Challenges of Pain Management in Long-Term Care

Persistent pain is known to be common among older persons residing in long-term care (LTC) facilities, yet it continues to go unrecognized and undertreated despite pain guidelines, such as those put forth by the American Geriatrics Society (AGS) and AMDA–Dedicated to Long Term Care Medicine (previously known as the American Medical Directors Association [AMDA]), having been in existence for more than a decade. In 1998, the AGS published its first clinical practice guidelines on the management of persistent pain in older adults,¹ which were revised in 2002 and 2009.^2,3 Compared with the 1998 guidelines, the 2002 guidelines offer a wider range of pain assessment and management strategies, including nonpharmacologic pain management approaches, pharmacologic guidelines, and consideration of cognitively impaired patients. The 2009 update to the AGS pain guidelines focuses on details of pharmacologic management, incorporating newer evidence-based pharmacologic approaches into the protocol. AMDA released its first guidelines on managing chronic pain in the nursing home setting in 1999,⁴ and they were subsequently revised in 2003, 2009, and 2012.^5-7

Our literature review evaluates how guidelines, such as those put forth by the AGS and AMDA, on persistent pain in older persons have been applied in the LTC setting with regard to pain assessment and management protocols, including in cognitively impaired individuals. However, given the relative dearth of data on the application of pain guidelines in the LTC setting, we broadened our review to include an overview of the general literature regarding barriers to effective pain assessment and management in nursing home residents and of strategies that can be employed to improve pain management in this population.

Examining the Scope of Pain in LTC Residents

Documented rates of persistent pain in nursing home residents vary throughout the literature. In a systematic review by Fox and colleagues⁸ that included six studies with data from self-reporting or chart reviews,the prevalence of pain in US nursing homes and abroad ranged between 49% and 83%. When only the five studies with data on analgesic use were considered, the prevalence of pain ranged between 27% and 44%. In a study by Teno and associates,⁹ which analyzed the Minimum Data Set (MDS) data for approximately 2.2 million US nursing home residents, the rate ranged between 39.5% and 49.5%.

Untreated pain can impact LTC residents physically, mentally, and socially in many ways, including by interfering with their activities of daily living, sleep, and mobility. Pain can also lead to depression, anxiety, and other physical stresses.¹⁰ Among the many barriers to effective pain management in nursing homes are high staff turnover; government regulatory issues; lack of formal pain education for staff, including limited physician involvement; and cognitive impairment, which is seen in many nursing home residents.^11-13 Older adults may not report pain to their providers because they think it is a normal consequence of aging, and patients and families may not report it because they fear addiction issues as portrayed in the media.^10,14 Furthermore, the pain experience for patients may be complicated by emotional, spiritual, and physical suffering, making it difficult for nursing home staff to adequately quantify or qualify pain.¹⁵

There is also likely a gap between the perception of pain management in a given facility and the existence of an actual standardized approach that staff must use for assessment and treatment. In an interview of 49 LTC administrators across Kentucky, all respondents answered “yes” to the question, “Does your staff do a good job of assessing and treating pain in your residents?”¹³ However, none of the facilities had a formal, routine pain assessment protocol in place that was used on a daily or weekly basis, and only one respondent reported having a pain assessment protocol in place for cognitively impaired residents. Some facilities did have tools for measuring pain intensity, most often the Wong-Baker FACES Pain Rating Scale, but there were no policies requiring staff to use this tool.

Pain Assessment and Management Protocols in LTC

There are marked inconsistencies between pain guidelines and the actual practice of pain assessment and management in LTC facilities, with pain management practices varying widely.^16-20 One of the biggest obstacles to optimal pain management facing many nursing homes is the lack of a comprehensive pain assessment protocol that is administered on a frequent basis. Although pain evaluations using the MDS are mandatory upon admission to LTC facilities, a subset of MDS items is administered only quarterly thereafter or when there is a change in a resident’s status.^15,21 Pain evaluation between these quarterly assessments may be informal or lacking altogether. One study showed that nursing home staff may rely on relationship-centered daily pain assessments (meaning the staff determines a resident’s pain levels based on their knowledge of the resident’s behavior), rather than on a formal, standardized pain assessment tool.¹⁵ This may lead to staff misinterpreting behavior and nonverbal pain cues.^15,22

