Schervier's 2nd Annual Conference

—on Pain and Pain Management!

Keela Herr, Pain Conference Keynote Speaker

Pain Management Conference Reveals that Unrelieved, Persistent Pain in Older Adults Causes Severe and Preventable Problems

Disturbing facts about unrelieved persistent pain in older adults came to light at a conference held by the Schervier Center for Research in Geriatric Care, part of Bon Secours New York Health System.  The conference was held at Manhattan College on June 4^th, and was attended by more than 150 professionals and paraprofessionals interested in alleviating pain in older adults.

Entitled “Assessment and Treatment of Pain in Cognitively Impaired Older Adults,” the content of the conference is highly relevant to maintaining the quality of life of elderly persons.  Unfortunately, pain is a common problem among the elderly, and when left under-treated or untreated, can result in a substantially decreased quality of life.  Unremitting pain can result in sleep disturbances, malnutrition, physical decline, falls, depression, anxiety, impaired cognition, delirium and other serious problems, including higher health care utilization costs.

It is estimated that 49% to 83% of all nursing home residents have substantial pain that is under-detected and under-treated.  For the 25% to 33% of nursing home residents who are known to have moderate to severe pain on a daily basis, approximately one-fourth do not receive analgesia, i.e., pain relieving medications.  The problem is even worse for individuals with dementia who cannot express their pain verbally.

You may wonder why pain remains under-treated and untreated.  According to the keynote speaker, internationally renowned pain expert Keela Herr, PhD, RN, FAAN, AGSF, Professor and Chair of Adult and Gerontology Nursing in the College of Nursing at the University of Iowa, pain is often inadequately recognized.  Second, it is not clearly understood by many in the health professions that pain is whatever the person who has the pain says it is.  The ability to report one’s own pain is considered the Gold Standard in pain assessment.  Asking verbal adults to rate their pain using various pain scales is helpful.  In cognitively impaired and non-verbal older adults, it should be assumed that pain is present if there is reason to suspect it, as in pathological conditions and common problems or procedures known to cause pain, such as surgery, wound care, rehabilitation activities, positioning/turning, blood draws, heel sticks, a history of persistent pain, or the presence of diseases known to cause pain (e.g., osteoarthritis and cancer).  Other problems that may be causing discomfort should be ruled out or treated, such as infection or constipation.

How can you tell if a cognitively impaired older adult is experiencing pain if she cannot speak?  When the older adult has lost the ability to self-report pain, observation of changes in her behavior can indicate the presence of pain.  Behaviors like groaning, crying out or fidgeting may be present.  As pain worsens, these negative behaviors increase, and as it lessens, the behaviors decrease.  In nursing homes, certified nursing assistants, physical and occupational therapists, dietary and housekeeping staff all come in close and frequent contact with residents.  Together with family members, these are the people who can best notice behavioral changes.  Is the person in pain grimacing, moaning, grunting, rocking, crying, or frowning?  Is she restless, pacing, rocking, refusing to eat or breathing noisily?  Is she irritable, agitated, disruptive, aggressive, resistant or withdrawn?  Each of these behaviors may indicate pain in cognitively impaired older adults, and familiarity with, combined with observation of the elder is key to discovering and treating the pain.

The goals of care in managing pain in older adults include: providing comfort, improving sleep, increasing functional abilities, reducing pain-related mood disorders, and others.  Older adults with dementia are candidates for non-pharmacologic pain management strategies and for pharmacologic therapy. Non-drug interventions fall into two categories: physical and cognitive/psychosocial.  Physical interventions include: exercise, cold/heat, massage, positioning, whirlpool baths, and acupuncture/acupressure.  Cognitive/psychosocial interventions include: talking/listening, guided imagery, meditation/prayer, deep breathing, distraction, humor and spiritual counseling.

Several additional speakers provided a wealth of information during the day-long conference.

Terry Altilio, MSW, ACSW, LCSW, Social Work Coordinator in the Department of Pain Medicine and Palliative Care at Beth Israel Medical Center, spoke about “Psychosocial and Environmental Interventions for Treating Pain.”  She discussed the importance of context in determining how to deal with a person’s pain.  We should determine who the person “is,” both culturally and spiritually.  What are his interests, abilities, and preferences?  These components of the person’s personality will influence how he, or his family member/agent, will want pain managed.  Altilio also noted that those caring for persons with dementia should be mindful of the common human needs which bond the individual, family members and caregivers, including the need for privacy, respect, warmth, companionship, gentle treatment, and a calm, familiar environment.  Providing for these needs will help reduce the likelihood of pain and insure better outcomes of pain management strategies.  She stressed that non-pharmacologic pain interventions should also be considered, like music, massage, distraction, prayer, and even hugs.

