half reporting the use of pain-management clinical practice guidelines. The barriers to effective pain management by NPs included time constraints; prescribing restrictions; lack of knowledge; difficulties with assessing pain; reservations by physicians, staff, residents, and families toward use of opioids; and poor collaborative relationships with physicians. The design of this study would have been better suited using a grounded theory approach to generate a clearer understanding of the practice facilitators and barriers in prescribing opioids by NP for older adults. These results suggest that NPs may not be utilized to their fullest potential in managing persistent pain among older LTC residents. In addition, the results demonstrate that NPs may not be using current pain management guidelines and thereby inaccurately treating persistent pain in older adults.

In a subsequent study, Kaasalainen et al. (2010) investigated the role of the provider, the NP, in managing pain in the LTC environment and explored the barriers and facilitators toward the optimal use of NPs in managing resident’s pain from the perspective of physicians, pharmacists, nurse managers, staff and nurse practitioners. The researchers conducted focus groups and individual interviews. Five pain management activities performed by NPs were identified, including assessing pain, prescribing pain medication, monitoring pain levels and side effects of pain medications, consulting and advocating for staff and residents, and leading and educating staff related to pain management. Of particular interest from this study are the identified factors which influenced the NP’s role in pain management. Themes that emerged from the data analysis included the availability of the NP, scope of practice, role clarity, perceived added value of NP role, terms of employment, and NP-physician relationships. The data illuminates the pain management role of NPs in LTC and provides a springboard for further study. Clarifying our understanding of the obstacles NPs encounter gives guidance toward better assessment and management of persistent pain.

Gaps in the Literature

Provider programs and certification bodies require the inclusion of advanced knowledge and training in the prescribing and/or management practices for analgesics and opioids (Burman et al., 2009). Nurse practitioners who may not have prescribing authority of opioids should continue to remain knowledgeable and advocate for appropriate opioid use in the management of pain in older adults. There continues to be a lack of uniformed requirements and standards on the assessment and management of pain in older adults living in nursing homes (Brown & McCormack, 2006).

Gaps continue to exist in our understanding of provider pain management competencies with older populations and use of opioid analgesic in the management of persistent pain in older adults. Although mounting scientific evidence supports the use of opioid treatment for both continuous nociceptive and neuropathic persistent pain in older adults, the prescribing of opioid analgesic remains inconsistent. Few studies exist regarding knowledge and practices of NPs’ related to opioid usage in managing pain in older adults.

Theoretical Framework

The adoption of clinical practice guideline recommendations has been conceptualized within the framework of Roger’s Diffusion of Innovations Theory (Rogers,