To What Extent Is Chronic Pain Managed in the Community - Essay Example

TO WHAT EXTENT IS CHRONIC PAIN MANAGED IN THE COMMUNITY Introduction Pain management amongst elderly starts with detection and assessment (Daniel Monti & Elizabeth Kunkel, 1998). Pain has to be assessed and reassessed because elderly patients tend to be reluctant in reporting pain-related symptoms (Monti & Kunkel). Our elderly need more understanding and proper care because some undetected illness may force them to have very adverse effects in daily living and quality of life (Daniel Monti & Kunkel, 1998). But Harkins, Price & Bush say that "chronic pain is prevalent among older adults, but it is a normal part of aging. Physical pathology and/or psychopathology are always involved (Harkins, Price & Bush 1994). The job of the clinician or the nursing aide has to be both a combination of psychologist/psychiatrist and caregiver in order to be able to give the needed care to the elderly. The general practitioner may not always be there present to check on the patient. However, pain is a very common problem for adults of advanced age, with persistent or bothersome (chronic) pain affecting more than 50% of older persons living in a community setting and greater than 80% of nursing home residents. (Ferrer et al. 1995; Helme and Gibson 2001). According to Action on Pain website, 1 in 7 people in the UK population have chronic pain which increases to 1 in 4 who is actually affected by it when including family members, friends and carers. (Action on Pain website) In one study, 66 percent of geriatric nursing home residents had chronic pain, but it was not detected by the treating physician in 34 percent of cases. Action on Pain further states that: Chronic pain begins at some point in life, maybe with acute pain following any injury, but the pain persists after the injury and original source of pain has healed. The nervous system, which sends pain signals, may have become disturbed. The pain itself, however it began, has become the problem. Chronic pain is a long-term, complex condition which serves no useful purpose and yet, it causes disability and great distress to both individuals and their families. It is a very real condition which is notoriously difficult to treat and the reality is there is rarely miracle cure. (Action on Pain website) Objectives of this study This study aims to determine, and if possible give, a comprehensive approach to the management of pain amongst the elderly in the community. Along with this line is the understanding of the meaning of pain in the context of the nursing practice and the treatment process. There are assessment tools available and are discussed and analysed in the literature review. A brief study of the different treatments available: pharmacological and non-pharmacological, is also one of the objectives. Methodology To gather an understanding of how pain is managed in the community, a review published by the Australian Journal of Advanced Nursing, a credible journal, assisted the author to link pain management to current community setting and to evaluate this to past and future clinical placements. This Journal and the other literature available on the web, a number of books and periodicals, made a connection between community nursing and patient / population groups living in their own homes. This includes assessment of the environment, social and personal factors which can affect the health status of the individuals who require help in maintaining or achieving optimal health. It is the speculation of the writer that the aging population needs more understanding and care. Through socio-economic help, better health care and education, negativity and pain rates can be reduced. To identify a direct link between whether pain is managed in the community reference can be made to the National Service Framework, (NSF). Within the National Service Framework there are conditions to provide long term care at home as part of a programme offered by the Department of Health (DoH 2004). This programme is managed in the form of physical (behavioural), psychological (cognitive) and pharmacological strategies and relates to chronic aspects of pain management. However this self management maybe unsuitable to the elderly because of prevalence of co-morbidities such as arthritis, vascular disease and neurological deficits may hamper diagnosis (DoH, 2001b). Literature Review Pain is an unpleasant sensation that originates from ongoing or impending tissue damage. Management of different types of pain (acute, postoperative, inflammatory, neuropathic or cancer) is the most frequent issue encountered by clinicians and pharmacological therapy is the first line of approach for the treatment of pain. (Guindon et al, 2007) Some pain has to be diagnosed and detected in the elderly, and sometimes this is a challenging job of the nurse or the pain team. The team has to be a team who must work with the patient, who is himself/herself a part of that team, in recognising the illness and required treatment. Pain