Assessing Pain and Falls Risk in Residents With Cognitive Impairment: Associated Problems With Overlooked Assessments
by A. Burfield and J. Cooper; Annals of Long-Term Care; May 2014


According to the American Geriatrics Society Panel on Persistent Pain in Older Persons, approximately 45% to 80% of long-term care (LTC) residents experience substantial pain. The literature indicates that approximately 25% of LTC residents who experience daily pain receive no pain interventions (ie, analgesics, nonpharmacologic treatments), indicating more should be done to better recognize pain on this population. When pain remains undiagnosed and uncontrolled, it can lead to a selection of adverse outcomes, including falls. In fact, the prevalence of falls in nursing facilities is similar to that relating to pain, with 50% to 75% of residents falling each year. Even more troubling is always that nursing home residents more than 65 years are the cause of 20% coming from all fall-related deaths. As these data show, pain and falls are major challenges in LTC settings, making comprehensive pain and fall assessments essential; however, these assessments can cause a particular challenge in cognitively impaired persons, as these individuals might not be able to fully communicate their experiences. In this column, we describe two original tools, under development, that LTC providers may use to more thoroughly assess pain and falls risk inside their cognitively impaired residents. It is important to note, however, that these instruments are not validated in large-scale studies.

Assessing Pain in the Cognitively Impaired

Pain recognition remains a challenge inside the LTC setting. When examining Minimum Data Set 2.0 data for 52,996 residents (mean age, 83.many years) from Medicare-certified LTC facilities through the entire United States, we found that residents with mild to severe cognitive impairment and the ones unable to report pain verbally had the very best risk of experiencing pain. Using pain frequency and intensity because the only indicators of pain revealed a standard pain prevalence of 31%; however, when taking cognitive status into account, 48% of the intact group had pain, in comparison with 40% of those with mild cognitive impairment, 30% of these with moderate cognitive impairment, and 18% of those with severe cognitive impairment. These data indicate that pain recognition and reporting decreases with decreasing cognition. Therefore, regularly scheduled pain assessments are important for adequate pain recognition inside cognitively impaired.

Although healthcare providers may question whether pain assessment scales are useful in cognitively impaired persons, there's some evidence they can be effective. In one study, which included 129 older adults with severe dementia, 61% of participants demonstrated comprehension of at least one pain scale.6 We observed similar leads to an unpublished follow-up study that people conducted. Of the 155 cognitively impaired skilled nursing facility (SNF) senior care recipients included in the study, one-third might use a visual analog pain scale (ie, 0-10 scale) to characterize their pain, whereas two-thirds required a nonverbal pain scale as a result of cognitive impairment. Based on these studies, we designed a checklist that healthcare providers can use to identify nonverbal cues of chronic pain in elderly residents. The use of such an instrument may will better identify those cognitively impaired persons who will manage to benefit from a pain management plan.

Assessing Falls Risk inside the Cognitively Impaired

A recently published article in Annals of Long-Term Care by Willy and Osterberg provides an excellent summary of fall risk considerations, so when this article among others demonstrate, all an elderly care facility residents have reached risk for falls. However, the risks are amplified in cognitively impaired residents. One study reported that elderly an elderly care facility residents with dementia are seven or more times more prone to experience falls than elderly residents without significant cognitive impairment. Although these residents were no prone to experience injuries than their cognitively intact counterparts, their likelihood of sustaining injurious falls was significantly higher due to their increased propensity to fall, highlighting the call to implement fall prevention programs with this population.

A crucial element of any fall prevention program is conducting regular fall risk assessments, because they can provide important insights on the way to reduce fall risks. To maximize the advantages of these assessments, they should be completed within one day of admission, quarterly, whenever there is certainly a significant change in a resident’s cognitive or physical status, and following any fall. In approximately 33% of cases, just one potential cause may be identified, whereas in approximately 66% of cases, multiple risk factor is involved. To assess the multifactorial reason for falls, we highly encourage healthcare providers to consider using the falls risk assessment instrument furnished by clicking here or about the right-hand image. This instrument originated based on our long-term observations and numerous published reports regarding falls inside LTC environment. Our assessment instrument takes into mind the inability of numerous residents to accomplish common fall risk assessment tests, such because timed Get Up and Go test, because of their cognitive and motor impairment(s).

