Analgesic Trial for Suspected Pain in Older Adults with Cognitive Impairment

Initiate an analgesic trial if any of the following are present:

  • Pathologic conditions likely to cause pain exist
  • Procedures likely to cause pain are scheduled
  • Behaviors suggest pain, based on the scores of an observational pain tool such as the PACSLAC or the PAINAD
  • Pain behaviors continue after attention to cause of pain
  • Pain behaviors continue after attention to basic needs and comfort measures
  • Surrogates report previous chronic pain or behaviors indicative of pain

Provide an analgesic trial and titration appropriate to the estimated intensity of pain based on the above, analgesic history, and prior assessment.

  • Mild to moderate pain — Nonopioid analgesic may be given initially (e.g. acetaminophen 500 to 1000 every 6 hours for 24 hours, using lower dosing of acetaminophen if liver dysfunction is present.)
  • If behaviors improve (as documented on observational assessment tools), assume pain was cause and continue analgesic and add appropriate non-pharmacologic interventions.
  • If behaviors continue (and scores on observational assessment tools remain unchanged), consider a single low dose, short-acting opioid (e.g. hydrocodone, oxycodone, or morphine) and observe the effect.
  • If no change in behavior (and no change in scores on observational assessment tools) within 24 hours, titrate dose upward by 25% to 50% and observe effect.
  • Continue to titrate upward until a therapeutic effect is seen, bothersome side effects occur, or no benefit is determined.
  • Explore other potential causes if behaviors continue after reasonable analgesic trial.

May be duplicated for use in clinical practice. Used with permission of Keela Herr, PhD, RN, The University of Iowa, College of Nursing, 2009. 

Based on data from Herr, K, Coyne, P, et al. Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations, Pain Manage Nurs, Vol. 7, (2) 44-52.

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