management involves a multidisciplinary approach and in some health care settings there is a nurse specialist or a designated pain team (Main and Spanswick 2000). Giving an explanation of pain so that people voluntarily go on treatment, Action on Pain states, in its website, that "Chronic pain is an illness, and it's a complicated condition. The fact that chronic pain has a bio-psycho-social impact on the person in pain is not unexpected. Chronic pain impacts on all aspects of normal life-family, relationships, career, finance, social life - this may result in feelings of anxiety, despair, helplessness, isolation, loss of self-esteem, no confidence and tiredness. Such feelings make it even more difficult to accept the fact that the cause of the pain may never be found, and the doctors may not be able to offer a clear diagnosis which may leave you feeling fearful and uncertain as to what the future holds." According to McCaughan (1999) future nurses need to be able to research information so they can safely and effectively apply knowledge to clinical practice. Pain management is of immense importance in nursing practice. You can help in the treatment of pain if you know the necessary information underlying the illness. Pain is always undertreated in older persons with dementia (Morrison and Siu 2000). A systematic review by Sandra MG Zwakhalen (2006) on pain assessment scales for elderly people with severe dementia states that more than 50% of US nursing home residents have substantial cognitive impairment or dementia. This situation is comparable to that in European countries like Austria and the UK, where dementia has been found to occur in over 60% of the institutionalised population and in the Netherlands, where more than half of the nursing home residents have been diagnosed with dementia (Zwakhalen 2006). Dementia is a complex of symptoms characterized by progressive global deterioration of cognitive functioning, and caused by a variety of conditions. The impairment level is often categorized by means of Mini Mental State Examination (MMSE) scores (Zwakhalen 2006). Dementia causes serious and unique barriers to pain assessment and can be characterized by memory loss, personality changes and loss of other functions such as judgement, abstract thinking and language skills. Zwakhalen further revealed that there is evidence that pain assessment is currently inadequate and that elderly people with dementia are being undertreated. This undertreatment could lead to various additional problems like cognitive (e.g. concentration problems) and behavioural symptoms (e.g. aggression or depression) at patient level, as well as to greater and heavier demands on caregivers and increased care demands and costs at organisation level. The main reason for undertreatment is underdetection. There is then a need for manageable valid and reliable pain assessment tools. Treatment can only be given after detection and assessment. TREATMENT A. Nonpharmacologic treatment This strategy encompasses a broad range of treatments and physical modalities. Heat, cold, biofeedback, and relaxation training can be beneficial, depending on the etiology of the pain. Transcutaneous electrical nerve stimulations (TENS) is indicated for both acute and chronic pain conditions. TENS is associated with endorphin release, which might contribute to its analgesic effects. Acupuncture can also be applied to certain painful conditions. Patient education about the nature of pain, self assessment, and treatment strategies can significantly improve overall pain management. Low-level activity programs, such as walking a short distance, can be beneficial physically while enhancing confidence and a sense of well-being. Carefully guided flexion and extension exercises also are beneficial, especially for low-back pain. Fitted appliances such as canes, walkers, bathtub rails, and modified eating utensils can be quite helpful to patients with limited functioning. (Monti & Kunkel 1998) B. Pharmacologic treatment Elderly patients show measurable pharmacokinetic differences that result in higher, more prolonged plasma drug concentrations, which may cause more adverse effects, toxicity, and unfavourable drug interactions. In addition, drug effects can be different for elderly patients, even when their plasma drug concentrations are similar to those of younger patients. The clinician should start analgesics at low doses - in general, half of the usual adult dose - and slowly titrate upward. Medications with a short half-life decrease the risk of over-accumulation while they are being titrated to steady state. Prescribing one drug at a time avoids unnecessary additive effects. (Monti & Kunkel, 1998) It is important to establish whether the pain is nociceptive or neurogenic. Nociceptive pain originates from the mechanical, chemical, or thermal stimulation of peripheral sensory receptors. Nociceptive pain often responds to nonopioid analgesia such as nonsteroidal anti-inflammatory drugs (NSAIDS). Neurogenegic pain originates from damage to the central or