Original Article Health-Related Profile and Quality of Life Among Nursing Home Residents: Does Pain Matter? ---
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From the *School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong; †Prince Margaret Hospital, Kowloon, Hong Kong. Address correspondence to Mimi M. Y. Tse, RN, PhD, School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong. E-mail: [email protected] Received May 26, 2011; Revised October 14, 2011; Accepted October 17, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.10.006
Mimi M. Y. Tse, RN, PhD,* Vanessa T. C. Wan, RN, MSc,† and Sinfia K. S. Vong, PT, MPhil*
ABSTRACT:
The purpose of this exploratory cross-sectional study was to explore the health-related profile and quality of life among older persons living with and without pain in nursing homes. Ten nursing homes were approached, and 535 older persons were invited to join the study from 2009 to 2011. The nursing home residents’ demographic information and information regarding their pain situation and the use of oral analgesic drug and nondrug therapy among the older residents with chronic pain were also collected. Residents’ physical health (using the Barthel Activities of Daily Living (ADL) and Elderly Mobility Scores); psychologic health, including happiness, life satisfaction, depression, and loneliness (using the Happiness Scale, the Life Satisfaction Scale, the Geriatric Depression Scale, and the UCLA Loneliness Scale); and quality of life were investigated. Among the 535 nursing home residents, 396 (74%) of them suffered from pain, with mean pain scores of 4.09 ± 2.19, indicating medium pain intensity a remaining 139 (26%) reported no pain. The location of pain was mainly in the knees, back and shoulders. Our results demonstrated that, with the exception of the no-pain group (p < .05), nursing home residents’ pain affected both their psychologic health, including happiness, life satisfaction, and depression, and their physical quality of life. Nevertheless, only one-half of the older persons with pain used oral analgesic drug or nondrug therapy to relieve their pain. Pain had a significant impact on their mobility and ADL, was positively correlated with happiness and life satisfaction, and was negatively correlated with loneliness and depression. Pain management is a high priority in elderly care; as such, innovative and interdisciplinary strategies are necessary to enhance quality of life particularly for older persons living in nursing homes. Ó 2013 by the American Society for Pain Management Nursing Older adults may have various physical impairments due to functional deterioration and/or suffering from chronic illness in the process of aging (Albert & Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e173-e184
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Freedman, 2010; Leung & Lo, 1997; Sidell, 1995). As the proportion of older people increases, there will be an increase in the number of more dependent oldold, as well as a greater need for a higher level of care, including nursing home care (Williams, 2007). In Hong Kong, 10% of older persons live in institutions with residential care (Census and Statistics Department, Hong Kong, 2008). Residential care services for older adults aim to provide residential care and facilities for those aged $65 years who, for personal, social, health or other reasons, cannot be taken care of adequately at home. Persons aged 60-64 years can receive residential care if there is a proven need (Social Welfare Department, 2005). In a recent study by Tse (2007), Chinese older persons expressed that living in a nursing home rendered them insecure, lonely, feeling abandoned by their family members, and full of suffering. Indeed, many older persons suffered a great deal when they had to make the decision to live in a nursing home, because it was expected to be the final destination in their earthly journey. Besides distress from chronic diseases, nearly 45%80% of nursing home residents suffer from pain (American Geriatric Society Panel on Chronic Pain in Older Persons, 1998; Ferrell, 1995; Helme & Gibson, 2001; Williams, 2007). Indeed, the pain condition among older residents may be caused by their reluctance to report pain, their acceptance of pain as part of aging, and/or their fear of using pharmacologic interventions (Schofield, 2006). Low expectations from medical staff and their lack of awareness of pain relief strategies may be another reason (Higgins, Madjar, & Walton, 2004; Murphy, 2007; Schofield, 2006). With these pain beliefs and lack of knowledge, the pain condition among older residents may become worse. Pain can cause inactivity and progressive disability in older persons, as well as social isolation and decreased quality of sleep and appetite. Older persons with pain may also suffer loneliness, loss, helplessness, and depression (Gran, Festvag, & Landmark, 2009; Murphy, 2007). Indeed, inadequate pain management may have a consequent cost to health and social services. In view of the increase of the ageing population, the purpose of the present study was to explore the health-related profile and quality of life among older persons living with and without pain in nursing homes. It was hoped that more information about older adults would be collected and consequently that better pain control methods or interventions could be tailor made for residents. In the present study, health-related profile included the presence and intensity of pain, physical health parameters, psychologic health parameters, and quality of life.
METHODS Design and Sample This study used an exploratory cross-sectional design. After gaining approval from the Ethics Committee of the university, ten nursing homes, including two private and eight nongovernment organizations in different districts of Hong Kong, were invited to participate in the study. A total of 535 older residents were recruited as a convenience sample. Written consent was obtained from each of the participants. The inclusion criteria of the residents were age $60 years, ability to communicate in Cantonese, and awareness of time, place, and persons. The researcher would start ‘‘small’’ talk with the residents by asking the date, time, and place and see whether these residents could understand these questions and were able to provide correct answers/responses orally. The exclusion criteria were having been in the nursing home for 101 years, with a mean age of 85.17 6.48 years. The majority (69.1%) of the participants were
Pain intensity and pain site (mean SD) for the pain group (n ¼ 396).
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widowed, many (39.4%) had been in nursing homes for 1-3 years, and many (35.1%) received visits from family members every week. More than one-half of the nursing home residents had received no formal education. Their major underlying medical problems included hypertension (65.4%), cataract (43.7%), heart disease (29.5%), history of cerebrovascular accident (24.7%), and arthritis (22.6%). For the pain group, Table 2 shows that 45.7% (n ¼ 181) of them reported experiencing pain all the time. Figure 1 shows that 396 participants reported having experienced pain and had a mean pain score of 4.09 2.19 (on a 0–10-point scale), the most severe pain sites being the ankles, multiple joints, and hips. Nevertheless, only one-half of the older residents used oral analgesic drug or nondrug therapy for pain management. Furthermore, one-fourth of them did not use any pharmacologic or nonpharmacologic methods to relieve their pain (Tables 3 and 4). Physical and Psychologic Health Table 5 presents the physical and psychologic parameters for the pain and no-pain groups. In physical health, there were no significant differences in mobility or ADL for the pain and no-pain groups (p > .05). However, pain had a great impact on the psychologic health of the older adults. It was found that older adults in the pain group had significantly lower happiness and life satisfaction scores; also, they were more depressed than their counterparts without pain (p < .05). In addition, significant differences were found in the physical component of quality of life between the pain and nopain groups (p < .05), with the pain group reporting a significantly lower physical component of quality of life. Correlation Tables 6-8 present the correlation of pain intensity and various physical and psychologic parameters among participants in the pain and no-pain groups. Spearman correlation was used to measure the demographic data and physical and psychologic parameters. There were various correlations between sex, marital status, education level, length of time in nursing home, use of oral drug and nondrug strategies, physical and psychologic parameters, and quality of life in both groups. For the pain group, more significant positive correlations were found between education level and loneliness; years in nursing home and happiness, life satisfaction, and ADL; use of oral analgesics and physical health, including mobility and ADL; and use of nondrug therapy and the physical component of quality of life (p < .01). Significant negative correlations were also noted between length of time in nursing homes
TABLE 3. Use of Oral Analgesic Drugs/Nondrug Therapy in the Pain Group (n ¼ 396)
Use of oral analgesic drug Yes Type of oral analgesic drug used Panadol Dologesic Dologesic & Panadol Niclofen Na Allopurinol & Aspirin Niclofen Na & Dologsic Allopurinol Naproxen Aspirin Dihydrocodeine tartrate Panadol & Tramadol Allopurinol & Niclofen Na Allopurinol & Naproxen No Use of nondrug therapy methods Yes Type of nondrug therapy used Topical ointment Massage Resting Physiotherapy Hot pad Watching TV Listening to music Chatting to friends Deep breathing Cold pad No
n
(%)
201
(50.8)
196 64 10 9 8 4 7 3 15 1 1 1 1 195
(49.5) (16.2) (2.5) (2.3) (2.0) (1.0) (1.8) (0.8) (3.8) (0.3) (0.3) (0.3) (0.3) (49.2)
308
(57.6)
268 99 36 30 27 13 7 5 5 4 227
(67.7) (25.0) (9.1) (7.6) (6.8) (3.3) (1.8) (1.3) (1.3) (1.0) (42.4)
and loneliness; and pain intensity and the use of pharmacologic and nonpharmacologic therapy (p < .01). However, for the no-pain group, the only negative correlation was found between duration in nursing home and depression (p < .01). In Table 8, physical parameters such as ADL and mobility were significantly correlated with psychologic parameters, including happiness, loneliness, life satisfaction, and depression, among all of the older residents (both pain and no-pain groups; p < .05). In addition, negative correlations were found in pain and depression, and positive correlations were found in pain and physical parameters, including ADL and mobility, happiness, and life satisfaction, for participants in both the pain and the no-pain groups. In comparing the pain and no-pain groups, the only significant correlation noted for the pain group was that their physical parameters were negatively correlated with loneliness, indicating that pain may affect
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Pain and Quality of Life in Nursing Homes
TABLE 4. Different Kinds of Pain-Relieving Treatments Total (n ¼ 535)
Analgesic drugs & nondrug methods Analgesic drugs only Nondrug methods only Neither analgesic drugs nor nondrug therapy
Without Pain (n ¼ 139)
With Pain (n ¼ 396)
n
(%)
n
(%)
Pain Intensity
n
(%)
p Value
173
(32.3%)
171
(43.2%)
4.52 2.11
2
(1.4%)
.000*
73 134 135
(13.6%) (25.0%) (25.2%)
44 129 49
(11.1%) (32.6%) (12.4%)
3.58 2.10 4.06 2.31 3.03 1.90
29 5 86
(20.9%) (3.6%) (61.9%)
.004* .000* .000*
*p < .05 was considered to be statistically significant.
