The Myth: Pain is an unavoidable part of growing old.

The Reality: Chronic pain is common after age 65, and painful conditions such as degenerative joint disease (also known as osteoarthritis) increase with age. The prevalence of pain in nursing home residents is estimated at 45–83%. Although pain is common in older nursing home residents, it is not inevitable. More important, it does not have to be tolerated—effective treatments are available.

The Myth: Residents with dementia are unable to report their pain

The Reality: Several studies have shown that many people with dementia, even those with moderate to severe dementia, can reliably report pain. Therefore, do not assume that residents can’t report their pain based on a diagnosis or score on a dementia rating scale. Evaluate first whether or not a person can self-report before relying on caregiver report or behavioral cues to determine pain.

The Myth: Pain is mostly an emotional or psychological problem.

The Reality: Pain isn’t “in somebody’s head.” There are physical reasons for pain. However, pain can cause negative emotions that can worsen a person’s perception of pain. Therefore, be sure to identify and address psychological issues that affect an older adult’s pain experience.

The Myth: Doctors and nurses are the experts about pain.

The Reality: No, the older adult is the expert. Pain is a complex, subjective experience that is best described by the person who feels it. When the older adult cannot report pain because of cognitive impairment or stroke, the people who know the individual best should be consulted. These people usually include family members and nursing assistants.

The Myth: It’s important to be stoic about pain.

The Reality: Being stoic about pain often is valued in our society. This tendency may be more common among older persons. Unfortunately, stoicism can prevent health care providers from identifying and treating pain. Teach older adults who “don’t want to complain” that reporting pain is the only way to identify the problem and treat it. They have a right to have their pain treated and when they let their caregivers know they are experiencing pain, they are not complaining.

The Myth: Any painful condition causes the same amount and type of pain in all people.

The Reality: Pain perception is affected by many factors, such as previous injury, stress, emotions, and fatigue. So, depending on the person and the situation, two people can respond very differently to the same painful stimulus.

The Myth: There’s not much that can be done to relieve pain in nursing home Residents.

The Reality: There is much that can be done. Effective chronic pain management often requires more than one treatment approach. Therefore, a pain management plan should include both medications and non-drug strategies. Finding the best therapeutic regimen for a particular individual may also involve several trials using different strategies. Encourage older adults and families to be hopeful and patient.

Strategies for using this information:

  • Staff in-services: print each myth on a separate sheet of paper. Divide the class into small groups and give each group 1-2 of the sheets. Ask each group to discuss and write a response to the myth. Share responses and “The Reality” with the entire class.
  • Share the handout with family members and older adults at resident council meetings or family support group meetings. Discuss the handout.
  • Include the handout with admission materials. Emphasize to older adults and families that your facility is dedicated to regular pain assessment and treatment. Older Adults and families are part of the pain management team.

Table 1. Assessment and Intervention Approaches for Specific Older Adult or Family Barriers

Barrier Nursing Approaches
Fear of Injections
  • Explain that oral medicines are the preferred route of pain medicines.
  • Emphasize that even if the oral route becomes untenable, transdermal or indwelling parenteral routes can be used rather than injections.
Desire to Be a "Good Patient"
  • Explore cultural influences on resident-provider relationship, e.g., communication styles that may hinder open discussion with provider.
  • Explain that older adults are partners in their care and that the partnership requires open communication of both resident and provider.
Desire to be Stoic
  • Explain that while stoicism often is a valued behavior in our culture, failing to report pain can result in undertreatment and severe, unrelieved pain.

  • Teach older adult and family the adverse effects of unrelieved pain, e.g., loss of sleep, depression, impaired immune response.

  • Explore meaning of the disease and spiritual/cultural beliefs.
Fear of Distracting the Physician from Treating the Disease
  • Explain that reporting pain is important in treating both the disease and the symptoms.

  • Emphasize that older adults have a right to have their disease and their symptoms treated.
Concern that Pain Signifies Disease Progression
  • Explain that increased pain or analgesic needs may reflect tolerance.

  • Emphasize that new pain may come from a non-life threatening source, e.g., muscle strain, UTI.

  • Institute pharmacologic and non-pharmacologic interventions aimed at decreasing resident anxiety.

  • Ensure that the older adult and family have current, accurate, and comprehensive information about their disease and prognosis.

  • Provide psychological support; refer to social worker, psychologist, or chaplain as appropriate.

  • Discuss older adult and family goals for care in light of disease progression and prognosis.
Fatalism: Dealing with the Older Adult’s and/or Family’s Belief that Pain is Inevitable and Untreatable
  • Explain that research has shown that pain can be controlled in most older adults.2

  • Explain that establishing an optimal therapeutic regimen can require a period of trial and error.

  • Emphasize that many side effects can be prevented or controlled.
Ineffective Medication
  • Teach that there are multiple options within each category of medication (e.g., opioid, NSAIDs) and another medication from the same category may provide better relief.

  • Emphasize that finding the best treatment regimen often requires periods of trial and error.

  • Incorporate non-drug approaches in the treatment plan.

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References

  1. Ersek M. Enhancing effective pain management by addressing patient barriers to analgesic use. Journal of Hospice and Palliative Nursing. 1999(1):87-96.
  2. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain. Oct 1995;63(1):65-76