peripheral nervous system; this type of pain has a worse prognosis and is more difficult to treat. Anticonvulsants and tricyclic antidepressants can be helpful, although opioids sometimes are required. Examples of neurogenic pain include neuropathies, neuralgias, and central pain syndromes following stroke. Pain associated with malignant disease, as well as certain spinal disorders such as vertebral canal stenosis, may have mixed pathogeneses. (Monti & Kunkel, 1998) Non-verbal assessment tools based on behavioural observation methods include observation of changes in behaviour and functioning, involving sleep, appetite, physical activity, mobility and facial/body language. Physiological measures, like heart rate or blood pressure, can also provide important information, especially in the assessment of non-verbal demented elderly people. Therefore, behavioural pain assessment scales often use physiological indicators in combination with other (e.g. social) indicators. Research into physiological measures has been scarce, due to their limited validity and practical limitations. Physiological responses are often not specific enough to serve as pain indicators, and autonomous physiological responses to pain are difficult to discriminate from other states of distress. (Zwakhalen, 2006) Amanda Williams (2000) says that "Considerable energy and effort has been devoted to developing psychological measures in pain, but the choice still requires a balance between advantages and disadvantages in terms of coverage, comprehensibility, acceptability to respondents, reliability and validity." Williams further reveals the role of psychiatric disorder in chronic pain: observations were made on the apparent similarity between depressed patients and chronic pain patients. Psychological and psychiatric measures have been used in a number of ways in the assessment of chronic pain (Williams 2000). More recent developments of specific cognitive measures such as the Coping Strategies Questionnaire (CSQ : Rosenstiel & Keefe, 1983) and the Pain Beliefs and Perceptions Inventory (PBPI : Williams & Thorn, 1989) have been more useful in prediction of outcome of treatment. Psychometric measures do have uses as screening procedures, and as outcome measures, but frequently they are too insensitive to detail the processes of change involved in the rehabilitative process. Most of the best known instruments can be used only as a guide in terms of individual management; identification of obstacles to recovery requires a new generation of measurement tools validated specifically for use in the context of individualised intervention. To identify a direct link between whether pain is managed in the community reference can be made to the National Service Framework, (NSF). Within the National Service Framework there are conditions to provide long term care at home as part of a programme offered by the Department of Health (DoH 2004). This programme is managed in the form of physical (behavioural), psychological (cognitive) and pharmacological strategies and relates to chronic aspects of pain management. However this self management maybe unsuitable to the elderly because of prevalence of co-morbidities such as arthritis, vascular disease and neurological deficits may hamper diagnosis (DoH, 2001b). Evidence based practice describes the delivery of health care interventions based on the systematic analysis of information available about the effectiveness of the interventions in relation to cost-effective health outcomes. Current reforms to the NHS (Department of Health (DoH), 2004, 2005, 2006) are intended to promote continuity in effective, evidence-based care in all encounters between patients and health professionals in primary, secondary and tertiary care. Williams and Main (2000) led a series of five prospective studies which revealed maladaptive pain coping patterns as high risk factors for chronic pain, and high levels of depression combined with chronic stress at work as high risk factors for not returning to work. In most studies the amount of variability in outcome criteria could be best described using a combination of biomedical, psychological and social parameters. (Williams & Main 2000) They propose a multifactorial biopsychosocial risk factor model for the prediction of failed back surgery syndrome. First assumptions regarding interrelations of psychological, biomechanical and neurophysiological factors will be elucidated. In addition, clinical assessments for risk factors will be presented as a tool for identifying patients who need psychosocial intervention in addition to medical therapy. Stannard and Johnson (2003) studied a recent survey which involved GPs (general practitioners) who would like to see an improvement in the current provision for patients with chronic pain and are willing to take additional training to support this. This may give a more holistic approach within the community health care providers to give education and responsibility to patients, to manage their own pain. However, it can be suggested