Nursing Education Intervention Effects on Pain Intensity of Nursing Home Residents with Different Levels of Cognitive Impairment: A Cluster-Randomized Controlled Trial.

PURPOSE: Pain management in nursing homes is challenging and pain prevalence remains high. The objective of this study was to improve the pain situation of nursing home residents following a nursing-related educational intervention within a cluster-randomized controlled trial (2016-2018). PARTICIPANTS: Clusters were nursing homes from one nursing home operator in Bavaria, Germany. Nursing home residents who were permanently registered in the facilities, at least 60 years of age, and who themselves or their legal guardians provided informed consent were included. INTERVENTION: In addition to the implementation of pain nurses and pain care assistants, staff of the intervention group received an educational intervention in pain management, containing classroom (quality circles) and web-based training for nurses. METHODS: Based on the Mini-Mental State Examination (MMSE), residents were either interviewed (MMSE 10-30) using self-report instruments or observed (MMSE 0-9) by proxy assessment. The primary outcome in residents able to self-report was maximum pain intensity according to Brief Pain Inventory (BPI); in those not able to self-report treatment-relevant pain above cut-off (≥2) on the Pain Assessment in Advanced Dementia (PAINAD). RESULTS: Out of 20 randomly selected clusters, 9 nursing homes from the control, and 6 nursing homes from the intervention group participated. Multilevel linear (n=347 residents, MMSE 10-30) and logistic regression (n=222 residents, MMSE 0-9) analyses were conducted. Maximum pain intensity was higher after intervention (B=1.32, p<0.01), decreased with a better quality of life (B=-0.07, p<0.001), and was lower when dementia diagnoses were present (B=-1.12, p<0.01). PAINAD scores before and after intervention did not differ significantly (OR=0.89, p=0.724), but chances to exhibit treatment-related pain were higher with decreasing MMSE (OR=0.94, p<0.05). CONCLUSION: While no significant positive intervention effect was measured, findings suggest nurses' raised awareness towards pain management. Overall results indicate that large-scale educational interventions seem to be less effective in complex nursing home settings without also including specific individual-based intervention measures.

Quality of life in nursing home residents with pain: pain interference, depression and multiple pain-related diseases as important determinants.

AIM: Quality of life is an essential outcome parameter in geriatric research and presents an important indicator for the evaluation of care treatments. The present study analyses potential impact factors on health-related quality of life (HRQOL) of nursing home residents (NHR) who are in pain. METHODS: Data came from the cRCT 'PIASMA'. Statistical analyses of 146 respondents were carried out by multiple linear regressions based on the EQ-5D index (Euroquol Quality of Life) as dependent variable. Potential impact factors were applied and categorised in five blocks: pain intensity and interference (according to the Brief Pain Inventory), intervention effect, sex and age, pain-related diagnoses, and scales regarding depressive symptoms and cognitive impairment (based on the Geriatric Depression Scale and the Mini-Mental State Examination). RESULTS: On average, residents showed a pain intensity of 18.49, a pain interference of 29.61, a MMSE score of 22.84, a GDS score of 5.65 and an EQ-5D index of 0.52. Residents with more diagnoses, more depressive symptoms, and a higher pain interference showed a significantly reduced HRQOL. CONCLUSION: Findings underline the importance of identifying and applying treatment options for both pain (especially interference) and depressive disorders to maintain HRQOL of NHR.

[Parkinson's disease, Alzheimer's disease and oncological diseases in residential geriatric care : Pain frequency and selected healthcare features in comparison]. / Morbus Parkinson, Morbus Alzheimer und onkologische Erkrankungen in der stationären Altenhilfe : Schmerzhäufigkeit und ausgewählte Versorgungsmerkmale im Vergleich.