the physical ability of older adults, which may in turn increase their feelings of loneliness.
DISCUSSION In this study, >75% (n ¼ 402) of the nursing home residents were aged $81 years and were thus old-old and widowed. Most of them had one or more chronic illnesses, and >80% in the pain group had arthritis, which is frequently a cause of musculoskeletal pain. Comprehensive care, including feeding, toileting, grooming, dressing, bathing, and limited recreation and physical exercise, was provided by nursing home staff to their residents. However, as a result of the aging process, the deterioration of functioning and the onset of chronic illnesses, as well as suffering from chronic pain, life for these nursing home residents was quite difficult. In the present study, >70% (n ¼ 396) of the nursing home residents were suffering from pain. Nevertheless, the pain management strategies used by older adults were found to be inadequate. Only 50%
of them used oral analgesic drugs, and 50% used nondrug therapy methods, including topical ointment, massage, and physiotherapy. It was disturbing to find that 12.4% of older residents had a pain intensity of 3.03 1.90 yet were using neither analgesic drugs nor nondrug strategies to relieve pain. The reasons for the inadequate use of pain relief methods could be explained by older residents themselves as well as the nursing home staff and physicians. Older persons may consider pain to be a normal part of ageing, and some may be reluctant to seek help in the nursing home or are afraid of the adverse effects of analgesics (Schofield, 2006). Nursing staff may also misunderstand the pain suffering of older persons or lack sufficient knowledge in pain management (Higgins, Madjar, & Walton, 2004; Lui, So, & Fong, 2008; Yu & Petrini, 2007). Physicians may hesitate to prescribe oral analgesics, and they rarely review the effects of medication (Murphy, 2007). Given the various barriers to pain management, chronic pain is a major problem among older persons (Mann & Carr, 2006; Clarke & Ryan, 2007). Unrelieved
TABLE 5. Physical and Psychologic Parameters (n ¼ 535), Mean ± SD
Physical Elderly Mobility Barthel ADL Psychologic Happiness Life Satisfaction Depression UCLA Loneliness Quality of life SF-12 Physical SF-12 Mental
Pain Group (n ¼ 396)
No-Pain Group (n ¼ 139)
p Value
15.66 4.79 17.55 3.97
16.16 5.27 17.87 3.86
.306 .414
18.10 5.99 9.47 4.27 6.36 3.99 40.83 11.74
19.34 5.72 10.68 4.05 5.35 3.74 40.02 11.96
.034* .003* .009* .508
34.34 9.88 57.36 7.63
45.11 8.72 58.79 5.87
.000* .122
*p < .05 was considered to be statistically significant. Independent t test was used.
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TABLE 6. Correlations Between Pain/Physical/Psychologic and Significant Demographic Data in the Pain Group (n ¼ 396) Sex Pain intensity Knees Back Shoulders Multiple joints Neck Ankles Hips All Psychologic Happiness Loneliness Life satisfaction Depression Physical Barthel index Elderly mobility Quality of life Physical Mental
Marital Status
Education Level
Years in Nursing Home
Sleep Hours
Use of Drugs
Use of Nondrug Methods
0.129* 0.054 0.148* 0.157* 0.050 0.110* 0.021 0.094
0.064 0.020 0.041 0.051 0.001 0.031 0.043 0.075
0.012 0.039 0.007 0.003 0.029 0.009 0.039 0.020
0.131**
0.260**
0.012 0.175* 0.087 0.055
0.010 0.149** 0.022 0.042
0.170** 0.139** 0.137** 0.068
0.080 0.048 0.067 0.009
0.028 0.091 0.002 0.045
0.013 0.031 0.036 0.019
0.031 0.029
0.083 0.048
0.113* 0.032
0.162** 0.069
0.006 0.076
0.089 0.122
0.125* 0.020
0.097 0.074
0.107* 0.092 0.107* 0.103* 0.064 0.056 0.072 0.041
0.089 0.049 0.090 0.104* 0.139* 0.078 0.002 0.038
0.118* 0.030 0.032 0.057
0.034 0.098
0.105 0.015
0.161** 0.172**
0.059 0.051
0.063 0.098
0.162** 0.127*
Spearman rho correlation (r) was used. *p # .05. **p < .01.
pain may have an impact on physical and psychologic health and quality of life among older persons, which can be the cause of unnecessary hospital admission and thus lead to stress placed on the acute care hospital. In this study, the older persons suffering from
pain had poor sleep habits, less happiness and life satisfaction, and greater depression, and they scored lower in the physical components of quality of life. In the study, 45% of the older persons in the pain group reported having pain all the time. According
TABLE 7. Correlations Between Physical/Psychologic and Significant Demographic Data in the No-Pain Group (n ¼ 139)
Pain intensity Psychologic Happiness Loneliness Life satisfaction Depression Physical Barthel index Elderly mobility Quality of life Physical Mental
Gender
Marital Status
Education Level
Years in Nursing Home
Sleep Hours
—
—
—
—
—
0.064 0.008 0.052 0.024
0.070 0.013 0.059 0.091
0.024 0.077 0.061 0.030
0.087 0.165 0.174* 0.229**
0.017 0.193* 0.137 0.047
0.120 0.031
0.024 0.053
0.071 0.129
0.057 0.012
0.135 0.126
0.104 0.015
0.125 0.065
0.063 0.010
0.038 0.215
0.062 0.189
Spearman rho correlation (r) was used. *p # .05. **p < .01.
