A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain

Abstract

Context: Pain assessment in people with cognitive impairment is challenging. Objective: The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months. Methods: Using national Minimum Data Set 3.0 data (2011-2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis. Results: Five latent statuses of pain were identified at admission: "Behavioral and Severe Depression" (prevalence stable, severe or worsening cognitive impairment: 11%, mild/ moderate or improved cognitive impairment: 10%), "Functional" (21%; 25%), "Physical" (22%; 23%), "Behavioral" (23%, 19%), and "Low" (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the "Behavioral" class transitioned to the "Behavioral and Severe Depression" class by 3 months. Fewer residents transitioned between latent classes in the 3-to 6-month period (>80% remained in their 3-month class). Conclusion:For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain.

A systematic review of prevalence of pain in nursing home residents with dementia

“…Seven studies had a longitudinal design [ 7 , 17 , 39 , 53 , 55 , 57 , 58 ], and 18 studies had a cross-sectional design.…”

“… 7 6 Estabrooks [ 39 ] + ? - + + - + + - 5 7 Forrester [ 53 ] + + + + + - + + - 7 8 Griffioen [ 31 ] + + + + + - + + + 8 9 Haasum [ 54 ] + + + + - + + + + 8 10 Helvik [ 15 ] + + + + + - + + + 8 11 Helvik [ …”

“…Staff assessment was used in 14 of the studies to explore prevalence of pain in all residents [ 11 , 15 – 17 , 31 , 50 , 53 , 55 , 58 – 63 ], while 4 studies used both self-report and staff assessment, depending on the severity of dementia and ability to communicate [ 39 , 52 , 56 , 57 ] (Table 4 ). An additional 5 studies reported the prevalence of pain after studying documentation of pain in the resident’s medical journal and nursing documents [ 7 , 13 , 14 , 18 , 32 ].…”

“…There were also differences in the time points at which the prevalence of pain was assessed during the NH stay, including shortly after admission (14 days to 8 weeks) [ 7 , 15 , 17 , 52 , 53 , 55 , 60 ], after 100 days or more [ 57 ], semiannually [ 7 ], annually [ 55 ], in the last year of life [ 39 ], in last 90 days of life [ 13 ], last 30 days of life [ 51 ] and during the last week of life [ 13 , 18 ]. However, the prevalence of pain was most often explored in residents with dementia independent of their length of stay, if they met the basic inclusion criteria [ 11 , 14 , 16 , 17 , 31 , 32 , 50 , 54 , 56 , 58 , 59 , 61 – 63 ].…”

“…The prevalence of pain among NH residents with dementia shortly after admission [ 7 , 15 , 52 , 53 , 55 , 60 ] was between 35.5% [ 15 ] and 52% [ 7 ], either reported as clinically relevant or as the presence of pain (Table 1 , Fig. 2 ).…”