Pain is underreported, underdiagnosed, and undertreated in elderly people, causing suffering, delayed diagnosis, and increased disability [8]. There are many reasons why this might be so including patient fear, failure to report pain (assumed to be part of growing older), concern about medication side effects, and insufficient provider educa- tion. Accurate pain assessment is essential if pain is to be managed effectively. This assessment can be even more challenging in the older adult with communication diffi- culties such as those with aphasia or cognitive impairment due to Alzheimer’s disease or other dementia. Nursing home residents may also have a delay in diagnosis because they may have atypical disease presentations, false-positive serologies, and/or multiple coexisting conditions that can confound the presentation and diagnosis.
Rheumatic diseases, disorders of joints and related struc- tures, are characterized by pain, inflammation, and degen- eration as well as metabolic and structural derangement.
Because these problems are common in older adults, his- tory and physical examination should be the mainstay of assessment of the arthritis in the frail elderly population [9]. We also know that the incidence of rheumatic disease, especially osteoarthritis, increases in frequency with increasing age. Osteoarthritis is probably the most com- monly seen rheumatic disease in nursing home residents and may occur in as many as 57% of all adults aged over 85 years [10]. In fact, as noted previously, osteoarthritis is so common as to not even be noted on many problem lists.
Monoarticular joint inflammation is also commonly seen in nursing home residents, frequently related to crystal arthropathy or sepsis. Arthrocentesis performed during the first 24–48 h of an acute flare is the gold standard for the diagnosis of any acute monoarthritis, but often an unrealistic option in the nursing home population. These residents may only be seen monthly or less by a health care provider who may not be comfortable with the procedure and who may not have immediate access to diagnostic laboratory testing. In this circumstance, these residents are often sent to the hospital emergency department for assessment and treatment. If a nursing home resident has fever or other signs of sepsis in addition to joint inflammation, a review of advance directives and care goals must be undertaken with the resident or health care proxy before a decision to treat or transfer is made.
75 8 Rheumatic Disease in the Nursing Home Patient
Many nursing home residents with advanced dementia or other chronic disabling disease have already determined that they would not want prolonged treatment with antibiotics and do not want further evaluation or transfer to hospital.
Many choose comfort measures even in the face of life-threatening infection.
Serologic studies should be reserved for the nursing home resident in whom an inflammatory disorder is suspected, such as sepsis, crystal arthropathy, rheumatoid arthritis, polymyalgia rheumatica, temporal arteritis, and systemic lupus erythematosus [11].
Pain Assessment
A comprehensive assessment of pain should include the identification of relevant underlying physical pathologies whenever possible and other conditions that may influence pain perception, reporting, and management.
The incidence of severe cognitive impairment in the nursing home population over the age of 65 years is estimated at >50%, with rates as high as 65% in smaller private facili- ties [12]. In addition to many other functional disabilities seen in these patients, severe dementia can impact a nursing home resident’s ability to report pain accurately. Although dementia itself is not specifically associated with pain, these nursing home residents are among the oldest and frailest often with the most comorbidities including musculoskeletal diseases as well as fractures, circulatory problems, hematol- ogy/oncology problems, and pressure ulcers [13]. This loss of ability to process, understand, and describe pain can often lead to behavioral expressions of distress including repetitive crying out or agitation [14].
Pain assessment tools are commonly used in the nursing home population. Self-reporting with descriptors is preferred and the use of a pain map or drawing may be helpful. Pain assessment tools designed specifically for the nursing home patient with communication difficulties include the faces pain scale (FPS) and the pain assessment in advanced demen- tia (PAINAD) scale. The vertical visual analog scale (VAS) and the verbal descriptor scale (VDS) have also been used successfully and compare favorably to each other [15, 16].
An equally important part of the history is the evaluation of comorbid conditions that influence pain perception and pain behavior. Especially common comorbid conditions in the nursing home population are cognitive impairment, mood disturbance, sleep disturbance, anxiety disorders, cardiovas- cular and cerebrovascular disease, and degenerative neuro- logic conditions. Clinicians should be aware that the physical environment in which a pain history is taken can also influ- ence pain reporting. For example, pain perception can be
increased by the anxiety induced by the physician’s assessment or by the presence or absence of family members.
Pain management is a goal often more important than the cause of the pain itself. Many nursing home residents and their families are less concerned about an accurate diagnosis than about assuring comfort. Of course, an accurate clinical diagnosis allows for more effective pain management; how- ever, we should always be aware of the treatment goals estab- lished by the resident or family. Many nursing home residents cannot or refuse to be transported to hospital for imaging studies or laboratory tests. In situations where the diagnosis is less clear, pain management is aimed at the safest and most effective approach for the individual.
Pharmacologic Management
Pharmacologic management of pain in nursing home resi- dents with rheumatic disease is complicated by the fact that there are, to date, no evidence-based studies specific to this issue. All information is extrapolated from guidelines for treating rheumatic diseases and criteria for prescribing medi- cation to elderly individuals. In general, try to avoid medica- tions that are considered inappropriate for use in elderly individuals, monitoring for side effects as well as drug–drug interactions and adherence to patient wishes and values.