that this would cause GP's to become more overstretched and in effect this would not succeed. A patient suffering chronic pain can have a good interpretation of his/her condition and how to bring symptom relief. However chronic pain can interfere with the older person's abilities to perform activities of daily living. Researchers found older people with chronic pain require more assistance with daily living whether they live in the community, nursing home or hospital, compared to those that are pain free (Ross and Crook 1998). It is this writer's own interpretation that this has an impact on their physical functioning and can be seen or perceived as a disability. As chronic pain may have more than one pain symptoms, this makes the patient difficult to assess. Seventy five percent of cancer patients present with pain and thirty five percent of whom will have pain in three or more sites (Grond et al 1996). Pain in cancer patients may be caused by the cancer itself, by the treatment which they are receiving or it may be associated with a debilitating disease such as a pressure ulcer or headaches which may not actually be related to the disease or treatment. Therefore it is essential to identify each individual pain and to treat it accordingly. With older people suffering from arthritis, bone and joint disorders, back problems (and other chronic conditions). The reporting of musculoskeletal pain was high, showing that the other population are in need of effective community based support to relieve the pressures on hospital health care systems (AGS Panel on chronic pain in the older person 1998). Patients find it hard to mobilise with pain and they suffer in silence in their own home and become isolated and disabled. Overall the evidence so far suggests that pain has a long way to go yet in its management within the community. A quasi-experimental study published in the Journal of Advanced Nursing compared the degree of satisfaction with nursing care among patients receiving post-operative pain relief via patient-controlled analgesia (PCA) and those receiving traditional intramuscular injection (IMI) regimes. The study involved a total of 79 patients (mainly female) undergoing major abdominal surgery. There were then two parts: first, the amount of time taken by nurses to carry out pain control procedures on 11 matched pairs of PCA and traditional patients was recorded. And then, all patients were asked to fill in a questionnaire regarding their satisfaction with the quality of nursing care they had received on their third post-operative day. The results of the findings were that PCA saved time and improved the nursing care quality of the whole ward, though not resulting in higher satisfaction amongst those patients who used PCA. Younger and the more highly educated patients were found to be especially critical and be less satisfied with care. The article concluded that "the implications for nursing practice and management are addressed, with special emphasis placed on the notion that time saved with PCA should be used to increase patient-nurse contact and should not be used to compensate for a reduction in nursing staff." (Koh & Thomas, 1994) The presence of acute pain remains approximately the same across the adult life span, but there is an age-related increase in the prevalence of chronic pain at least until the seventh decade of life. There is also limited evidence to suggest a plateau or even a slight reduction in the frequency pain complaints beyond this age (Brattber et all 1997; Helme and Gibson 2001, cited in Charlton 2005.) Depression (including suicide risk), anxiety, sleep disruption, appetite disturbance/weight loss, cognitive impairment, and interference with performance of activities of daily living might be directly related to pain and, therefore, would be expected to improve with effective pain management (For et al. 1992; Helme et al. 1996; American Geriatrics Society 2002, as cited in Charlton 2005.) Pain assessment in older people can be complex because of health issues, beliefs, attitudes and a health professional's lack of knowledge and understanding. To understand their pain level, nursing teams focus on tools to measure their pain accurately along with physical symptoms, such as body language and treat accordingly (Herr et al 2004). It was found whilst on placement that numerical rating scales and face pain scales are now more commonly used. These are more valid and reliable for older persons and are suitable with mild to moderate cognitive impairment. This is usually assessed by questionnaire on a scale system , for example numbers one to ten , one being no or very slight pain and ten being severe pain. The control of pain is directed by the 'Analgesic Ladder' which was presented by the World Health Organisation (WHO 1996). The Analgesic Ladder is used starting at the base as mild then proceeds upwards towards moderate and severe acute pain. When the pain reaches a higher level and the current analgesia is no longer effective then a more suitable analgesia is