TABLE 8. Correlations Among Total (n ¼ 535), Pain Group (n ¼ 396), and No-Pain Group (n ¼ 139) to Psychologic and Physical Parameters Happiness Scale r
Life Satisfaction
Geriatric Depression Scale
Barthel ADL
Total Mobility
p Value
r
p Value
r
p Value
r
p Value
r
p Value
r
p Value
.029* .041*
0.025 0.060
.557 .232
0.121 0.118
.005* .019*
0.110 0.118
.011* .019*
0.099 0.070
.022* .162
0.105 0.159
.015* .002*
— — —
0.574 0.589 0.535
.000* .000* .000*
0.640 0.663 0.518
.000* .000* .000*
0.651 0.676 0.544
.000* .000* .000*
0.230 0.254 0.136
.000* .000* .000*
0.235 0.261 0.121
.000* .000* .000*
0.551 0.577 0.472
.000* .000* .000*
0.530 0.555 0.460
.000* .000* .000*
0.187 0.207 0.133
.000* .000* .118
0.176 0.210 0.071
.000* .000* .407
0.764 0.775 0.706
.000* .000* .000*
0.331 0.344 0.284
.000* .000* .001*
0.334 0.352 0.272
.000* .000* .001*
0.347 0.354 0.289
.000* .000* .001*
0.359 0.365 0.281
.000* .000* .001*
.000* .000* .000*
1.000 1.000 1.000
— — —
.000* .000* .000*
0.551 0.577 0.472
.000* .000* .000*
1.000 1.000 1.000
.000* .000* .000*
0.530 0.555 0.460
.000* .000* .000*
0.764 0.775 0.706
.000* .000* .000*
1.000 1.000 1.000
.000* .000* .000*
0.187 0.207 0.133
.000* .000* .118
0.331 0.344 0.284
.000* .000* .001*
0.374 0.354 0.289
.000* .000* .001*
1.000 1.000 1.000
— — —
0.714 0.771 0.692
.000* .000* .000*
.000* .000* .000*
0.176 0.210 0.071
.000* .000* .407
0.334 0.352 0.272
.000* .000* .001*
0.359 0.365 0.281
.000* .000* .001*
0.714 0.711 0.692
.000* .000* .000*
1.000 1.000 1.000
— — —
— — —
— — —
Pain and Quality of Life in Nursing Homes
Pain status Total 0.094 Pain group .103 Happiness Scale Total 1.000 Pain group 1.000 No-pain group 1.000 UCLA Loneliness Scale Total 0.574 Pain group 0.589 No-pain group 0.535 Life Satisfaction Index Total 0.640 Pain group 0.663 No-pain group 0.518 Geriatric Depression Scale Total 0.651 Pain group 0.676 No-pain group 0.544 Barthel ADL Total 0.230 Pain group 0.254 No-pain group 0.136 Total Mobility Total 0.235 Pain group 0.261 No-pain group 0.121
UCLA Loneliness
Spearman rho correlation (r) was used. Guideline (Cohen, 1988): r ¼ 0.10-0.29 or 0.10 to 0.29 / small; r ¼ 0.30-0.49 or 0.30 to 0.49 / medium; r ¼ 0.50-1.00 or 0.50 to 1.00 / large. *p < .01 was considered to be statistically significant.
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to Leveille, Jones, Kiely, Hausdorff, Shmerling, Guralnik,.....& Bean (2009), older persons with chronic musculoskeletal pain at more than one site were significantly more likely to experience a fall. Mamun and Lim (2009) suggested that falls could be reduced with appropriate use of analgesics to relieve pain. Owing to the various impacts of chronic pain, there is an urgent need for health care professionals to focus on pain management among older adults, especially in nursing homes. The initial pain management may start from pain assessment among the staff in nursing homes or self-reporting pain diaries by older persons, which would reduce the underrecognized pain situation among the elderly, thus enabling caregivers to determine how to manage the pain and suffering of older residents in a timely fashion (Chapman, 2010; Gran, Festvag, & Landmark, 2009; Hadjistavropoulos & Fine, 2006; Hager & Brockopp, 2007; Tsai, Chu, Lai, & Chen, 2008). Nurses and caregivers need to undergo continuing education on pain management, because they play an important role in pain management in homes for the aged. Timely and appropriate pain management can reduce suffering among older persons (Tse & Chan, 2004). It is usually physicians who prescribe oral analgesics, if necessary, for older residents, so that nurses administer them only after appropriate pain assessment of the older person (Mezinskis, Keller, & Luggen, 2004).To advocate for the needs of patients, nurses have to observe and report the effects and/or adverse effects of oral analgesics among their patients during physicians’ consultation. Therefore, nurses need to pay more attention to older residents’ needs and listen to their pain-related concerns during daily activities (Higgins, Madjar, & Walton, 2004). The use of oral analgesics and nondrug therapy for pain management was effective, familiar, less toxic, and more acceptable to older persons. Physiotherapy and physical exercise can be helpful for their pain management, and they are also valued for their ability to improve physical functioning, quality of life, and a person’s ability to maintain independence (Rydwik, Kerstin, Akner, 2005; Scudds & Scudds, 2005; Tse, Wan, & Ho, 2011). Multisensory stimulation also had an effect on pain among older persons (Tse, 2010; Tse & Ho, 2010). Furthermore, some studies have
supported the use of cognitive behavior therapy in chronic pain management (Johnson & Kazantzis, 2004; Kazantzis, Pachana, & Sceker, 2003; Morley, Eccleston, & Williams, 1998). In addition, Clark (1999) recalled that the total pain concept introduced by Dame Cicely Saunders should include physical, psychologic, social, emotional, and spiritual elements. Therefore, multidisciplinary pain management must include geriatricians, primary care physicians, nurses, physical therapists, occupational therapists, social workers, and other professionals to provide multifaceted interventions to older persons with pain (Katz, Scherer, & Gibson, 2005). The present study represents nursing home residents that were able to communicate and were aware of time, place, and persons; those who were cognitively impaired and/or unable to communicate orally were not included, which constitutes a limitation. Other limitations were that data were collected using orally administered instruments, except for the physical parameters. This meant that older persons unable to express themselves could not participate in the present study. In future studies, nursing home residents that are unable to communicate or are cognitively impaired could be the target populations, and relevant instruments and tools could be used.
CONCLUSION Older persons in residential care have limited methods of receiving health information, so they depend on nurse and caregiver support in the nursing home. Therefore, training and continued education among staff in nursing homes is essential to improve nursing practices that reduce the physical and psychologic suffering among nursing home residents, enabling them to enjoy their later life in nursing homes. Acknowledgments The authors thank all of the study participants. Thanks also to Professors Robert Kane, Rosaline Kane, and Kerry Lam for their tremendous input in the study. Special thanks go to Cadenza: a Jockey Club Initiative for Seniors, Hong Kong Jockey Club Charities Trust, for providing financial support for this study.
REFERENCES Albert, S. M., & Freedman, V. A. (2010). Public health and aging: Maximizing function and well-being, (2nd ed.) New York: Springer.
American Geriatrics Society Panel (1998). The management of chronic pain in older persons. AGS Panel on Chronic Pain in Older Persons, 46(5), 635–651.
