Kathleen F. Jett
Pain and comfort
THE LIVED EXPERIENCE
Ms. S. had cancer of the stomach and was in moderate to severe pain most of the time. She was referred to the local hospice, and the nurse worked with her and her physician to make Ms. S. comfortable. First the nurse assessed potential causes for the pain, the level of pain, the type of pain, and what level of relief was desired. After a careful titration of her medications, it was found that only a long-acting morphine provided her with comfort and an improved quality of life. However, at the dose needed she also hallucinated, seeing several puppies in the room with her. When asked if she wanted to reduce the dosage to eliminate this side effect, she responded, “No—I’ll keep the puppies, I know they are not real and they don’t hurt anything. I’d rather have them with me than the pain.”
Helen, age 93
Learning objectives
Upon completion of this chapter, the reader will be able to:
• Define the concept of pain and how this may be interpreted by the older adult.
• Differentiate the various types of pain.
• Identify data to include in a pain assessment.
• Describe pharmacological and nonpharmacological measures to promote comfort for the person in pain.
• Discuss the goals of pain management in aging.
• Discuss the special circumstances of pain in the cognitively impaired or nonverbal person.
• Develop a nursing care plan for an elder in acute pain and chronic pain.
Glossary
Titration The adjustment of the dosage of a given medication until the desired effect is produced.
evolve.elsevier.com/Ebersole/gerontological
Pain is a sensation of distress, be it physical, psychological, or spiritual; it occurs at the foundational level of Maslow’s Hierarchy of Needs. Pain is a multidimensional phenomenon, and usually one type is intertwined with another. Pain is always a subjective experience; it is whatever a person says it is. When one is in pain it can result in reduced socialization, impaired mobility, or even a reconsideration of the meaning of one’s life.
How pain is expressed is highly influenced by the unique history of the individual and the meaning he or she ascribes to the pain. Some are only able to express pain in terms of “not feeling well,” others are highly articulate but controlled; still others are highly vocal and expressive. It is important for the nurse to realize that an individual responds to pain in a way that reflects his or her own cultural expectations and understanding of acceptable behavior. How we respond to pain is part of who we are—part of our very core. Even the words we use to describe it are personal and many. Pain may be referred to as an ache, a hurt, a pester, a nuisance, a bother and so forth, with the language and the willingness to express it a manifestation of the person’s relationship to whom he or she is speaking.
The communication of pain is often not straightforward. Depression masks expression, as do sedating drugs (which do not necessarily ease pain). The nurse cannot assume that those individuals who do not, cannot, or will not verbalize their pain in ways that are standard practice in the medical model (see Chapter 4), for whatever reason, do not have pain or as much pain as others. Instead, the nurse must be alert to the cues that suggest that pain and discomfort are present. He or she must counter myths, stereotypes, and generalizations often held about aging and pain, such as that older adults, especially those with cognitive impairments, don’t feel as much pain, or that they complain all the time (and are therefore ignored) (Box 15-1). The nurse can be instrumental in understanding the person and providing comfort.
This measurement of comfort provided to patients is a quality indicator, that is, a marker of the level of care that is being provided (Joint Commission, 2012; Schofield, 2010). As is pain, comfort is uniquely defined, experienced, and expressed by each person as members of a family, community, and culture. Comfort is a personal and intrinsic balance of the most basic physiological, emotional, social, and spiritual needs. Without the level of comfort sought by the individual, wellness is beyond reach.
Expert pain management is now part of evidence-based practice (see the Evidence-Based Practice box). Health care providers, including nurses, are expected to adequately address patients’ pain; it is now considered the “fifth vital sign.” Nonetheless, there remains inadequate assessment and undertreatment of pain, especially when the patient is an older adult, from a minority group, or residing in a nursing home (Inelman et al., 2011; Smith, 2005). The reasons for this undertreatment are many and include the nurses’ own definitions and expectations of how pain is expressed. As are patients, nurses are influenced by the way we respond to pain—in this case, the pain of others. The influences come from the nurses’ personal and professional experiences, culture, and so on. Yet we have a responsibility to let go of our own expectations and promote comfort for those who are suffering, regardless of the cause and manner of expression of this suffering. The best gerontological nursing care is that which is provided in a nonjudgmental manner with the goal of comfort always—not just to lessen pain but to relieve it and prevent its reoccurrence.
EVIDENCE-BASED PRACTICE
Pain Management
• Evidence-based recommendations from the International Association for the Study of Pain for the management of neuropathic pain (2007):
http://www.rsds.org/pdfsall/Dworkin_OConner_Backonja.pdf
• Consensus Statement from an Expert Panel related to the use of WHO step III opioids (2008):
http://onlinelibrary.wiley.com/doi/10.1111/j.1533-2500. 2008.00204.x/pdf
• Clinical Practice Recommendations from the American Society of Pain Management Nurses (2006):
http://www.painmanagementnursing.org/article/S1524-9042(06)00033-6/abstract
• Nursing Standard of Practice Protocol: Pain Management in Older Adults (2012):
Acute and persistent pain
Pain is first classified as that which is related to cancer or noncancer. It is either acute or persistent, otherwise known as chronic, and finally it is classified as nociceptive, neuropathic, or idiopathic. It also may be of mixed types (Box 15-2).
Acute pain
Acute noncancer pain in late life, as in earlier life, is usually episodic in nature. Acute physical pain is temporary and includes postoperative, procedural, and traumatic pain. Acute physical pain is usually easily controlled by common analgesic medications. In the hospital setting an analgesic pump controlled by the patient is used for a restricted period. Acute pain at some point is a universal experience for older adults owing simply to the length of life lived, opportunities for traumatic injury, and the development of pain-producing illness. At the same time, the older one is, the more likely one will have an adverse reaction to a medication (see Chapter 8). For example, most analgesics cause sedation. Although use of the medication may be necessary, this side effect also increases the risk for falls, delirium, and any of the geriatric syndromes. In most cases acute pain in older adult is superimposed on a preexisting level of persistent pain, primarily because of the very high prevalence of osteoarthritis (see Chapter 18).
