Guideline:
Pain management in the long-term care setting
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [22 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association. Chronic pain management in the long-term care setting. Columbia (MD): American Medical Directors Association; 1999. 39 p.
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Treatment
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
- To improve the quality of care delivered to patients with acute or chronic pain in long-term care settings
- To guide care decisions and to define roles and responsibilities of appropriate care staff
Target Population
Elderly residents of long-term care facilities with acute or chronic pain or who are at risk of pain
Interventions and Practices Considered
Diagnosis/Assessment
- Regular and systematic assessment for presence of pain
- Observation for nonspecific signs and symptoms that suggest pain
- Use of Minimum Data Set (MDS) as a tool to aid in pain assessment.
- Identification of characteristics and causes of pain
- Use of a standardized scale to quantify the intensity of the patient's pain
- Identification and addressing of risk factors for pain
- Assessment of impact pain has on function and quality of life
- History and physical examination
- Diagnostic testing as indicated
- Laboratory testing such as fasting glucose blood urea nitrogen creatinine liver profile urinalysis uric acid alkaline phosphatase;
- Radiologic testing such as spine x-rays computed tomography (CT) or magnetic resonance imaging (MRI) scan
- Consultation with pharmacist and pain specialists as needed
Management/Treatment
- Interdisciplinary care planning
- Environment support to promote comfort (temperature control minimization of background noise clean & dry skin comfortable positioning in bed or chair reassuring words and touch back rub hot or cold compresses whirlpool services of a chaplain or other appropriate pastoral counselor comforting music)
- Pharmacologic treatment
- Non-opioid analgesics such as acetaminophen aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) cyclooxygenase-2 (cox-2) inhibitors and tramadol. NOTE: The NSAIDs indomethacin piroxicam tolmetin and meclofenamate are considered but not recommended for chronic use. Propoxyphene meperidine pentazocine butorphanol and other agonist-antagonist combinations are considered but not recommended.
- Opioid analgesics (oxycodone; morphine; transdermal fentanyl; hydromorphone; methadone; combination opioid preparations such as codeine hydrocodone oxycodone)
- Other classes of drugs (corticosteroids anticonvulsants clonazepam carbamazepine anti-arrhythmics intravenous local anesthetics baclofen)
- Complementary (nonpharmacologic) therapies
- Education cognitive/behavioral therapy exercise
- Other physical therapies (physical and occupational therapy positioning cutaneous stimulation neurostimulation chiropractic magnet therapy)
- Other nonphysical therapies (psychological counseling spiritual counseling peer support groups alternative medicine aromatherapy music art drama therapy biofeedback meditation other relaxation techniques hypnosis)
- Evaluation of response to treatment monitoring of patient’s pain and adjustment of treatment as needed
Major Outcomes Considered
- Pain intensity
- Pain relief
- Mood function sleep and quality of life
- Safety and side effects of medications
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Interdisciplinary workgroups developed the guidelines using a process that combined evidence- and consensus-based approaches. Workgroups included practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency association or organization such as the Agency for Healthcare Research and Quality (AHRQ) pertinent articles and information and a draft outline each group worked to make a concise usable guideline tailored to the long-term care setting. Because scientific research in the long-term care population is limited many recommendations were based on the expert opinion of practitioners in the field.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians specialists and organizations that are knowledgeable of the guideline topic and the long-term care setting.
Major Recommendations
The algorithm Pain Management in the Long-Term Care Setting is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
An algorithm is provided for Pain Management in the Long-Term Care Setting.
Type of Evidence supporting the Recommendations
The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.
Potential Benefits
- This guideline recommends processes that if followed will help to ensure that pain among long-term care patients is adequately recognized assessed treated and monitored.
- By implementing the steps described in this guideline health care providers can meet the expectations of patients their families advocates and policy makers for adequate compassionate management of pain in the long-term care setting.
Potential Harms
- See Table 9 in the original guideline document for a listing of possible adverse effects associated with non-opioid analgesics commonly used in the long-term care setting.
- See Table 17 in the original guideline document for a listing of possible adverse effects associated with non-analgesic drugs sometimes used for analgesia in the long-term care setting.
Qualifying Statements
- This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association their heirs executors administrators successors and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use negligent or otherwise of this clinical practice guideline.
- The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.
Description of Implementation Strategy
The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.
- Recognition
- Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
- Assessment
- Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
- Implementation
- Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
- Identify individual responsible for each step of the CPG.
- Identify support systems that impact the direct care.
- Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
- Monitoring
- Evaluate performance based on relevant indicators and identify areas for improvement.
- Evaluate the predefined performance measures and obtain and provide feedback.
Implementation Tools
Clinical Algorithm
Personal Digital Assistant (PDA) Downloads
Tool Kits
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [22 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Medical Directors Association
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association. Chronic pain management in the long-term care setting. Columbia (MD): American Medical Directors Association; 1999. 39 p.
Guideline Availability
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Availability of Companion Documents
The following are available:
- Guideline implementation: clinical practice guidelines. Columbia MD: American Medical Directors Association 1998 28 p.
- We care: implementing clinical practice guidelines tool kit. Columbia MD: American Medical Directors Association 2003.
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
The following is also available:
- PDA application: pain management. Available in Palm/PDA and PocketPC formats from the American Medical Directors Association (AMDA) Web site.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on July 6 2004. The information was verified by the guideline developer on August 4 2004. This summary was updated by ECRI on January 12 2005 following the release of a public health advisory from the U.S. Food and Drug Administration regarding the use of some non-steroidal anti-inflammatory drug products. This summary was updated on April 15 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16 2005 following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI Institute on January 10 2008 following the U.S. Food and Drug Administration advisory on Carbamazepine.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. For more information please contact the American Medical Directors Association (AMDA) at (800) 876-2632.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.
All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.
Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .
NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.
Readers with questions regarding guideline content are directed to contact the guideline developer.