Pain and Quality of Life in Nursing Homes
Census and Statistics Department (2008). Hong Kong 2006 population by census thematic report: Older persons. Retrieved February 1, 2010, from http://www.censtatd.gov. hk/freedownload.jsp?file¼publication/stat_report/popula tion/B11200532006XXXXB0100.pdf&title¼HongþKongþ 2006þPopulationþBy-censusþThematicþReportþ%3aþ OlderþPersons&issue¼-&lang¼1&c¼1 Chan, A. C. M. (1996). Clinical validation of the Geriatric Depression Scale (GDS). Journal of Aging and Health(8), 238–253. Chapman, S. (2010). Managing pain in the older person. Nursing Standard, 25(11), 35–39. Chi, I., & Boey, K. W. (1992). Validation of measuring instruments of mental health status of the older in Hong Kong. Department of Social Work & Social Administration, University of Hong Kong. Chou, K. L., Jun, L. W., & Chi, I. (2005). Assessing Chinese older adults’ suicidal ideation: Chinese version of the geriatric suicide ideation scale. Aging and Mental Health, 9(Suppl. 2), 167–171. Clark, D. (1999). ‘ Total pain,’’ disciplinary power and the body in the work of Cicely Saunders, 1958-1967. Social Science & Medicine, 49, 727–736. Clarke, A., & Ryan, T. (2007). Creaking joints, a bit of arthritis, and aches and pains: Older people’s experiences and perceptions of pain. In P. Schofield (Ed.), The management of pain in older people (pp. 49–63). John Wiley & Sons. Ferrell, B. A. (1995). Pain evaluation and management in the nursing home. Annals of Internal Medicine, 123, 681–687. Flaherty, E. (2008). Using pain-rating scales with older adults. American Journal of Nursing, 108(6), 40–47. Gran, S. V., Festvag, L. S., & Landmark, B. T. (2009). ‘Alone with my pain—It can not be explained, it has to be experienced.’’ A Norwegian in-depth interview study of pain in nursing home residents. International Journal of Older People Nursing, 5, 25–33. Hadjistavropoulos, T., & Fine, P. G. (2006). Chronic pain in older persons: Prevalence, assessment and management. Clinical Gerontology, 16, 231–241. Hager, K. K., & Brockopp, D. (2007). Pilot project: The chronic pain diary. Journal of Gerontological Nursing, 2007, 14–19. Helme, R. D., & Gibson, S. J. (2001). The epidemiology of pain in older people. Clinics in Geriatric Medicine, 17, 417–431. Higgins, I., Madjar, I., & Walton, J. A. (2004). Chronic pain in older nursing home residents: The need for nursing leadership. Journal of Nursing Management, 12, 167–173. Johnson, M. H., & Kazantzis, N. (2004). Cognitive behavioral therapy for chronic pain: Strategies for the successful use of homework assignments. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 22(3), 189–218. Jones, K. R., Vojir, C. P., Hutt, E., & Fink, R. (2007). Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents. Journal of Rehabilitation Research & Development, 44(2), 305–314. Katz, B., Scherer, S., & Gibson, S. J. (2005). Multidisciplinary pain management clinics for older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 309–326). Seattle: International Association for the Study of Pain. Kazantzis, N., Pachana, N. A., & Secker, D. L. (2003). Cognitive behavioural therapy for older adults: Practical
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guidelines for the use of homework assignments. Cognitive and Behavioral Practice, 10, 324–332. Kurlowicz, L., & Greenberg, S. A. (2007). The Geriatric Depression Scale (GDS). Retrieved May 12, 2010, from http://consultgerirn.org/uploads/File/trythis/issue04.pdf. Lam, L. K., Tse, Y. Y., & Gandek, B. (2005). Is the standard SF-12 Health Survey valid and equivalent for a Chinese population? Quality of Life Research, 14, 539–547. Leung, E., & Lo, M. (1997). Social and health status of older people in Hong Kong. In S. K. Lam (Ed.), The health of the older in Hong Kong (pp. 43–61). Hong Kong: Hong Kong University Press. Leveille, S. G., Jones, R. N., Kiely, D. K., Hausdorff, J. M., Shmerling, R. H., Guralnik, J. M., Kiel, D. P., Lipsitz, L. A., & Bean, J. F. (2009). Chronic musculoskeletal pain and the occurrence of falls in an older population. The Journal of the American Medical Association, 302(20), 2214–2221. Lui, L. Y. Y., So, W. K. W., & Fong, D. Y. T. (2008). Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17, 2014–2021. Lyubomirsky, S., & Lepper, H. (1999). A measure of subjective happiness: Preliminary reliability and construct validation. Social Indicators Research, 46, 137–155. Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 56–61. Mamun, K., & Lim, J. K. H. (2009). Association between falls and high-risk medication use in hospitalized Asian older patients. Geriatrics and Gerontology International, 9, 276–281. Mann, E., & Carr, E. (2006). Pain management. Oxford: Blackwell. Mezinskis, P. M., Keller, A. W., & Luggen, A. S. (2004). Assessment of pain in the cognitively impaired older adult in long-term care. Geriatric Nursing, 25(2), 107–112. Morley, S., Eccleston, C., & Williams, A. (1998). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1–13. Mui, A. C. (1996). Geriatric depression scale as a community screening instrument for older Chinese immigrants. International Psychogeriatrics, 8, 445–458. Murphy, K. (2007). The state of chronic pain in the older. Working With Older People, 11(2), 32–34. National Institutes of Health (2003). Pain intensity instruments. Available at: http://painconsortium.nih.gov/ pain_scales/NumericRatingScale.pdf (accessed 30 October 2010) Neugarten, B. L., Havighurst, R. J., & Tobin, S. S. (1961). The measurement of life satisfaction. Journal of Gerontology, 16, 134–143. Ng, M. F. W., Tong, R. K. Y., & Li, L. S. W. (2008). A pilot study of a randomized clinical controlled trial of gait training in subacute stroke patients with partial body-weight support electromechanical gait trainer and functional electrical stimulation: Six-month follow-up. Stroke, 39, 154–160. Prosser, L., & Canby, A. (1997). Further validation of EMS for measurement of the mobility of hospitalised older people. Clinical Rehabilitation, 11(4), 338–343. Russell, D. W. (1996). UCLA Loneliness Scale (version 3): Reliability, validity and factor structure. Journal of Personality Assessment, 66(Suppl. 1), 20–40. Rydwik, E., Kerstin, F., & Akner, G. (2005). Physical training in institutionalized older people with multiple
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diagnoses—a controlled pilot study. Archives of Gerontology and Geriatrics, 40, 29–44. Schofield, P. (2006). Pain management in care homes. Journal of Community Nursing, 20(6), 30–34. Scudds, R. J., & Scudds, R. A. (2005). Physical therapy approaches to the management of pain in older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 223–237). Seattle: International Association for the Study of Pain. Sidell, M. (1995). Health in old age: Myth, mystery and management. Buckingham: Open University Press. Shyu, Y. I. L., Liang, J., Wu, C. C., Su, J. Y., Cheng, H. S., Chou, S. W., Chen, M. C., & Yang, C. T. (2008). Interdisciplinary intervention for hip fracture in older Taiwanese: Benefits last for 1 year. Journal of Gerontology, 63(1), 92–97. Smith, R. (1994). Validation and reliability of the Older Mobility Scale. Physiotherapy, 80, 744–747. Social Welfare Department (2005). Residential care services for the older. Retrieved March 13, 2011, from http:// www.swd.gov.hk/en/index/site_pubsvc/page_older/sub_ residentia/id_introducti/. Sonja, L., & Heidi, S. L. (1999). A measure of subjective happiness: Preliminary reliability and construct validation. Social Indicators Research, 46, 137–155. Tsai, Y. F., Chu, T. L., Lai, Y. H., & Chen, W. J. (2008). Pain experiences, control beliefs and coping strategies in Chinese elders with osteoarthritis. Journal of Clinical Nursing, 17, 2596–2603.
Tse, M. M. Y. (2007). Nursing home placement: Perspectives of community-dwelling older persons. Journal of Clinical Nursing, 16, 911–917. Tse, M. (2010). Multisensory environments and their effect on pain. CyberTherapy & Rehabilitation, 3(1), 28–29. Tse, M. M. Y., & Chan, B. S. H. (2004). Knowledge and attitudes in pain management: Hong Kong nurses’ perspective. Journal of Pain & Palliative Care Pharmacotherapy, 18(1), 47–58. Tse, M. M. Y., & Ho, S. S. K. (2010). Management of chronic pain for older persons: A multisensory stimulation approach. Journal of CyberTherapy & Rehabilitation, 3(3), 313–323. Tse, M. M. Y., Wan, V. T. C., & Ho, S. S. K. (2011). Physical exercise: Does it help in relieving pain and increasing mobility among older adults with chronic pain? Journal of Clinical Nursing, 20, 635–644. Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item shortform health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233. Williams, L. (2007). Pain mismanagement. Nursing Homes, 56(6), 52–54. Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. B., & Leirer, V. O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. Yu, H. D., & Petrini, M. A. (2007). A survey of Chinese nurses’ current knowledge of pain in older people. Journal of Clinical Nursing, 16, 963–970.
