UMSON Researcher Awarded $2.13M to Revolutionize Pain Management for Dementia Patients in Nursing Homes

Baltimore, Md. - Barbara Resnick, PhD ’96, RN, CRNP, FAAN, FAANP, professor, Sonya Ziporkin Gershowitz Chair in Gerontology, and associate dean for research at the University of Maryland School of Nursing (UMSON), has been awarded a five-year, $2.13 million grant from the National Institutes of Health’s National Institute on Aging to address the treatment of pain in nursing home residents with dementia. The focus of this work is how to implement use in nursing homes of the recently revised Pain Management Clinical Practice Guideline from AMDA — The Society of Post Acute and Long-Term Care.   

Findings from the study, “Testing the Pain Management Clinical Practice Guideline (Pain Management CPG)-Evidence Integration Triangle (EIT),” will explore how best to improve the way in which pain is assessed, diagnosed, and managed among older adults living with dementia in nursing homes and to improve health equity of aging populations experiencing pain.

“This research is critically important from two perspectives,” said Resnick, who also has been recognized as a University of Maryland, Baltimore (UMB) Distinguished University Professor. “First, the diagnosis and management of pain is a major issue for older adults living with dementia in nursing homes. The new clinical practice guideline for pain management developed by a team of us from the Society of Post-Acute and Long-Term Care Medicine serves as a wonderful resource to help improve the diagnosis and management of pain but only if it is implemented. Therefore, the second focus of this work is on demonstrating the efficacy of our approach for implementation of the guideline to change how staff diagnose and manage pain in nursing homes.”

There are evidence-based processes for assessment and management of pain using pharmacologic and nonpharmacological approaches. These were reviewed and included within the Pain Management CPG recently developed by AMDA. There are, however, many challenges to translating the use of the CPG into clinical settings, Resnick wrote in her grant proposal. To overcome these challenges, Resnick and her team developed and previously tested a theoretically based approach and merged this approach with the Pain Management CPG; the result is referred to as the PAIN-CPG-EIT. The PAIN-CPG-EIT involves a research nurse facilitator working with an identified community champion and stakeholder team for 12 months to provide the following four components:

• establishing and meeting monthly with a stakeholder team
• educating staff
• mentoring and motivating staff to address pain
• evaluating resident pain outcomes on an ongoing basis.

Resnick’s research team will be implementing guidelines using their approach in a clinical trial with 12 nursing homes, randomized to the use of either of two implementation approaches: Six communities will be randomized to treatment (PAIN-CPG-EIT) and six randomized to education only, which involves providing the same education to staff as is done as a component of PAIN-CPG-EIT.

Twenty-five residents with dementia and pain from each of the 12 nursing homes will be recruited to participate in the study. The primary aims are to evaluate the effectiveness of PAIN-CPG-EIT to improve the assessment, diagnosis, and management of pain and decrease pain intensity among the nursing home residents and to evaluate treatment fidelity, which is how treatments are delivered competently and as intended. A secondary aim of the study is to consider differences in measurement, treatment, and response to treatment between male and female and Black vs. white residents living with dementia. Although inconsistent, in some studies Black individuals living with dementia were more likely to have depression and sleep disturbances associated with pain and less likely to be treated for pain when compared to white individuals.

“This research impacts both residents and staff living and working in these communities,” Resnick said.

Pain is experienced by 30% - 80% of residents living with dementia in nursing homes, Resnick said. For those with moderate to severe dementia, verbal reporting of pain may not be reliable, and observational approaches are recommended, as pain in these individuals is more likely to present with facial expressions or behaviors such as aggression, agitation, or restlessness. Lack of accurate pain assessment results in untreated or over-treated pain.

Untreated pain can lower quality of life; negatively impact function; impair sleep; and increase depression, agitation, aggression, resistiveness to care, and use of psychotropic medications. Further, the evaluation, management, and treatment of pain are complicated by differences in pain sensitivity; verbal reporting; or presentation of pain among genders, races, and ethnicities.

The team anticipates that implementation and use of the Pain Management CPG will help staff to improve the assessment of pain among residents with dementia, diagnose the underlying cause of the pain, and improve management of pain in these individuals.

Findings from this study will provide a two-fold benefit, Resnick said.

“First of all, demonstrating use of the Pain Management Clinical Practice Guideline will show how to use it to improve pain management among older adults in nursing homes; and secondly, demonstrating the effectiveness of this approach will provide support that this model can be used to effectively disseminate the use of a similar approach to implement this and other clinical practice guidelines in nursing homes,” Resnick said.

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