Steven L. Grenell, MD, Clinical Assistant Professor of Neurology at the Albert Einstein College of Medicine and Attending Neurologist at Montefiore Medical Center, debunked myths about the treatment of pain.  In the past, it was believed that the administration of opioid medications for pain treatment could easily lead to addiction. Now it is more widely understood that opioids are safe and effective when used properly. Under-treated pain, said Grenell, impairs mood, sleep and healing, extends length of stay in hospitals and sub-acute facilities, and reduces patient satisfaction with quality of care.  Sadly, he added, it is historical, political and sociocultural – not medical – factors that explain why safe and powerful analgesics have long been bypassed in favor of therapeutic agents that are more toxic and less effective.  Grenell ended his talk by discussing the fact that people contemplate suicide because their untreated pain is intolerable.

Jeffrey N. Nichols, MD, Vice President for Medical Services of the Cabrini Eldercare Consortium spoke about “Ethical Issues in Pain Management.” He asked the audience, “Whoever wants to die in pain, please raise your hand.” Not surprisingly, not one hand was raised. Nichols began his interactive discussion with the statements: “Pain is bad; pain-free is good; identifying patients who are in pain and making it go away must be good; allowing patients who cannot speak for themselves to die in pain must be bad.” Using these premises, Nichols subsequently involved conference participants in a dialogue based on a case study of a terminally ill patient. The discussion included multiple ethical principles, like privacy, autonomy, beneficence and non-maleficence, and how these principles influence ethical decisionmaking.  He also discussed the principle of double intent, which applies when an action to be taken has both beneficial and potentially harmful effects.  An excellent example of double intent occurs in situations where, in attempting to manage severe terminal pain effectively, sedation or death may actually occur.

Susan Caccappolo, MSSW, LCSW, Palliative Care Coordinator of the Schervier Center for Research in Geriatric Care, discussed “Surmounting the Barriers to Effective Pain Management.”  She spoke about the challenges to effective pain management found within the general population, among physicians, within nursing home populations, and specifically among cognitively impaired nursing home populations.  She enlisted conference participants in describing some of the specific challenges they face in attempting to manage pain, and sought their collective wisdom in identifying some solutions for those challenges.  She cited legal bases for treating pain, such as the Patient Self-Determination Act (1990) which encourages nursing home residents to complete Advance Directives, and the US Supreme Court ruling (1997) that included the statement that high doses of opioid medications for pain management is appropriate palliative care.  Caccappolo ended her presentation with the anonymous quote: “Pain is inevitable.  Suffering is optional.”

Schervier Home Health Care is Ranked Among Top 25 %  of U.S. Home Health Providers for 2007

Bon Secours New York Health System is pleased to announce that the Schervier Home Health Care Program has been named to the 2007 HomeCare Elite, a compilation of the most successful Medicare-certified home health care providers in the United States. This annual review identifies the top 25% of agencies, ranked by an analysis of performance measures in quality outcomes, quality improvement and financial performance. The data used for analysis was compiled from publicly available information.

“Being noted as one of the top performers in the nation in the very competitive home health care environment shows that Schervier Home Health Care is dedicated to quality and performance,” says Barbara Knott, Vice President of Home Care Services for Bon Secours Health System, Inc.

Leslie Reed, Director of the Schervier Home Health Care Program, says, “Helping to improve the lives of the most vulnerable members of our population is one of the founding principles of our mission, which is to bring compassion to health care and to be ‘good Help’ to those in need.”

The 2007 HomeCare Elite is the only performance recognition of its kind in the home health industry. The 2007 HomeCare Elite is brought to the industry by OCS, Inc., the leading provider of healthcare informatics and DecisionHealth, publisher of home care’s most respected independent newsletter Home Health Line. The entire list of the 2007 HomeCare Elite agencies can be viewed by visiting the OCS web site at www.ocsys.com.