BACKGROUND: Adequate pain management and palliative care structures are of significant importance in residential nursing homes. Whilst professional pain treatment and palliative care measures are frequently implemented for residents with oncological diseases, this is often not the case for residents with neurological disorders. Such a potential undertreatment is even more challenging when the means of interaction and communication with affected persons are aggravated by impairments in cognitive function. OBJECTIVE: To examine differences in selected health care service characteristics between nursing home residents with Parkinson's disease, Alzheimer's disease and residents diagnosed with cancer. MATERIAL AND METHODS: Secondary data analysis of residents' survey and medical record data from 13 nursing homes as part of the study "Action Alliance Pain-free City Münster". RESULTS: Compared with residents with Parkinson's disease and cancer, nursing home residents with Alzheimer's disease exhibited significantly more severe impairment in cognitive function, less additional pain-associated diagnoses, shorter length of stay in nursing homes and more indications of pain. CONCLUSION: The generally high level of pain in all observed residents elucidates the principle necessity of adequate pain assessment and an interprofessional pain treatment. Furthermore, there seems to be a still unmet need for specifically adapted pain management strategies especially for the steadily increasing number of people with Parkinson's disease and Alzheimer's disease living in nursing homes. This should be a future high priority task for (nursing) practice and research against the background of the vulnerability of nursing home populations.

[Restricted mobility in nursing home residents : The role of pain and cognitive capacity]. / Mobilitätseinschränkungen bei Altenheimbewohnern : Die Rolle von Schmerz und kognitiver Leistungsfähigkeit.

BACKGROUND: Pain, restriction of mobility and cognitive impairment are often present in old age and intensify each other. OBJECTIVES: Is there a relationship between mobility, pain, cognitive capacity, diagnoses and number of prescribed medication for residents of nursing homes? METHODS: Subgroup analysis of the baseline data from an intervention study for optimization of the medication safety of 120 nursing home residents. RESULTS: Pain was presumed in 77.8% of the residents. Persons with cognitive impairment were more frequently affected. The results of the observational and self-reported pain assessment in cognitively impaired patients did not agree for two-thirds of the cases. A correlation between prevalence of pain, pain intensity and mobility could only be shown for persons without cognitive impairment. Half of the persons were unable to walk; 80% of the residents with analgesics as a permanent medication were more restricted in their mobility. CONCLUSIONS: Cognitive impairment is associated with pain and reduced mobility, whereby self-rated pain did not concur with the observational pain assessment for two-thirds of the residents with cognitive impairment. This illustrates the difficulty of observational pain assessment.

[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

[Pain and pain-assessment in nursing homes : Results of the OSiA study]. / Schmerz und Schmerzerfassung in Altenpflegeheimen : Ergebnisse der OSiA-Studie.

BACKGROUND: Adequate and sufficient data on pain in nursing home residents is still lacking in Austria. This study intends to gather and increase available data on pain and pain assessment as well as identify potential improvement possibilities. STUDY PARTICIPANTS AND METHODS: Using a cross-sectional design, 425 residents from 12 Austrian nursing homes were recruited. The selected homes were selected as a cluster sample from 29 homes operated by one carrier. Pain assessment of cognitively intact as well as cognitively impaired residents was conducted using questionnaires, observation, and medical record examination. RESULTS: Pain prevalence was dependent on type of resident and ranged between 37.9 and 73.1 %. Sensitivity of the proxy assessment instruments varied between 47.7 and 87.7 %. Overall, 81 % of residents with daily recurring pain have been pain sufferers for at least one year. Between 40 and 68 % do not disclose their pain or consider their pain as being a part of aging. CONCLUSION: Our data on pain indicate a definite need for action. Accurately detecting pain requires reliable and resident-adapted means of assessment. Varying prevalence, specificity, and sensitivity numbers indicate the need for further research.

[Social desirability in pain therapy. Response behavior of various professional groups on the implementation of multi-professional pain management]. / Soziale Erwünschtheit in der Schmerztherapie. Antwortverhalten verschiedener Berufsgruppen zur Umsetzung eines berufsgruppenübergreifenden Schmerzmanagements.

