Pain Trajectories in Nursing Home Residents

Pain among individuals in nursing homes is common, with 85% of residents experiencing pain and nearly 60% reporting persistent pain. Consequently, there has been a great deal of research on refining assessment tools and techniques for this population. However, there has been much less work examining how the course of pain in nursing home residents changes over time, wrote the authors of a study published in the Journal of the American Geriatrics Society.¹

“Understanding and appreciating pain changes in the elderly can be tremendously important,” said Alan David Kaye, MD, PhD, professor of anesthesiology and pharmacology at Tulane School of Medicine. This is in part because “many elderly patients are put on medications which cause central nervous system effects,” he said. “The side effects can create an even worse situation for the elderly than the intended benefits of the drugs.”

Study Design

Tapping information from the Minimum Data Set (MDS 3.0), a tool used for both assessing and facilitating care management in nursing homes, the team conducted a longitudinal analysis of data from patients who lived in 44 Indiana nursing homes from September 27, 2011, to December 16, 2019. Data from 4,864 nursing home residents were included in the final analysis. Residents with a length of stay of fewer than 100 days were excluded, as were patients for whom there were fewer than three pain observation time points.

< 60 — 8.8 %

60 to 69 — 11.9%

70 to 79 — 21.9%

80 to 89 — 37%

≥ 90 — 20.4%

BMI was in the normal range for 38.8% of the residents analyzed; 8.5% were underweight, 27.8% were overweight, and 24.9% were obese. Most (76.7%) of the participants lived in an urban area.

Findings on Pain Trajectories

The researchers identified four pain trajectories:

1. absence of consistent pain (48.9%)
2. decreasing-increasing pain presence: defined as pain that initially decreased, held steady, then increased over time (21.8%)
3. increasing-decreasing pain presence: defined as pain that initially increased, held steady, then decreased over time (15.3%)
4. pain consistently present (14.0%)

Of residents who died during the period the analysis covered, 45.6% were in the increasing-decreasing category; 41.3% of those who died were in the absence of consistent pain category.

Hip fracture was associated with a five-fold increase in the risk of persistent pain. Understanding the increased risk for persistent pain due to hip fracture “allows residents and clinicians to plan care and set priorities,” the authors wrote.¹ Living in a rural area was also a predictor of persistent pain. The authors speculated that this might be due to fewer resources outside urban areas for identifying and treating pain.

Practical Takeaways

In terms of limitations, the analysis did not account for comorbidities that change over time, or treatments meant to improve pain.

Still, said Dr. Kaye, “the study serves to clarify or better define a trajectory of pain in any given patient, because trends have predictive value. In certain sub-populations of patients who might have diminished cognitive function or comorbidities associated with aging, this can be extremely valuable in assessment and choice of therapeutic interventions.”