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From the *School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong; †Prince Margaret Hospital, Kowloon, Hong Kong. Address correspondence to Mimi M. Y. Tse, RN, PhD, School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong. E-mail: [email protected] Received May 26, 2011; Revised October 14, 2011; Accepted October 17, 2011. 1524-9042/$36.00 Ó 2013 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2011.10.006
Mimi M. Y. Tse, RN, PhD,* Vanessa T. C. Wan, RN, MSc,† and Sinfia K. S. Vong, PT, MPhil*
ABSTRACT:
The purpose of this exploratory cross-sectional study was to explore the health-related profile and quality of life among older persons living with and without pain in nursing homes. Ten nursing homes were approached, and 535 older persons were invited to join the study from 2009 to 2011. The nursing home residents’ demographic information and information regarding their pain situation and the use of oral analgesic drug and nondrug therapy among the older residents with chronic pain were also collected. Residents’ physical health (using the Barthel Activities of Daily Living (ADL) and Elderly Mobility Scores); psychologic health, including happiness, life satisfaction, depression, and loneliness (using the Happiness Scale, the Life Satisfaction Scale, the Geriatric Depression Scale, and the UCLA Loneliness Scale); and quality of life were investigated. Among the 535 nursing home residents, 396 (74%) of them suffered from pain, with mean pain scores of 4.09 ± 2.19, indicating medium pain intensity a remaining 139 (26%) reported no pain. The location of pain was mainly in the knees, back and shoulders. Our results demonstrated that, with the exception of the no-pain group (p < .05), nursing home residents’ pain affected both their psychologic health, including happiness, life satisfaction, and depression, and their physical quality of life. Nevertheless, only one-half of the older persons with pain used oral analgesic drug or nondrug therapy to relieve their pain. Pain had a significant impact on their mobility and ADL, was positively correlated with happiness and life satisfaction, and was negatively correlated with loneliness and depression. Pain management is a high priority in elderly care; as such, innovative and interdisciplinary strategies are necessary to enhance quality of life particularly for older persons living in nursing homes. Ó 2013 by the American Society for Pain Management Nursing Older adults may have various physical impairments due to functional deterioration and/or suffering from chronic illness in the process of aging (Albert & Pain Management Nursing, Vol 14, No 4 (December), 2013: pp e173-e184
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Freedman, 2010; Leung & Lo, 1997; Sidell, 1995). As the proportion of older people increases, there will be an increase in the number of more dependent oldold, as well as a greater need for a higher level of care, including nursing home care (Williams, 2007). In Hong Kong, 10% of older persons live in institutions with residential care (Census and Statistics Department, Hong Kong, 2008). Residential care services for older adults aim to provide residential care and facilities for those aged $65 years who, for personal, social, health or other reasons, cannot be taken care of adequately at home. Persons aged 60-64 years can receive residential care if there is a proven need (Social Welfare Department, 2005). In a recent study by Tse (2007), Chinese older persons expressed that living in a nursing home rendered them insecure, lonely, feeling abandoned by their family members, and full of suffering. Indeed, many older persons suffered a great deal when they had to make the decision to live in a nursing home, because it was expected to be the final destination in their earthly journey. Besides distress from chronic diseases, nearly 45%80% of nursing home residents suffer from pain (American Geriatric Society Panel on Chronic Pain in Older Persons, 1998; Ferrell, 1995; Helme & Gibson, 2001; Williams, 2007). Indeed, the pain condition among older residents may be caused by their reluctance to report pain, their acceptance of pain as part of aging, and/or their fear of using pharmacologic interventions (Schofield, 2006). Low expectations from medical staff and their lack of awareness of pain relief strategies may be another reason (Higgins, Madjar, & Walton, 2004; Murphy, 2007; Schofield, 2006). With these pain beliefs and lack of knowledge, the pain condition among older residents may become worse. Pain can cause inactivity and progressive disability in older persons, as well as social isolation and decreased quality of sleep and appetite. Older persons with pain may also suffer loneliness, loss, helplessness, and depression (Gran, Festvag, & Landmark, 2009; Murphy, 2007). Indeed, inadequate pain management may have a consequent cost to health and social services. In view of the increase of the ageing population, the purpose of the present study was to explore the health-related profile and quality of life among older persons living with and without pain in nursing homes. It was hoped that more information about older adults would be collected and consequently that better pain control methods or interventions could be tailor made for residents. In the present study, health-related profile included the presence and intensity of pain, physical health parameters, psychologic health parameters, and quality of life.
METHODS Design and Sample This study used an exploratory cross-sectional design. After gaining approval from the Ethics Committee of the university, ten nursing homes, including two private and eight nongovernment organizations in different districts of Hong Kong, were invited to participate in the study. A total of 535 older residents were recruited as a convenience sample. Written consent was obtained from each of the participants. The inclusion criteria of the residents were age $60 years, ability to communicate in Cantonese, and awareness of time, place, and persons. The researcher would start ‘‘small’’ talk with the residents by asking the date, time, and place and see whether these residents could understand these questions and were able to provide correct answers/responses orally. The exclusion criteria were having been in the nursing home for 101 years, with a mean age of 85.17 6.48 years. The majority (69.1%) of the participants were
Pain intensity and pain site (mean SD) for the pain group (n ¼ 396).
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widowed, many (39.4%) had been in nursing homes for 1-3 years, and many (35.1%) received visits from family members every week. More than one-half of the nursing home residents had received no formal education. Their major underlying medical problems included hypertension (65.4%), cataract (43.7%), heart disease (29.5%), history of cerebrovascular accident (24.7%), and arthritis (22.6%). For the pain group, Table 2 shows that 45.7% (n ¼ 181) of them reported experiencing pain all the time. Figure 1 shows that 396 participants reported having experienced pain and had a mean pain score of 4.09 2.19 (on a 0–10-point scale), the most severe pain sites being the ankles, multiple joints, and hips. Nevertheless, only one-half of the older residents used oral analgesic drug or nondrug therapy for pain management. Furthermore, one-fourth of them did not use any pharmacologic or nonpharmacologic methods to relieve their pain (Tables 3 and 4). Physical and Psychologic Health Table 5 presents the physical and psychologic parameters for the pain and no-pain groups. In physical health, there were no significant differences in mobility or ADL for the pain and no-pain groups (p > .05). However, pain had a great impact on the psychologic health of the older adults. It was found that older adults in the pain group had significantly lower happiness and life satisfaction scores; also, they were more depressed than their counterparts without pain (p < .05). In addition, significant differences were found in the physical component of quality of life between the pain and nopain groups (p < .05), with the pain group reporting a significantly lower physical component of quality of life. Correlation Tables 6-8 present the correlation of pain intensity and various physical and psychologic parameters among participants in the pain and no-pain groups. Spearman correlation was used to measure the demographic data and physical and psychologic parameters. There were various correlations between sex, marital status, education level, length of time in nursing home, use of oral drug and nondrug strategies, physical and psychologic parameters, and quality of life in both groups. For the pain group, more significant positive correlations were found between education level and loneliness; years in nursing home and happiness, life satisfaction, and ADL; use of oral analgesics and physical health, including mobility and ADL; and use of nondrug therapy and the physical component of quality of life (p < .01). Significant negative correlations were also noted between length of time in nursing homes
TABLE 3. Use of Oral Analgesic Drugs/Nondrug Therapy in the Pain Group (n ¼ 396)
Use of oral analgesic drug Yes Type of oral analgesic drug used Panadol Dologesic Dologesic & Panadol Niclofen Na Allopurinol & Aspirin Niclofen Na & Dologsic Allopurinol Naproxen Aspirin Dihydrocodeine tartrate Panadol & Tramadol Allopurinol & Niclofen Na Allopurinol & Naproxen No Use of nondrug therapy methods Yes Type of nondrug therapy used Topical ointment Massage Resting Physiotherapy Hot pad Watching TV Listening to music Chatting to friends Deep breathing Cold pad No
n
(%)
201
(50.8)
196 64 10 9 8 4 7 3 15 1 1 1 1 195
(49.5) (16.2) (2.5) (2.3) (2.0) (1.0) (1.8) (0.8) (3.8) (0.3) (0.3) (0.3) (0.3) (49.2)
308
(57.6)
268 99 36 30 27 13 7 5 5 4 227
(67.7) (25.0) (9.1) (7.6) (6.8) (3.3) (1.8) (1.3) (1.3) (1.0) (42.4)
and loneliness; and pain intensity and the use of pharmacologic and nonpharmacologic therapy (p < .01). However, for the no-pain group, the only negative correlation was found between duration in nursing home and depression (p < .01). In Table 8, physical parameters such as ADL and mobility were significantly correlated with psychologic parameters, including happiness, loneliness, life satisfaction, and depression, among all of the older residents (both pain and no-pain groups; p < .05). In addition, negative correlations were found in pain and depression, and positive correlations were found in pain and physical parameters, including ADL and mobility, happiness, and life satisfaction, for participants in both the pain and the no-pain groups. In comparing the pain and no-pain groups, the only significant correlation noted for the pain group was that their physical parameters were negatively correlated with loneliness, indicating that pain may affect
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Pain and Quality of Life in Nursing Homes
TABLE 4. Different Kinds of Pain-Relieving Treatments Total (n ¼ 535)
Analgesic drugs & nondrug methods Analgesic drugs only Nondrug methods only Neither analgesic drugs nor nondrug therapy
Without Pain (n ¼ 139)
With Pain (n ¼ 396)
n
(%)
n
(%)
Pain Intensity
n
(%)
p Value
173
(32.3%)
171
(43.2%)
4.52 2.11
2
(1.4%)
.000*
73 134 135
(13.6%) (25.0%) (25.2%)
44 129 49
(11.1%) (32.6%) (12.4%)
3.58 2.10 4.06 2.31 3.03 1.90
29 5 86
(20.9%) (3.6%) (61.9%)
.004* .000* .000*
*p < .05 was considered to be statistically significant.
