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BY: ANNE MARIE KELLY, BSN, RN-BC, CHPN

Ms. Kelly is a pain management educator and consultant, Catholic Memorial Home, Fall River, Mass.

Older adults (65 and above) will number 70 million by 2030, representing the fastest-growing segment of the U.S. population. They will account for 20 percent of the country's total populace.¹

As baby boomers enter their later years, many will wonder about pain from various ailments. After all, pain is still thought by many to be a normal part of aging, and recent medical research has provided tremendous advances in pain relief. Consequently, pain management is not perceived as an urgent geriatric care need.²

Yet, research studies indicate that 71 to 83 percent of nursing home residents have persistent pain that is under-treated or untreated.³ The clinical manifestations of untreated pain in older adults are serious and include depression, anxiety, impaired functional ability, decreased socialization, sleep disturbances and increased health care utilization and costs.⁴ The prevalence of inadequate pain treatment was considered such a wide problem that The Joint Commission issued new standards on pain management in 1999, and the American Geriatrics Society developed clinical guidelines on the Management of Persistent Pain in Older Persons in 2002.^{5, 6} These standards and guidelines challenge health care providers with the responsibility and ethical obligation to develop the means and resources to effectively manage pain in all age groups.

Leadership Role
Catholic Memorial Home, a 300-bed, skilled long-term care facility, assumed a leadership role in treating pain for the elderly by developing a dynamic interdisciplinary pain management program in 1997. The home is part of the Diocesan Health Facilities (www.dhfo.org), a system of five, long-term care facilities sponsored by the Roman Catholic Diocese of Fall River, Mass. The pain program at the home is focused on the mission of providing compassionate care to the elderly and infirm in a Christian environment where the relief of pain and suffering is a top priority. The staff's mission reflects the values and purpose of the organization and serves as the foundation for the pain management program. Strong institutional commitment and accountability provided the leadership that resulted in institutional practice change.⁷

Pain Program Development
Upon admission or re-admission to the facility, a seven-day pain assessment is initiated. Residents are monitored for seven days, on each shift, to assess the possible presence, location and severity of pain. If any pain is reported or observed during that time period, the nurse performs a comprehensive pain assessment and provides education to the resident and/or family.⁸ When pain is severe or difficult to control, the resident is admitted into the pain program by Catholic Memorial Home to be assessed by each interdisciplinary team member (social worker, pastoral care counselor, rehab therapist, therapeutic activity personnel) for signs of any psychological, spiritual, functional or social distress. The pain team meets weekly to discuss and develop an individualized treatment plan for each resident requiring pain control. The plan is collaborated with the physician and responsible family member, according to the resident and/or family's goal for pain relief. The nurse manager/supervisor ensures the plan of care is implemented and monitors the resident's progress for pain relief. Pain team members collaborate daily as needed.

Documentation and Evaluation
Interdisciplinary team members document weekly progress notes related to interventions and outcomes. A pain flow sheet is utilized to tract the location, severity, interventions, outcomes, sedation level and respiratory status of each resident in need of pain control while receiving a scheduled analgesic. Quarterly chart audits and annual resident/family satisfaction surveys are conducted as a means to ensure the highest quality of care is provided. All documentation forms related to pain management are kept in the "pain management section" of the chart that clearly demonstrates that pain is a priority.

Multidisciplinary Approach to Education
Education was a key component in developing the program. Educators employed creative and diverse methods of teaching to meet everyone's learning needs. Besides formal lectures, other multidisciplinary approaches to education included:

• Pain Management Education Week — A week was designated in the facility in which each interdisciplinary department established a booth with educational materials pertaining to their specific role in pain management. This was an excellent means of providing information about the importance of the interdisciplinary team.
• Poster Presentations — Employees were invited to design posters which were displayed throughout the facility. It was a fun and creative way to teach staff about pain management and make pain "visible" in the facility.
• Portable Education Cart — A mobile cart displaying fact sheets, self-learning modules, articles, and other materials were placed on each unit for a week at a time. Employees appreciated the various ways in which to learn about pain management while remaining on their units.
• Pain Management Bulletin Board — A bulletin board was strategically placed by the time clock where information was posted regarding upcoming pain management programs, in-services, as well as current articles, pamphlets, and handouts. This kept everyone abreast of the pain management activities taking place inside and outside the facility.
• Pain Management Skills Lab — A skills lab is held for nurses and certified nursing assistants annually to evaluate competency in pain management. This includes use of equipment, completion of self-learning modules, videotapes, case studies and quizzes.

