Pain Management for Nursing Home Residents

A high percentage of nursing home residents experience pain that impairs mobility, diminishes quality of life and often goes unrecognized and untreated by healthcare providers. Pain is not a part of normal aging and unrelieved pain can have enormous physiological and psychological effects on residents. Pain management is a major challenge in nursing homes because many residents do not or cannot report the pain they are experiencing. 

Pain management is everyone’s responsibility on the care team, which includes the certified nursing assistants (CNAs), social workers and dieticians. The Nursing Home Quality Measures for Pain are for both short and long stay residents in the – Percent of Residents who Self-Report Moderate to Severe Pain.

Adverse effects of pain include the following:

  • Depression and anxiety
  • Weight loss
  • Sleep disturbance
  • Agitation and Aggression
  • Decreased mobility and/or functional impairment

Non-pharmacologic interventions should be considered first. It is critical for nursing homes to implement strategies that do not consider medications, such as opioids, to be the answer to all pain. In fact, non-pharmacologic therapy (including non-opioid pharmacologic therapy) are preferred for chronic pain.

Steps to Take to Provide Safer Pain Management and Decrease Opioid Use

Have standardized assessment tools for residents who can communicate (numeric rating or verbal descriptor) and for residents who cannot communicate (non-verbal indicators, such as fidgeting, jaw clenching, resistance to moving).  Assess for pain at the following points in care:

  1. Upon resident admission to the facility and at each quarterly and annual review;
  2. Whenever a resident has an acute illness or injury or experiences a decline in function or a change in mood or cognition
  3. Whenever a resident exhibits unexpected social withdrawal or signs of depression
  4. At least daily for patients with a known painful condition
  5. Before and after administration of as-needed analgesic medication

If pain is expressed by the resident, first consider non-pharmacologic interventions, or at least in combination with a pharmacologic intervention which might allow for a lower potency/dosing. The National Nursing Home Quality Improvement Campaign website has a list of evidenced-based non-pharmacologic interventions for pain to share with your staff and educate on these alternatives to medication therapy. 

The Center for Disease Control and Prevention (CDC) provides clinical guidelines for prescribing opioids for chronic pain, should pharmacologic management be recommended for an expected duration of time.  In terms of duration, please keep in mind that for acute pain three days or less will often be sufficient and more than seven days will rarely be needed. Evaluation of the risk factors for opioid-related harms should be considered before starting and periodically during continuation of opioid therapy. 

Pain management should be focused on “mindful care” and demonstrate the following:

The nursing home’s overall organizational behavior and psychology must be geared toward organizational commitmentThe following strategies will assist in reinforcing commitment.

  • Develop interdisciplinary workgroup
  • Analyze current pain management practices
  • Analyze and implement pain management practice consistent with guidelines
  • Establish accountability for pain management
  • Provide information about pharmacologic and non-pharmacologic interventions to clinicians
  • Promise quick response to report of pain
  • Provide education for staff
  • Continuous evaluation and improvement of pain management process