the physical ability of older adults, which may in turn increase their feelings of loneliness.
DISCUSSION In this study, >75% (n ¼ 402) of the nursing home residents were aged $81 years and were thus old-old and widowed. Most of them had one or more chronic illnesses, and >80% in the pain group had arthritis, which is frequently a cause of musculoskeletal pain. Comprehensive care, including feeding, toileting, grooming, dressing, bathing, and limited recreation and physical exercise, was provided by nursing home staff to their residents. However, as a result of the aging process, the deterioration of functioning and the onset of chronic illnesses, as well as suffering from chronic pain, life for these nursing home residents was quite difficult. In the present study, >70% (n ¼ 396) of the nursing home residents were suffering from pain. Nevertheless, the pain management strategies used by older adults were found to be inadequate. Only 50%
of them used oral analgesic drugs, and 50% used nondrug therapy methods, including topical ointment, massage, and physiotherapy. It was disturbing to find that 12.4% of older residents had a pain intensity of 3.03 1.90 yet were using neither analgesic drugs nor nondrug strategies to relieve pain. The reasons for the inadequate use of pain relief methods could be explained by older residents themselves as well as the nursing home staff and physicians. Older persons may consider pain to be a normal part of ageing, and some may be reluctant to seek help in the nursing home or are afraid of the adverse effects of analgesics (Schofield, 2006). Nursing staff may also misunderstand the pain suffering of older persons or lack sufficient knowledge in pain management (Higgins, Madjar, & Walton, 2004; Lui, So, & Fong, 2008; Yu & Petrini, 2007). Physicians may hesitate to prescribe oral analgesics, and they rarely review the effects of medication (Murphy, 2007). Given the various barriers to pain management, chronic pain is a major problem among older persons (Mann & Carr, 2006; Clarke & Ryan, 2007). Unrelieved
TABLE 5. Physical and Psychologic Parameters (n ¼ 535), Mean ± SD
Physical Elderly Mobility Barthel ADL Psychologic Happiness Life Satisfaction Depression UCLA Loneliness Quality of life SF-12 Physical SF-12 Mental
Pain Group (n ¼ 396)
No-Pain Group (n ¼ 139)
p Value
15.66 4.79 17.55 3.97
16.16 5.27 17.87 3.86
.306 .414
18.10 5.99 9.47 4.27 6.36 3.99 40.83 11.74
19.34 5.72 10.68 4.05 5.35 3.74 40.02 11.96
.034* .003* .009* .508
34.34 9.88 57.36 7.63
45.11 8.72 58.79 5.87
.000* .122
*p < .05 was considered to be statistically significant. Independent t test was used.
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TABLE 6. Correlations Between Pain/Physical/Psychologic and Significant Demographic Data in the Pain Group (n ¼ 396) Sex Pain intensity Knees Back Shoulders Multiple joints Neck Ankles Hips All Psychologic Happiness Loneliness Life satisfaction Depression Physical Barthel index Elderly mobility Quality of life Physical Mental
Marital Status
Education Level
Years in Nursing Home
Sleep Hours
Use of Drugs
Use of Nondrug Methods
0.129* 0.054 0.148* 0.157* 0.050 0.110* 0.021 0.094
0.064 0.020 0.041 0.051 0.001 0.031 0.043 0.075
0.012 0.039 0.007 0.003 0.029 0.009 0.039 0.020
0.131**
0.260**
0.012 0.175* 0.087 0.055
0.010 0.149** 0.022 0.042
0.170** 0.139** 0.137** 0.068
0.080 0.048 0.067 0.009
0.028 0.091 0.002 0.045
0.013 0.031 0.036 0.019
0.031 0.029
0.083 0.048
0.113* 0.032
0.162** 0.069
0.006 0.076
0.089 0.122
0.125* 0.020
0.097 0.074
0.107* 0.092 0.107* 0.103* 0.064 0.056 0.072 0.041
0.089 0.049 0.090 0.104* 0.139* 0.078 0.002 0.038
0.118* 0.030 0.032 0.057
0.034 0.098
0.105 0.015
0.161** 0.172**
0.059 0.051
0.063 0.098
0.162** 0.127*
Spearman rho correlation (r) was used. *p # .05. **p < .01.
pain may have an impact on physical and psychologic health and quality of life among older persons, which can be the cause of unnecessary hospital admission and thus lead to stress placed on the acute care hospital. In this study, the older persons suffering from
pain had poor sleep habits, less happiness and life satisfaction, and greater depression, and they scored lower in the physical components of quality of life. In the study, 45% of the older persons in the pain group reported having pain all the time. According
TABLE 7. Correlations Between Physical/Psychologic and Significant Demographic Data in the No-Pain Group (n ¼ 139)
Pain intensity Psychologic Happiness Loneliness Life satisfaction Depression Physical Barthel index Elderly mobility Quality of life Physical Mental
Gender
Marital Status
Education Level
Years in Nursing Home
Sleep Hours
—
—
—
—
—
0.064 0.008 0.052 0.024
0.070 0.013 0.059 0.091
0.024 0.077 0.061 0.030
0.087 0.165 0.174* 0.229**
0.017 0.193* 0.137 0.047
0.120 0.031
0.024 0.053
0.071 0.129
0.057 0.012
0.135 0.126
0.104 0.015
0.125 0.065
0.063 0.010
0.038 0.215
0.062 0.189
Spearman rho correlation (r) was used. *p # .05. **p < .01.