Multi-modal Treatment
Non-pharmacologic interventions are included as an integral part of the pain program.⁹ In conjunction with analgesics, other methods employed in treating pain include physical and occupational therapy, repositioning, application of heat and cold, positioning devices, TENS (transcutaneous electrical nerve stimulation), range of motion exercises, relaxation techniques, aromatherapy, pet therapy, massage, music, social activities and distraction. Multi-modal treatment is the cornerstone of an effective pain management program.¹⁰

Pain Program Accreditation
In 1999, the pain program at Catholic Memorial Home received national accreditation by the American Academy of Pain Management. We sought accreditation to help us raise the bar of excellence by having experts in the field focus solely on pain management practice and assist us in providing the best quality of care in accordance with national standards. The Diocesan Health Facilities system, which is part of the home, is the first (and only) long-term care system in the country to be accredited in pain management.

Benefits of Pain Management Program
There have been numerous benefits of the Pain Program, some of which include:

• A sense of pride and accomplishment for staff members
• Increased competency in pain management for staff members
• Improved functional ability of residents
• Families seek admission to the facility feeling confident that effective means of pain relief will be provided for their loved one.
• Physicians and consultants refer patients who are in need of pain management and/or palliative care.
• We are frequently asked to educate other facilities and health care professionals about pain management in the elderly.
• Ability of team members to provide optimal pain management in the safest and least intrusive manner possible

The benefits of the program have been the ability to relieve pain and suffering in the elderly within a collaborative environment, improve skills and competency in the field of pain management, and keep abreast of changes in treatment modalities to consistently provide the highest standards of pain management. Relieving pain and suffering is at the core of any health care professional's commitment to his or her job.

NOTES

1. U.S. Census Bureau, Table 2a., Projected Population of the United States, by Age and Sex: 2000 to 2050, Washington, D.C., 2004, (www.census.gov/ipc/www/usinterimproj/natprojtab02a.pdf).
2. Herr, KA, and Mobily, PR, "Complexities of pain in the Elderly: Clinical Considerations," Journal of Gerontological Nursing, 1991, 17: pp. 12-19.
3. Gagliese, L, and Melzack, R, "Chronic Pain in Elderly People," Pain, vol. 70, no. 1, 1997, pp. 3-14.
4. Helm, RD, and Gibson, SJ, "Pain in Older People," In: Crombie, IK, Croft, PR, Linton, SJ, et al., eds., Epidemiology of Pain, IASP Press, Seattle, 1999, pp. 103-112.
5. Dahl, JL, "New JCAHO Standards Focus on Pain Management," Oncology Issues, vol. 14, no. 5, 1999, pp. 27-28.
6. American Geriatrics Society Panel on Persistent Pain in Older Persons, "Clinical Practice Guidelines: The Management of Pain in Older Persons," JAGS, vol. 50, no. 6, 2002, S205-S224.
7. Gordon, DB, Dahl, JL, and Stevenson, KK, Building an institutional commitment to pain management, University of Wisconsin-Madison Board of Regents, 1996.
8. Ferrell, BA, "Pain," In: Osterweil, D, Brummel-Smith, K, Beck, JC, eds., Comprehensive Geriatric Assessment, New York: McGraw Hill, 2000, pp. 381-397.
9. Ferrell, BR, "Patient Education and Non-Drug Interventions," In: Ferrell, BR, Ferrell, BA, eds., Pain in the Elderly, IASP Press, Seattle, 1996, pp. 35-44.
10. Wood, RH, Reyes-Alvarez, R, Maraj, B, et al., "Physical Fitness, Cognitive Function, and Health Related Quality of Life in Older Adults," Journal of Aging and Physical Activity, 1999, 7: pp. 217-230.

Contact Information
For more information about the pain management program at Catholic Memorial Home, contact Anne Marie Kelly, pain management educator and consultant, at (508) 679-0011 or [email protected].