In 2009, Decker and colleagues¹⁷ conducted a descriptive study of 215 residents from 13 Iowa nursing homes and found that face-to-face patient interviews involving four yes/no questions about the presence of pain revealed higher rates of pain responses than those documented in the MDS, which at the time used a numerical scale to determine pain levels. The MDS was updated in 2010 to version 3.0 and now includes interview-type questions about pain; however, while MDS 3.0 also includes a pain assessment protocol for nurses to evaluate pain behaviors in residents who are unable to respond to the interview questions, patients with cognitive impairment may still be at a disadvantage if they cannot remember, process, or communicate details of their pain to the nurse assessor.^21,23

Cohen-Mansfield and Lipson²⁴ demonstrated the challenge of pain assessment in cognitively impaired individuals in a cross-sectional analysis that evaluated the reliability and validity of geriatricians’ assessments of pain in cognitively impaired nursing home residents. The study included 79 cognitively impaired residents (median age, 87 years), 31 with mild to moderate impairment and 48 with severe impairment, whose pain levels were assessed by two outside geriatricians via a physical examination, completion of a detailed pain assessment, and an evaluation of the residents’ laboratory results. The authors found that the reliability and validity of the pain assessments dropped significantly for the residents with severe cognitive impairment, and they concluded “There is a need for increased awareness of pain in this population and a need for improved methodologies to identify it.”²⁴ A later study by the same authors involving 121 nursing home residents with dementia sought to examine the utility of nine pain assessments in identifying pain and documenting responsiveness to pain medication in cognitively impaired individuals; these assessments included self-report, informant ratings by nursing staff, and direct observations.¹⁴ Residents who met the criteria for pain on at least two of the assessment instruments were treated with a medication protocol based on current guidelines. Patients were assessed every 2 weeks and advanced to the next phase of medication if they were still considered to be in moderate pain on at least two assessment instruments. The authors found that using multiple assessments along with a pain medication protocol were effective in reducing pain, particularly when informant ratings and self-report assessment tools were employed.¹⁴ This and other studies indicate that specialized assessment tools for cognitively impaired LTC residents are necessary.^14,22,24-27

Without adequate pain assessment, it is difficult to determine an appropriate treatment plan. Few studies in the literature detail interventions for pain in the LTC setting. Herman and colleagues²⁸ conducted a structured review in 2009 of prospectively designed intervention studies in managing pain in the LTC setting. Overall, they found uneven quality in the research designs, varying end point measures, and differing characteristics of the resident populations.

When pain management strategies do exist, they are not uniform. One study involving 2065 LTC residents across the United States demonstrated that, in addition to a lack of appropriate pain assessments in this population, nonpharmacologic pain interventions were rarely used and prescribing patterns were variable and often included the inappropriate use of analgesics, most commonly propoxyphene.¹⁸ The authors concluded that the frequent prescribing of inappropriate pain therapies for older people attests to the urgent need to educate nursing home practitioners on the appropriate use of analgesics.

In 2009, a study including 215 residents from 13 rural Iowa nursing homes sought to identify patients’ musculoskeletal diagnoses associated with pain and then compared pain management strategies in these patients with those outlined in the 1998 AGS evidence-based pain guidelines.¹⁷ Again, analgesic medications given for pain were inconsistent, and propoxyphene, which was discouraged in the AGS pain guidelines and taken off the US market in 2010, was used in 10.7% of the study cases. A high percentage (32.9%) of residents expressing daily pain received no analgesics, and nonpharmacologic interventions were used by only 13.5% of the study group, with topical agents being the most common therapy. The authors concluded that the AGS evidence-based guidelines for managing chronic pain were inconsistently implemented in the nursing homes they assessed.¹⁷

Pharmacologic and Nonpharmacologic Pain Management Strategies

Clinical trials of analgesic drugs and nonpharmacologic therapies have often excluded older patients, specifically those in the nursing home setting, which is problematic when prescribing treatments for this patient population.² The few articles looking at specific analgesics recommended by the AGS pain guidelines have shown unclear benefit or have been inconclusive. For example, Buffum and colleagues²⁷ studied the effect of regularly scheduled acetaminophen in 39 LTC residents in California who had dementia and a painful condition. They found that a 2600-mg daily dose of acetaminophen provided inadequate pain control for elderly nursing home patients who had significant discomfort. Chibnall and associates²⁹ also studied the effect of acetaminophen (3000 mg/day) on behavior and well-being in nursing home residents, hypothesizing that scheduled pain medication would improve agitation, which was the primary outcome measure of their study. Although the results were inconclusive, with no effects observed on agitation, emotional well-being, or use of as-needed psychotropic medications, the authors did report that when participants received acetaminophen versus the placebo, they were more prone to engaging in activities and socializing with people, experienced less unattended distress, and were less isolated.²⁹