BACKGROUND: Research on the quality of pain management is often based on self-reported data pertaining to internal regulations provided by employees. However, data examining the correctness of the information given are rare. The project "Pain-Free Hospital" facilitated such an analysis and compared the answers provided by staff members with currently existing regulations. METHODS: In the course of the project (2004-2006) data on internal pain-related therapy plans, pain management-related regulations as well as the level of knowledge of 3421 nurses, 1757 physicians (825 conservative ward physicians, 728 surgeons and 526 anesthesiologists) from a total of 19 hospitals were collected and examined prior to and after the implementation of a specific training intervention. The congruence of the answers given was measured. RESULTS: After training 16 surgical wards (previously 12) and 13 conservative wards (previously 2) had standardized therapy plans. Regulations existed in 13 conservative (previously 12) and 16 surgical wards (previously 12). In those hospitals with standardized therapy plans, a significantly higher level of knowledge was found among staff members after the intervention (p < 0.05), especially on surgical wards. In hospitals without therapy plans and regulations there were significantly more incongruent answers (p < 0.05). In comparison to colleagues from conservative wards, surgical nurses and physicians provided significantly more incongruent answers. CONCLUSION: Therapy plans and pain management-related regulations are known in hospitals after a systematic training. Data suggest that hospitals without regulations show a trend towards social desirability.

[Pain management in patients with cancer. Perspectives of various network participants]. / Schmerzmanagement bei Menschen mit Tumorerkrankung. Die Sicht einzelner Netzwerkakteure.

BACKGROUND: High healthcare needs are evident for pain caused by cancer. Those affected are not only looking for help in acute inpatient structures but also for a much larger part in outpatient care structures. To avoid mistreatment, undertreatment or overtreatment of pain in people with cancer, it is necessary to differentiate the tasks and roles of different providers while highlighting the specific aspects of pain management within the given network structures. MATERIALS AND METHODS: Aspects, such as pain assessment and the necessary scope of action in pain treatment are illustrated from the perspective of nurses from home care services, primary physicians as well as the general or special ambulatory palliative care (AAPV or SAPV) on the basis of initial survey results and a documentation analysis. RESULTS: Ambulatory care nurses (93 %) and primary caregivers (64 %) use pain assessment scales. The kind of scales used varies. The ability to provide adequate pain care for patients in the immediate care situation is reported as given by more than half of the nurses (56.6 %). CONCLUSIONS: In order to ensure an adequate pain therapy targeted interprofessional coordination is required between outpatient and primary physicians with respect to aspects of pain assessment, scope of action and accessibility.

[The pain situation for residents of nursing homes. Results of a study in Münster]. / Die Schmerzsituation von Bewohnern in der stationären Altenhilfe. Ergebnisse einer Studie in Münster.

BACKGROUND: Little is known about the phenomenon of pain in German nursing homes. In particular, it is unknown to what extent and severity pain occurs among residents and how their pain can be described. MATERIAL AND METHODS: A total of 13 nursing homes located in the city of Münster, Germany, were included as part of the health services research project "Action Alliance Pain-free City Münster." Data were collected from 436 residents over 65 years old via self-report or the observational pain tool pain assessment in advanced dementia, german version (PAINAD-G), according to the cognitive status of the residents. RESULTS: At the time of the interview, the majority of the residents questioned reported suffering from pain at rest and/or during movement. Approximately one quarter of residents complained about moderate to intolerable pain at rest and nearly 45% during movement. Residents encountered pain most often when standing up, sitting, resting in bed and walking and three quarters of residents had suffered from pain for more than 1 year. Many residents experienced pain in several body regions. Among residents assessed solely by the observational pain scale PAINAD-G, signs indicating pain existed in 21% (≥ 6) or 69% (≥ 2), respectively, depending on the cut-off value chosen on the PAINAD-G scale. CONCLUSION: Pain in nursing homes is a challenge that needs more attention as it has considerable negative consequences for the persons concerned. The extent of pain in the studied facilities indicates an urgent need for action on the part of all professionals caring for residents in nursing homes.

[Non-pharmacologic measures in pain therapy. Application in 25 German hospitals]. / Nichtmedikamentöse Massnahmen in der Schmerztherapie. Anwendung in 25 deutschen Krankenhäusern.

BACKGROUND: The application of non-pharmacologic therapy (NPT) within pain therapy increases patient satisfaction and is, in addition to pharmacologic methods, recommended in the National Expert Standard on Pain Management in Nursing of the German Network of Quality Development in Nursing. If and to what extent non-pharmacologic methods are applied within pain therapy in German hospitals has as yet been unknown. MATERIALS AND METHODS: Within the project "Pain-Free Hospital" 2,840 nurses in 25 hospitals were interviewed via questionnaire forms and oral interviews about the use of NPT. RESULTS: Of the nurses 80% confirmed the use of NPT. The majority of the interviewed nurses applied superficial cold, bedding and heat for pain relief. We identified barriers to the implementation of NPT, such as the scarce knowledge of nurses about these therapeutic areas and the uncertainty whether NPT needs to be described by doctors or not. CONCLUSION: Some of the NPTs are well established in hospitals. For nationwide use of NPT their systematic training and implementation is necessary.

