RESEARCH OBJECTIVE: Greater than 50% of nursing home residents are cognitively impaired, of which 45-80% experience pain on a daily basis. Current evidence indicates suboptimal pain management of cognitively impaired older adults. As residents with moderate to severe cognitive impairment are often unable to self-report pain, this subpopulation is at high risk for suffering. This problem paired with age-related physiological changes that place older adults at risk for adverse reactions to pain medication suggests a need for non-pharmacological interventions for pain. In this systematic review, studies of non-pharmacological interventions to reduce pain in cognitively impaired nursing home residents were reviewed. Study findings were assessed 1) to determine what interventions to reduce pain have been studied in cognitively impaired nursing home residents 2) to evaluate the effectiveness of these interventions, and 3) to assess the potential for these interventions to be implemented in nursing homes.
STUDY DESIGN: Included studies were published in English after January 1, 2001. End of life interventions, single case studies, and dissertations were excluded. PubMed, CINAHL, and Embase databases were searched on September 19, 2016. The quality of each study was evaluated regarding sample size, attrition, randomization, control, and blinding.
POPULATION STUDIED: Of 929 unique studies identified in a systematic search, the full texts of nine studies meeting criteria for inclusion were reviewed.
PRINCIPAL FINDINGS: Across the nine studies, there were seven different measures of cognitive impairment and eight different measures of pain, and this variability complicates comparison of intervention effectiveness. Studies reported three different categories of interventions: specialized dementia care units, training and tools to support pain assessment, and non-pharmacological therapies. Both studies of specialized dementia care units reported that residents on these units receive less pain medication than residents on open units; however, the studies did not describe the characteristics of these units, which complicates replication. Two out of four interventions involving training and tools to support assessment were associated with decreased pain. Results were mixed regarding whether staff assessment and recognition of pain was associated with non-pharmacological intervention. The non-pharmacological therapies of reflexology, Passive Movement Therapy (PMT), and Namaste were all associated with a decrease in pain, but long-term maintenance of efficacy is unknown. The Namaste study was the only study to require nursing staff reorganization. In addition to the training required to implement pain assessment systems, interventionists of the three non-pharmacological therapies required training. No study noted the cost of implementation.
CONCLUSIONS: The findings of this systematic review provide limited evidence of the effectiveness of systematic pain assessment, reflexology, PMT, and Namaste in reducing cognitively impaired nursing home residents’ pain. The limited number of non-pharmacological interventions studied in nursing homes is consistent with the lack of literature on complementary and alternative therapies to treat pain in older adults.