Acute pain may also be psychological or spiritual in nature, such as in early bereavement or in a major depressive episode. Because of the high number of losses in the lives of older adults (see Chapters 24 and 25), the risk for such acute pain is high.
Persistent pain
Research has indicated that physical pain in late life tends to be persistent, moderate to severe, and present in about 50% of those over 65 years of age living in the community in the United States (Horgas & Yoon, 2008; Schofield, 2010) and includes those with long-standing cancer pain. For those living in long-term care facilities, the number of those in pain, largely untreated or undertreated, is thought to be much higher, perhaps 85% (Horgas & Yoon, 2008; Robinson, 2010). The barriers to adequate care are many (Box 15-3).
The most common type of pain in later life is persistent, noncancer, and musculoskeletal in nature, and from arthritis and degenerative spinal conditions (e.g., degenerative joint disease [DJD]) (American Geriatrics Society [AGS], 2009). Neuralgias occur frequently from long-standing diabetes, peripheral vascular disease, herpes zoster, and other syndromes such as stroke and iatrogenic side effects with treatment such as following chemotherapy.
Loneliness and emotional pain from loss (see Chapters 22 and 25) decrease the ability to cope with physical pain. The psychosocial aspects of an elder’s pain experience are rarely or superficially assessed by the nurse or included in the plan of care. The current cohort of pre–baby boomers in pain may underreport pain and undertreat themselves because of the cost of the medications, belief in an associated stigma, attribution of the pain to normal burdens of “old age,” or the fear of addiction.
Persistent pain may be a sequela to an episode of acute pain (e.g., herpes zoster for physical pain or the emotional pain of bereavement); it is not time-limited and may vary in intensity throughout the day or with changes in activity. For example, persons with depression usually feel worse in the morning with a lifting of mood as the day progresses (see Chapter 22). Persons with rheumatoid arthritis also have the most pain in the morning with slow but limited improvement with movement. Herpes zoster presents a unique situation in part due to a number of factors.
Herpes zoster
Nearly 1 million cases of herpes zoster (HZ), or shingles, occur each year, most often in persons between 60 and 79 years of age, most often after the age of 50. About 1 in 5 people who have had chickenpox will develop shingles at some time in their lives (NINDS, 2011). HZ is a viral infection which is dormant in the nerve cells only to erupt decades later. It is characterized by the sensations of itching, and what is often acute stinging, burning pain along the pathway of the affected nerve (dermatome). Finally serous vesicles erupt in the area where the pain was felt. An acute episode or outbreak lasts from days to weeks. When the eye is affected, it is a medical emergency with a high risk of blindness and brain involvement.
A combination of antiviral medications, steroids, aspirin, and topical anesthetics may be the most effective for the acute outbreaks. However, the most important aspect of an HZ outbreak is in the risk for the development of a chronic neuropathic pain syndrome after the resolution of the acute infection and pain. The chronic pain condition is known as postherpetic neuralgia (PHN) and can be quite intense. Antiviral agents such as acyclovir and famciclovir may shorten the duration of an outbreak and may prevent PHN when given promptly. PHN is persistent pain from the now damaged nerves following HZ and hard to treat once established. Narcotics may be necessary for pain relief but as the cause is neuropathic they are not always effective. Low doses of tricyclic antidepressants (e.g., desipramine, amitriptyline [Elavil]) have also been used but in most cases considered inappropriate in older adults because of their anticholinergic effects and the availability of safer alternatives (AGS, 2012) (see Chapter 8). Instead, anticonvulsants especially gabapentin (Neurontin), and pregabalin (Lyrica) have been found to be useful for some persons with fewer side effects.
In promoting healthy aging the nurse can advocate for and facilitate shingles vaccine campaigns. Research has indicated that the number of expected cases can be reduced by over 50% for those who receive the vaccine. It cannot be used for those who have an acute infection or are suffering from PHN (NINDS, 2011).
Pain in elders with cognitive impairments
Persons with cognitive impairment are consistently untreated or undertreated for pain (Herr et al., 2006a, 2006b; Kovach et al., 2006a, 2006b; Ware et al., 2006). Studies have shown that older adults who are cognitively impaired receive less pain medication, even though there is no convincing evidence that peripheral transmission of the sensation of pain to the brain is impaired in people with dementia (Herr & Decker, 2004, pp. 47-48). However as persons with dementia cannot always express their pain or understand why or where they are feeling it, their expressions of pain may be different from those who can express themselves. It is best to practice under the “assumption that any condition that is painful to a cognitively intact person would also be painful to those with advanced dementia who cannot express themselves” (Herr, 2010, p. S1). Research has suggested that older people with mild to moderate cognitive impairment can provide valid reports of pain using self-report scales, but people with more severe impairment and loss of language skills may be unable to communicate the presence of pain in a manner that is easily understood.
For persons who are no longer able to express themselves verbally either due to dementia or other neurological conditions such as aphasia following a stroke, communication of pain usually occurs through changes in behavior, such as agitation, aggression, increased confusion, or passivity. Caregivers should be educated to be particularly alert for passive behaviors because they are less disruptive and may not be recognized as changes that may signal pain. Providing comfort to those who cannot express themselves requires careful observation of behavior and attention to caregiver reports, knowing when subtle changes have occurred, and a willingness to help (Box 15-4). In nursing homes, the certified nursing assistants (CMAs) play an important role in pain assessment.