TABLE 8. Correlations Among Total (n ¼ 535), Pain Group (n ¼ 396), and No-Pain Group (n ¼ 139) to Psychologic and Physical Parameters Happiness Scale r
Life Satisfaction
Geriatric Depression Scale
Barthel ADL
Total Mobility
p Value
r
p Value
r
p Value
r
p Value
r
p Value
r
p Value
.029* .041*
0.025 0.060
.557 .232
0.121 0.118
.005* .019*
0.110 0.118
.011* .019*
0.099 0.070
.022* .162
0.105 0.159
.015* .002*
— — —
0.574 0.589 0.535
.000* .000* .000*
0.640 0.663 0.518
.000* .000* .000*
0.651 0.676 0.544
.000* .000* .000*
0.230 0.254 0.136
.000* .000* .000*
0.235 0.261 0.121
.000* .000* .000*
0.551 0.577 0.472
.000* .000* .000*
0.530 0.555 0.460
.000* .000* .000*
0.187 0.207 0.133
.000* .000* .118
0.176 0.210 0.071
.000* .000* .407
0.764 0.775 0.706
.000* .000* .000*
0.331 0.344 0.284
.000* .000* .001*
0.334 0.352 0.272
.000* .000* .001*
0.347 0.354 0.289
.000* .000* .001*
0.359 0.365 0.281
.000* .000* .001*
.000* .000* .000*
1.000 1.000 1.000
— — —
.000* .000* .000*
0.551 0.577 0.472
.000* .000* .000*
1.000 1.000 1.000
.000* .000* .000*
0.530 0.555 0.460
.000* .000* .000*
0.764 0.775 0.706
.000* .000* .000*
1.000 1.000 1.000
.000* .000* .000*
0.187 0.207 0.133
.000* .000* .118
0.331 0.344 0.284
.000* .000* .001*
0.374 0.354 0.289
.000* .000* .001*
1.000 1.000 1.000
— — —
0.714 0.771 0.692
.000* .000* .000*
.000* .000* .000*
0.176 0.210 0.071
.000* .000* .407
0.334 0.352 0.272
.000* .000* .001*
0.359 0.365 0.281
.000* .000* .001*
0.714 0.711 0.692
.000* .000* .000*
1.000 1.000 1.000
— — —
— — —
— — —
Pain and Quality of Life in Nursing Homes
Pain status Total 0.094 Pain group .103 Happiness Scale Total 1.000 Pain group 1.000 No-pain group 1.000 UCLA Loneliness Scale Total 0.574 Pain group 0.589 No-pain group 0.535 Life Satisfaction Index Total 0.640 Pain group 0.663 No-pain group 0.518 Geriatric Depression Scale Total 0.651 Pain group 0.676 No-pain group 0.544 Barthel ADL Total 0.230 Pain group 0.254 No-pain group 0.136 Total Mobility Total 0.235 Pain group 0.261 No-pain group 0.121
UCLA Loneliness
Spearman rho correlation (r) was used. Guideline (Cohen, 1988): r ¼ 0.10-0.29 or 0.10 to 0.29 / small; r ¼ 0.30-0.49 or 0.30 to 0.49 / medium; r ¼ 0.50-1.00 or 0.50 to 1.00 / large. *p < .01 was considered to be statistically significant.
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to Leveille, Jones, Kiely, Hausdorff, Shmerling, Guralnik,.....& Bean (2009), older persons with chronic musculoskeletal pain at more than one site were significantly more likely to experience a fall. Mamun and Lim (2009) suggested that falls could be reduced with appropriate use of analgesics to relieve pain. Owing to the various impacts of chronic pain, there is an urgent need for health care professionals to focus on pain management among older adults, especially in nursing homes. The initial pain management may start from pain assessment among the staff in nursing homes or self-reporting pain diaries by older persons, which would reduce the underrecognized pain situation among the elderly, thus enabling caregivers to determine how to manage the pain and suffering of older residents in a timely fashion (Chapman, 2010; Gran, Festvag, & Landmark, 2009; Hadjistavropoulos & Fine, 2006; Hager & Brockopp, 2007; Tsai, Chu, Lai, & Chen, 2008). Nurses and caregivers need to undergo continuing education on pain management, because they play an important role in pain management in homes for the aged. Timely and appropriate pain management can reduce suffering among older persons (Tse & Chan, 2004). It is usually physicians who prescribe oral analgesics, if necessary, for older residents, so that nurses administer them only after appropriate pain assessment of the older person (Mezinskis, Keller, & Luggen, 2004).To advocate for the needs of patients, nurses have to observe and report the effects and/or adverse effects of oral analgesics among their patients during physicians’ consultation. Therefore, nurses need to pay more attention to older residents’ needs and listen to their pain-related concerns during daily activities (Higgins, Madjar, & Walton, 2004). The use of oral analgesics and nondrug therapy for pain management was effective, familiar, less toxic, and more acceptable to older persons. Physiotherapy and physical exercise can be helpful for their pain management, and they are also valued for their ability to improve physical functioning, quality of life, and a person’s ability to maintain independence (Rydwik, Kerstin, Akner, 2005; Scudds & Scudds, 2005; Tse, Wan, & Ho, 2011). Multisensory stimulation also had an effect on pain among older persons (Tse, 2010; Tse & Ho, 2010). Furthermore, some studies have
supported the use of cognitive behavior therapy in chronic pain management (Johnson & Kazantzis, 2004; Kazantzis, Pachana, & Sceker, 2003; Morley, Eccleston, & Williams, 1998). In addition, Clark (1999) recalled that the total pain concept introduced by Dame Cicely Saunders should include physical, psychologic, social, emotional, and spiritual elements. Therefore, multidisciplinary pain management must include geriatricians, primary care physicians, nurses, physical therapists, occupational therapists, social workers, and other professionals to provide multifaceted interventions to older persons with pain (Katz, Scherer, & Gibson, 2005). The present study represents nursing home residents that were able to communicate and were aware of time, place, and persons; those who were cognitively impaired and/or unable to communicate orally were not included, which constitutes a limitation. Other limitations were that data were collected using orally administered instruments, except for the physical parameters. This meant that older persons unable to express themselves could not participate in the present study. In future studies, nursing home residents that are unable to communicate or are cognitively impaired could be the target populations, and relevant instruments and tools could be used.
CONCLUSION Older persons in residential care have limited methods of receiving health information, so they depend on nurse and caregiver support in the nursing home. Therefore, training and continued education among staff in nursing homes is essential to improve nursing practices that reduce the physical and psychologic suffering among nursing home residents, enabling them to enjoy their later life in nursing homes. Acknowledgments The authors thank all of the study participants. Thanks also to Professors Robert Kane, Rosaline Kane, and Kerry Lam for their tremendous input in the study. Special thanks go to Cadenza: a Jockey Club Initiative for Seniors, Hong Kong Jockey Club Charities Trust, for providing financial support for this study.
REFERENCES Albert, S. M., & Freedman, V. A. (2010). Public health and aging: Maximizing function and well-being, (2nd ed.) New York: Springer.
American Geriatrics Society Panel (1998). The management of chronic pain in older persons. AGS Panel on Chronic Pain in Older Persons, 46(5), 635–651.