Guidelines for treating pain are available from the American Pain Society and the American Geriatrics Society [16–18].
In general, using the lowest effective dose and increasing dosages slowly are prudent. Nursing home residents are par- ticularly at high risk for developing adverse events as the average nursing home resident in USA uses 7–8 different medications [18].
Nursing home residents with mild to moderate arthritis pain may experience significant relief with acetaminophen in divided, scheduled doses totaling no more than 4 g in 24 h, given normal renal and hepatic function. Patients can also be tried on extended release formulations, which have the added benefit of requiring fewer tablets. Acetaminophen is also available in both liquid and suppository forms, greatly enhancing options in patients with swallowing difficulties or those whose consciousness levels wax and wane.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat rheumatic diseases but can be poorly tolerated in older nursing home residents who are at higher risk of gastrointestinal (GI) bleeding. The risk of GI bleeding associated with NSAID use in a general popula- tion is about 1%. For those aged 60 years or older, the risk reaches 3–4%, and for those aged 60 years or older with a history of GI bleeding, the risk is about 9% [16].
Contraindications to the use of traditional NSAIDs include
a history of previous GI bleeding, the current use of warfarin or other anticoagulants, or a history of previous side effects to NSAIDs including acute confusion, conges- tive heart failure, or dizziness. The addition of misopros- tol, H2 blockers, or proton pump inhibitors can reduce the risk of GI bleeding, but adds to the overall risks associated with polypharmacy including falls and delirium and do not protect against adverse effects of NSAIDs on the liver or kidneys. Cox-2 selective drugs can offer some protection against bleeding and have no platelet effects, making them a safer option for patients taking warfarin [19]. For many patients, chronic opioid therapy, low-dose corticosteroid therapy (for those with inflammatory conditions), or other adjunctive drug strategies (e.g., the use of antidepressants or anticonvulsants for neuropathic pain) may have fewer life-threatening risks than does long-term daily use of high-dose NSAIDs.
Chronic low-dose opioid therapy can be a well-tolerated and safe alternative for vulnerable nursing home residents [20]. Small doses of oxycodone or long-acting oxycodone (oxycontin), and even small doses of morphine can be effec- tive with minimal side effects. Many nursing home residents find that fentanyl transdermal is effective and often associ- ated with fewer side effects. The most common adverse reac- tion to all narcotic medication is constipation, so standing bowel orders should be written at the same time. Other side effects include sedation, confusion, nausea, or decreased appetite. There is a higher risk of falling in patients taking opioids. Patients and families should be told of the potential for tolerance and the possible need for higher doses to achieve the same effect, but should be reassured regarding the extremely low likelihood of “addiction” in this population.
Fears of drug dependency and addiction are often politically exaggerated by the desire to reduce illicit drug use in the broader society. However, fears of drug dependency and addiction do not justify the failure to relieve pain, especially for those near the end of life.
Propoxyphene, a weak opioid, has been prescribed for decades to older patients. Its efficacy is no better than that of acetaminophen with all the adverse effects of a narcotic and, therefore, should be avoided in this population [21].
Low-dose steroids are another well-tolerated option in the frail elder population. The use of steroids in this population can provide immediate improvement in quality of life with- out the concern of long-term side effects; therefore, they are necessary in younger patients. The nursing home residents who experience inflammation related to rheumatoid arthritis, polymyalgia rheumatica, or crystal arthropathy often respond well to prednisone doses of <10 mg once a day with fewer side effects than with chronic NSAID use. Certainly, one should have an awareness of the bone density of nursing home residents taking long-term steroids, and caution should be used in diabetics.
Non-pharmacologic Management
Non-pharmacologic treatment of pain and rheumatic dis- ease in nursing home residents used in conjunction with pain relieving medication or alone can be an effective method for treating rheumatic pain in this population.
These approaches come with little risk other than cost and offer individualized, hands-on techniques offering comfort and reassurance to patients. There is a broad range of modalities available including physical and occupational therapy, group and individual exercise programs, therapeu- tic recreation programs that offer diversion and exercise, massage, acupuncture, relaxation techniques, chiropractic techniques, and cognitive behavior therapies.
The physical medicine therapies, including physical therapy and occupational therapy, are available in all nursing homes. These therapists are part of the interdisciplinary team and perform evaluations on newly admitted residents and upon referral. The core of this approach is physical modali- ties and exercise.
Cryotherapy (ice, chemical cold packs, and ice massage) can be very effective if used for the initial management of acute musculoskeletal and soft tissue problems including sprains, strains, bursitis and tendinitis, and postoperative pain. Applications of cold can also help with chronic trigger point pain and myofascial pain syndromes [22].
Thermal therapy, the application of heat to relieve pain, has long been associated with comfort and relaxation. It is used effectively in the nursing home population to relieve muscle spasm, increase blood flow to a particular area, and loosen stiff joints in preparation for exercise. Heat can be applied directly to a painful area with hot packs or paraffin baths, or indirectly using hydrotherapy, short waves, or ultra- sound. The choice between moist and dry heat depends on the availability and patient choice. There is little difference in effectiveness [22].