[Health services research project "action alliance pain-free city Münster" : Objectives and methods]. / Versorgungsforschungsprojekt "aktionsbündnis schmerzfreie stadt Münster" : zielsetzung und methodik.

Inadequate pain care in health care facilities is still a major concern. Due to structural and organizational shortcomings the potential of modern analgesia is far from being exhausted. The project "Action Alliance Pain-free City Münster" is designed to analyze the multiprofessional pain management in health care facilities in the model City of Münster in an epidemiologic study and aims to optimize pain management in accordance with nursing standards and medical guidelines. Hospitals, nursing homes, outpatient nursing services, hospices and pain care centers will be examined. After an analysis of the current state on the basis of a pre-test, the necessary optimization measures will be developed and implemented. Subsequently, the pain management will be reevaluated in a post-test. In partly still unexplored health care areas of Germany, epidemiologic data will be generated, barriers to the implementation of standards and guidelines revealed and measures of improvements developed and tested. In addition, interface problems between the evaluated sectors will be identified. In this article the objective and the methods of the project are described.

[Pain management in nursing care--experts standard]. / Für die optimale Schmerztherapie brauchen Sie die Hilfe der Pflegenden.

The experts standard of pain management in nursing care regulates the measurement and recording of pain, medicational and non-medicational measures for the treatment and prevention of pain, the treatment of potential side effects of analgesics, and the counseling and training of nursing personnel. As such, it impacts on earlier shortcomings of interprofessional pain management, provides for therapeutic certainty, and improves the situation of those requiring permanent nursing care.

[Incidence and prevalence of postoperative acute confusion in heart surgery patients after coronary artery bypass and heart valve replacement surgeries]. / Inzidenz und Prävalenz postoperativer akuter Verwirrtheit kardiochirurgischer Patienten nach Bypassoperationen sowie Herzklappenersatz.

Compared to foreign countries, Germany does not have data about the occurrence of acute confusion following heart-surgery. However, the occurrence of acute confusion does extend the hospital length of stay for up to 13 days. Thus, this phenomenon is of high relevance to nursing. This prevalence/incidence study was implemented with the goal of obtaining exact information on the incidence rate of acute postoperative confusion after a heart surgery through a multicenter evaluation. The data evaluation took place in the form of a convenience sample survey in three different German clinics specializing on heart surgeries. The observation period lasted from the day of the surgery up to the fifth postoperative day. In the context of this prospective Cohort-study all patients aged 18 and older who had heart surgery between February 1st and April 30th, 2000, were considered suitable as participants in the study. In the end, 860 patients were included in this study. 152 patients (17.4%) showed symptoms of acute confusion (confidence interval 14-20%). Certain circumstances seemed to predispose patients to acute confusion. A widespread occurrence could be observed particularly at night. Patients aged 81-91 were mainly affected. A confusion rate of 43.5% could be determined for this group. These results confirm the clinical importance and suggest interdisciplinary approaches for solution.

[The influence of nursing measures on incision pain and the use of opioids in the postoperative period]. / Der Einfluss pflegerischer Massnahmen auf Inzisionsschmerz und Opioidverbrauch in der postoperativen Phase.

This experimental study was designed to investigate the influence of a cognitive behavioural technique on elective abdominal-surgical and orthopaedic patients at seven different time points within the first 72 postoperative hours. It examines the effect of deep breathing relaxation on the anxiety, distress, and incisional pain levels of postoperative surgical patients. The results show that the cognitive behavioural technique positively affects postoperative perception of pain, energy level, relaxed state and strain within the experimental group. The technique did not influence the patients' postoperative state-anxiety and agitation. Postoperatively, patients from the experimental group in both surgical areas used more opioids than patients from the control group. Preoperatively assessed personality factors did not differ between both groups. Overall the findings suggest that the implementation of a deep breathing relaxation technique positively influences the postoperative course of elective abdominal-surgical and orthopaedic patients.