prescribed in order to achieve maximum pain control. Accurate and ongoing assessments are imperative for efficient and effective pain control. CONCLUSION/RECOMMENDATION In conclusion, many key themes have been identified. These include health promotion, education, knowledge and information. They can be attained through a programmed collaboration/cooperation amongst stakeholders in the community, the nursing profession and the medical practitioners. The elderly or the patients have to be motivated to take an active role in their own diagnosis, assessment and treatment. Changing individuals' lifestyles is one key and is far from easy. However people are prisoners of their values and the values of society they live in. They are limited by their economic and social environment quiet apart from any health knowledge they possess. It is essential to recognise and understand the diverse and often conflicting pressures to which different groups of people are subjected to. Without this understanding, attempts to change behaviours may not be just ineffective but counterproductive. It is evident that knowledge of the physiology of pain and the pharmacology of its treatment is entirely useless unless it is linked to the professional practice of nursing that ensures that patients receive the best possible care. There is much evidence to support the need to educate staff to enable them to understand the specific needs of the older person as people who suffer from chronic pain. More information is needed to promote evidence-based practice to guide decision making. Information on research of evidence based care is important because it provides knowledge in quality, data, bench marking, and clinical expertise to identify further areas to promote nursing practice. It is also evident for all members in the care pathway to understand chronic pain. This can be achieved by reviewing research in pain control and raise the awareness of pain management in constructing protocols and developing action plans. RECOMMENDATIONS It is best to assess early the presence of pain in patients, and this can only be done through a close 'partnership' between patient and nursing aide. The government's "Essence of Care" and the eight areas of care for benchmark best apply to the care and the proper assessment of pain. Core Curriculum for Professional Education in Pain (edited by Charlton) suggests the following for assessment of pain: - Recognize potential indicators of pain (pain behaviours, e.g., bracing, rubbing, guarding, agitation, delirium, altered mobility/activity status, and facial expressions in those who are unable to report pain (e.g., those having suffered a stroke or those with Alzheimer's disease) and know the most effective way to observe these behaviours (i.e., against an established baseline or during movement) (Weiner et al 1996; Feldt 2000; Hadjistavropoulos et al. 2000, 2002a, b, all cited in Charlton 2005); - Understand the importance of a comprehensive medical history and physical examination when assessing the older pain patient. Know how to perform a comprehensive musculoskeletal examination including that of joints, soft tissues, and axial skeleton. Also know that chronic pain in older adults is often contributed to be more than one diagnosis, so comprehensive assessment should be performed routinely (Weiner et al. 1999; Herr and Garand 2001, both cited in Charlton 2005). - Appreciate the increased likelihood of a typical pain presentation in older people due to diminished physiological reserves and interacting comorbidities (Harkins 1994; Gibson and Helme 2001, both cited in Charlton 2005) - Recognize the high prevalence of incidental pathology (e.g., radiographic osteoarthritis in the absence of symptoms) and know that the history and physical examination should guide the acquisition of additional diagnostic studies and tests. Also know that identifiable pathology may be elusive in some older adults with chronic pain, but that pain itself is a treatable disorder and should be recognized as a discrete entity (Weiner et al. 1994, cited in Charlton 2005). The use of pain assessment tools in acute pain has been shown to increase both the effectiveness of nursing interventions and improve the management of pain (Harmer & Davis 1998). However it is not appropriate to use a pain assessment chart that has been designed for use with chronic pain to assess post-operative pain. There is less research on assessing the impact of chronic pain on the psychosocial well-being of the older person living in the community. Therefore, as this impedes on their activities of daily living the risk of depression increases. (Carrington , Reid et al 2003). References Action on Pain. http://www.action-on-pain.co.uk/home/content/view/1/2/. [cited 5 Nov 2007] Charlton, J. E. (ed.). Core Curriculum for Professional Education in Pain. Pain in older adults. IASP Press. 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Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgitool=pmcentrez&artid=1397844 [cited 29 October 2007] Read More