Pain and Quality of Life in Nursing Homes
Census and Statistics Department (2008). Hong Kong 2006 population by census thematic report: Older persons. Retrieved February 1, 2010, from http://www.censtatd.gov. hk/freedownload.jsp?file¼publication/stat_report/popula tion/B11200532006XXXXB0100.pdf&title¼HongþKongþ 2006þPopulationþBy-censusþThematicþReportþ%3aþ OlderþPersons&issue¼-&lang¼1&c¼1 Chan, A. C. M. (1996). Clinical validation of the Geriatric Depression Scale (GDS). Journal of Aging and Health(8), 238–253. Chapman, S. (2010). Managing pain in the older person. Nursing Standard, 25(11), 35–39. Chi, I., & Boey, K. W. (1992). Validation of measuring instruments of mental health status of the older in Hong Kong. Department of Social Work & Social Administration, University of Hong Kong. Chou, K. L., Jun, L. W., & Chi, I. (2005). Assessing Chinese older adults’ suicidal ideation: Chinese version of the geriatric suicide ideation scale. Aging and Mental Health, 9(Suppl. 2), 167–171. Clark, D. (1999). ‘ Total pain,’’ disciplinary power and the body in the work of Cicely Saunders, 1958-1967. Social Science & Medicine, 49, 727–736. Clarke, A., & Ryan, T. (2007). Creaking joints, a bit of arthritis, and aches and pains: Older people’s experiences and perceptions of pain. In P. Schofield (Ed.), The management of pain in older people (pp. 49–63). John Wiley & Sons. Ferrell, B. A. (1995). Pain evaluation and management in the nursing home. Annals of Internal Medicine, 123, 681–687. Flaherty, E. (2008). Using pain-rating scales with older adults. American Journal of Nursing, 108(6), 40–47. Gran, S. V., Festvag, L. S., & Landmark, B. T. (2009). ‘Alone with my pain—It can not be explained, it has to be experienced.’’ A Norwegian in-depth interview study of pain in nursing home residents. International Journal of Older People Nursing, 5, 25–33. Hadjistavropoulos, T., & Fine, P. G. (2006). Chronic pain in older persons: Prevalence, assessment and management. Clinical Gerontology, 16, 231–241. Hager, K. K., & Brockopp, D. (2007). Pilot project: The chronic pain diary. Journal of Gerontological Nursing, 2007, 14–19. Helme, R. D., & Gibson, S. J. (2001). The epidemiology of pain in older people. Clinics in Geriatric Medicine, 17, 417–431. Higgins, I., Madjar, I., & Walton, J. A. (2004). Chronic pain in older nursing home residents: The need for nursing leadership. Journal of Nursing Management, 12, 167–173. Johnson, M. H., & Kazantzis, N. (2004). Cognitive behavioral therapy for chronic pain: Strategies for the successful use of homework assignments. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 22(3), 189–218. Jones, K. R., Vojir, C. P., Hutt, E., & Fink, R. (2007). Determining mild, moderate, and severe pain equivalency across pain-intensity tools in nursing home residents. Journal of Rehabilitation Research & Development, 44(2), 305–314. Katz, B., Scherer, S., & Gibson, S. J. (2005). Multidisciplinary pain management clinics for older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 309–326). Seattle: International Association for the Study of Pain. Kazantzis, N., Pachana, N. A., & Secker, D. L. (2003). Cognitive behavioural therapy for older adults: Practical
e183
guidelines for the use of homework assignments. Cognitive and Behavioral Practice, 10, 324–332. Kurlowicz, L., & Greenberg, S. A. (2007). The Geriatric Depression Scale (GDS). Retrieved May 12, 2010, from http://consultgerirn.org/uploads/File/trythis/issue04.pdf. Lam, L. K., Tse, Y. Y., & Gandek, B. (2005). Is the standard SF-12 Health Survey valid and equivalent for a Chinese population? Quality of Life Research, 14, 539–547. Leung, E., & Lo, M. (1997). Social and health status of older people in Hong Kong. In S. K. Lam (Ed.), The health of the older in Hong Kong (pp. 43–61). Hong Kong: Hong Kong University Press. Leveille, S. G., Jones, R. N., Kiely, D. K., Hausdorff, J. M., Shmerling, R. H., Guralnik, J. M., Kiel, D. P., Lipsitz, L. A., & Bean, J. F. (2009). Chronic musculoskeletal pain and the occurrence of falls in an older population. The Journal of the American Medical Association, 302(20), 2214–2221. Lui, L. Y. Y., So, W. K. W., & Fong, D. Y. T. (2008). Knowledge and attitudes regarding pain management among nurses in Hong Kong medical units. Journal of Clinical Nursing, 17, 2014–2021. Lyubomirsky, S., & Lepper, H. (1999). A measure of subjective happiness: Preliminary reliability and construct validation. Social Indicators Research, 46, 137–155. Mahoney, F. I., & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 56–61. Mamun, K., & Lim, J. K. H. (2009). Association between falls and high-risk medication use in hospitalized Asian older patients. Geriatrics and Gerontology International, 9, 276–281. Mann, E., & Carr, E. (2006). Pain management. Oxford: Blackwell. Mezinskis, P. M., Keller, A. W., & Luggen, A. S. (2004). Assessment of pain in the cognitively impaired older adult in long-term care. Geriatric Nursing, 25(2), 107–112. Morley, S., Eccleston, C., & Williams, A. (1998). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1–13. Mui, A. C. (1996). Geriatric depression scale as a community screening instrument for older Chinese immigrants. International Psychogeriatrics, 8, 445–458. Murphy, K. (2007). The state of chronic pain in the older. Working With Older People, 11(2), 32–34. National Institutes of Health (2003). Pain intensity instruments. Available at: http://painconsortium.nih.gov/ pain_scales/NumericRatingScale.pdf (accessed 30 October 2010) Neugarten, B. L., Havighurst, R. J., & Tobin, S. S. (1961). The measurement of life satisfaction. Journal of Gerontology, 16, 134–143. Ng, M. F. W., Tong, R. K. Y., & Li, L. S. W. (2008). A pilot study of a randomized clinical controlled trial of gait training in subacute stroke patients with partial body-weight support electromechanical gait trainer and functional electrical stimulation: Six-month follow-up. Stroke, 39, 154–160. Prosser, L., & Canby, A. (1997). Further validation of EMS for measurement of the mobility of hospitalised older people. Clinical Rehabilitation, 11(4), 338–343. Russell, D. W. (1996). UCLA Loneliness Scale (version 3): Reliability, validity and factor structure. Journal of Personality Assessment, 66(Suppl. 1), 20–40. Rydwik, E., Kerstin, F., & Akner, G. (2005). Physical training in institutionalized older people with multiple
e184
Tse, Wan, and Vong
diagnoses—a controlled pilot study. Archives of Gerontology and Geriatrics, 40, 29–44. Schofield, P. (2006). Pain management in care homes. Journal of Community Nursing, 20(6), 30–34. Scudds, R. J., & Scudds, R. A. (2005). Physical therapy approaches to the management of pain in older adults. In S. J. Gibson, & D. K. Weiner (Eds.), Pain in older persons (pp. 223–237). Seattle: International Association for the Study of Pain. Sidell, M. (1995). Health in old age: Myth, mystery and management. Buckingham: Open University Press. Shyu, Y. I. L., Liang, J., Wu, C. C., Su, J. Y., Cheng, H. S., Chou, S. W., Chen, M. C., & Yang, C. T. (2008). Interdisciplinary intervention for hip fracture in older Taiwanese: Benefits last for 1 year. Journal of Gerontology, 63(1), 92–97. Smith, R. (1994). Validation and reliability of the Older Mobility Scale. Physiotherapy, 80, 744–747. Social Welfare Department (2005). Residential care services for the older. Retrieved March 13, 2011, from http:// www.swd.gov.hk/en/index/site_pubsvc/page_older/sub_ residentia/id_introducti/. Sonja, L., & Heidi, S. L. (1999). A measure of subjective happiness: Preliminary reliability and construct validation. Social Indicators Research, 46, 137–155. Tsai, Y. F., Chu, T. L., Lai, Y. H., & Chen, W. J. (2008). Pain experiences, control beliefs and coping strategies in Chinese elders with osteoarthritis. Journal of Clinical Nursing, 17, 2596–2603.
Tse, M. M. Y. (2007). Nursing home placement: Perspectives of community-dwelling older persons. Journal of Clinical Nursing, 16, 911–917. Tse, M. (2010). Multisensory environments and their effect on pain. CyberTherapy & Rehabilitation, 3(1), 28–29. Tse, M. M. Y., & Chan, B. S. H. (2004). Knowledge and attitudes in pain management: Hong Kong nurses’ perspective. Journal of Pain & Palliative Care Pharmacotherapy, 18(1), 47–58. Tse, M. M. Y., & Ho, S. S. K. (2010). Management of chronic pain for older persons: A multisensory stimulation approach. Journal of CyberTherapy & Rehabilitation, 3(3), 313–323. Tse, M. M. Y., Wan, V. T. C., & Ho, S. S. K. (2011). Physical exercise: Does it help in relieving pain and increasing mobility among older adults with chronic pain? Journal of Clinical Nursing, 20, 635–644. Ware, J. E., Kosinski, M., & Keller, S. D. (1996). A 12-item shortform health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220–233. Williams, L. (2007). Pain mismanagement. Nursing Homes, 56(6), 52–54. Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M. B., & Leirer, V. O. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. Yu, H. D., & Petrini, M. A. (2007). A survey of Chinese nurses’ current knowledge of pain in older people. Journal of Clinical Nursing, 16, 963–970.