Electrical stimulation uses electricity to block pain messages using Melzack and Wall’s 1965 description of gate control theory. In addition to blocking pain messages, electrical stimulation releases endorphins which bind to opiate sites blocking pain transmission [23]. A popular (and portable) delivery system is a transcutaneous electrical nerve stimulator (TENS) unit. There are also implanted nerve stimulators.
Manual therapy including traction, massage, osteopathic manipulation, and chiropractic manipulation can be used cautiously in this population as a gentle hands-on form of muscle stretching and distraction. There are contraindications to traction and manipulation, including severe osteoporosis or those with spondylosis with osteophytes impinging on nerve roots or the spinal cord [23]. Massage is used to relax muscles, improve circulation, loosen trigger points, and provide comfort. There are also specific contraindications to
77 8 Rheumatic Disease in the Nursing Home Patient
massage including cellulitis, deep vein thrombosis, and recent surgical incisions. Massage therapists are licensed in many states and many facilities require that therapists be licensed before providing care to residents. Massage is not covered by most insurance plans including Medicare and Medicaid, and is paid for by the nursing home resident or his family. There are volunteer massage therapists who provide services to dying patients at no cost in some areas.
Bracing or splinting of painful joints is commonly used as a pain reliever. Wrist and knee braces are very commonly prescribed and most patients tolerate them well. Knee bracing may be the only alternative for a frail nursing home resident with unstable knee osteoarthritis who is not a candidate for total knee arthroplasty. Lumbar support provides comfort and warmth while stabilizing abdominal muscles. Thoracic braces for the postural correction of osteoporotic kyphosis are uncomfortable and have not been successful at correcting posture in the population where fixed deformity is the rule. A soft cervical collar may feel good and act as a reminder but does little to restrict mobility in the patient with cervical instability. In the case of atlantoaxial instability, a firm, custom-fitted collar or halo bracing is the most effective way to provide desired activity restriction. An orthotist can be helpful in designing custom-fabricated, functional and stabilizing braces, splints, and orthotics for the frail nursing home resident suffering with painful joints [23].
Ambulatory assistive devices including canes, crutches, walkers of various types, and wheelchairs are ubiquitous in the nursing home. Other adaptive equipment for the purpose of protecting joints and improving function including reachers, sock aides, button hooks, dressing sticks, built-up utensils, and adaptive cups are also available. Assessment of need for this or other specialized equipment is commonly performed by the occupational therapist.
All of the above interventions, including pharmacother- apy, are enhanced with the addition of an exercise program.
Gone are the days when immobility was recommended for painful conditions. It is now widely recognized that physical activity significantly improves pain in older patients.
Moderate levels of training can improve flexibility, balance, strength, and general conditioning, thereby reducing the risk of falls, a particular threat in the frail population. Even the oldest old can improve strength and balance, with resistive exercise programs resulting in better performance with transfers, stair climbing, and ambulation [24].
Exercise programs for the nursing home resident can be individualized to target specific joints or muscle groups which can be effective at both managing pain and improving function, for instance, after joint replacement surgery.
Nursing home residents should also be encouraged to join general fitness group exercise programs, many conducted entirely in a seated position, as a way of maintaining joint range of motion and participating in a group activity.
Therapeutic recreational activities, designed primarily as social stimulation, can also provide exercise in the form of games and competition (balloon volley ball and bell ringing).
Each of these interdisciplinary team members contributes to the reduction of pain and the improvement of function in nursing home resident suffering with rheumatic disease.
Complementary and alternative medicine (CAM) practices used by patients or requested by families for their loved ones include acupuncture; magnet therapies; Reiki and Johrei, both of Japanese origin; qi gong, a Chinese exercise practice;
healing touch, in which the therapist is purported to identify imbalances and correct a client’s energy by passing his or her hands over the patient; and intercessory prayer, in which a person intercedes through prayer on behalf of another [25, 26].
Specialized diets remain popular including those that restrict so-called nightshades and acid-free diets. Many supplements are taken by nursing home residents or requested by families as a “safer” alternative to traditional medications.
Glucosamine/chondroitin, fish oil, and ayurvedic remedies are very commonly used by older adults as are other herbal preparations and supplements [27, 28]. Many of these complementary and alternative practices are unstudied and unproven but are increasingly popular with patients and families, and several have come into common usage for nursing home residents with rheumatic pain.
Conclusion
Rheumatic diseases causing pain and functional impairment in the frail nursing home population are often underreported, underdiagnosed, and undertreated. More valid and reliable pain assessments as well as less toxic treatment regimes, both pharmacologic and non-pharmacologic, are needed.
Treatments must be simple and effective and take into account the high incidence of comorbidities and compli- cated medication regimes common to the nursing home resident. Facilities must remain committed to pain relief and maximizing function in nursing home residents if we are to prove as a society that we value and respect these most vulnerable patients.
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