Psychotropics and Uncontrolled Pain as Precursors to Falls: Reducing Risks

As previously noted, cognitively impaired residents offer an increased probability of falls in contrast to their cognitively intact counterparts. Although there are wide ranging reasons for this, the behavioral and psychological signs and symptoms of dementia, which might develop as cognitive impairment progresses, may play a large role. In many cases, when such behaviors manifest (eg, agitation, aggression), these patients are placed on antipsychotics along with other psychotropic medications, which were associated with various adverse drug reactions, including falls. One study found an approximately 3.5-fold increased chance of falls across all psychotropic drug classes examined, including antidementia medications, antidepressants, antipsychotics, anxiolytics, hypnotics, and short-acting benzodiazepines.

When examining a resident’s medication regimen with a goal to cut back falls risk, the complete psychoactive drug load must be carefully considered. Psychoactives include all psychotropics, sedatives/hypnotics, neurological system stimulants, antiparkinson agents, anticonvulsants, metoclopramide, muscle relaxants, opioid analgesics, and antihistamines, and then for any drug which includes primary or secondary anticholinergic unwanted effects, which could include various agents employed for gastrointestinal, urinary tract, and pulmonary diseases. Appropriate tapering that is the reason for adverse drug withdrawal effects may improve cognition minimizing the frequency of falls, emergency department visits, and hospitalizations.

However, evidence also suggests that pain may be the source of these behavioral manifestations sometimes, along with a pain evaluation may be warranted before any psychotropic medications are administered. In 1998, research published in Annals of Long-Term Care reported a regular schedule of acetaminophen 3 g daily decreased behavioral signs of agitation, inappropriate outbursts, and aggression by 63%, and enabled a 75% discontinuation rate of psychotropics; however, the analysis did not address the consequence on falls. Subsequently, we conducted the same study that included SNF residents with dementia and agitation who were treated with conventional psychotropics. We found out that tapering psychotropics after which converting these residents to buspirone (ie, an anxiolytic that is not chemically or pharmacologically related on the benzodiazepines, barbiturates, or another sedative/anxiolytic drugs) decreased the quantity of agitation and fall episodes by 75% and improved cognition on the 6-month study period.

In a previously unpublished subset analysis with the aforementioned study, which included 12 of the 57 patients have been treated with acetaminophen 2.6 g to three g daily before psychotropic tapering and discontinuance, we observed less agitation (10 of 12 patients), fewer total episodes of agitation, and an 80% decrease inside the number of falls for a few months thereafter, as weighed against the 3-month period preceding digging in regularly scheduled acetaminophen.

These data suggest which a regular schedule of acetaminophen 2.6 g to three.0 g daily for anyone with good liver function may both decrease the need for psychoactive drugs and enable easier tapering of the inappropriate psychoactive drugs which are being used. When proceeding with an acetaminophen regimen, healthcare providers need to be cautious about the concurrent utilization of cold, flu, allergy, and any other medications that may contain acetaminophen, because they can markedly increase the risk of liver toxicity if added to an everyday schedule of acetaminophen. In addition, no ingested alcohol in a amount must be allowed in a patient taking any dose of acetaminophen. Concurrent usage of alcohol may increase the likelihood of severe liver damage, and yes it more than doubles the probability of kidney disease per an initial study presented in the 2013 American Public Health Association annual meeting.

Take-Home Message

Pain and fall risk assessments are very important in LTC settings, and cognitively impaired residents really should not be overlooked in relation to these assessments. In addition to helping healthcare providers better identify persons who will manage to benefit from pain management strategies, for example regular acetaminophen administration, and fall prevention strategies, like minimizing psychoactive drug loads, they're able to enable documentation from the effects of these interventions on both pain scores and falls. By comparing scores, interventions can be fine-tuned to optimize care. It is essential to remember that pain and falls are key quality measures in the an elderly care facility; thus, it behooves all LTC providers to strive to improve care during these areas, which begins with thorough assessments.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


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