Finally, Manfredi and colleagues³⁰ performed a trial of scheduled opioids for agitated nursing home patients with advanced dementia. It was presumed that agitation in these residents was related to uncontrolled pain and that reducing pain in these patients would concomitantly reduce their agitation. Although low-dose, long-acting opioids were shown to lessen agitation that is difficult to control in very old patients (≥85 years) with advanced dementia, the study was limited overall by its small size (only 25 completed this two-phase study), as there was a high dropout rate related to issues such as unsteady gait, increased agitation, fecal impaction, infection, and seizures.³⁰

Although the AGS and AMDA pain guidelines state that pharmacologic treatment is the cornerstone of pain management in the LTC setting, they note that a combination approach that includes both pharmacologic and nonpharmacologic pain treatments is often the most effective. According to the 2009 AMDA pain guidelines, nonpharmacologic comfort interventions, such as distraction, relaxation, massage, application of heat or cold, change of position, or exercise, should be the first approach employed to control pain when a patient’s physical examination and history are negative.⁷ Although nonpharmacologic interventions are generally supported by the various pain guidelines, research on the most effective complementary and alternative therapies to analgesic treatment in the LTC setting are lacking. In 2002, Simmons and colleagues³¹ conducted a randomized controlled trial to assess the efficacy of controlled exercise to manage pain in 51 nursing home residents. The authors found no significant changes in pain reports attributable to exercise, and while the participants in the exercise intervention group demonstrated improvements in physical performance, there was actually a tendency for pain to increase in this group. This finding led the authors to recommend preemptive analgesia or modified exercise regimens.³¹

Recognition of Pain in Cognitively Impaired LTC Residents

Some researchers in the LTC setting have addressed the challenge of pain recognition in patients with cognitive impairment by using multifaceted pain assessment and management approaches. In a study by Kovach and colleagues²⁶ involving a convenience sample of 104 residents at 32 Wisconsin LTC facilities, the Assessment of Discomfort in Dementia (ADD) protocol was used to both assess discomfort in people with dementia and to accurately and thoroughly treat pain, with the goal of decreasing the use of inappropriate psychotropic medications. Using the ADD protocol, behavioral symptoms of discomfort were significantly decreased, and there was an associated increase in the use of scheduled analgesics and nonpharmacologic comfort interventions.²⁶ A subsequent descriptive exploratory study by Kovach and associates³² that further assessed the ADD protocol was inconclusive on its effectiveness, as the study had limitations and potential nursing bias. Kovach and colleagues³³ later published a pain assessment and management protocol, called the Serial Trial Intervention (STI), which was based on the previous ADD protocol and had a goal to further address unmet needs of nursing home residents with late-stage dementia who were no longer able to communicate clearly. This study was a double-blind randomized trial that included 114 patients residing in 14 nursing homes. The outcome measured with the STI was discomfort using the Discomfort Scale for Dementia of the Alzheimer Type (DS-DAT) and the Behavioral Pathology in Alzheimer’s Disease (BEHAVE-AD) scale. In the study, the treatment group experienced significantly less discomfort and more often had their behavioral symptoms return to their baseline levels than the control group. Use of the STI also positively influenced nursing assessment, analgesic administration, and the nurses’ propensity to intervene when a patient was distressed.³³

Husebo and colleagues³⁴ assessed use of a stepwise protocol based on analgesic recommendations from the 1998 AGS pain guidelines to treat agitation that was presumably related to pain in 352 dementia patients at 18 nursing homes in Norway. The authors hypothesized that agitation, defined as a score of ≥39 on the Cohen-Mansfield Agitation Inventory, would significantly improve after pain management. Secondary outcome measures were aggression, pain, activities of daily living, and cognition. The investigators found a significant reduction in agitation, aggression, and pain. Neither activities of daily living nor cognition worsened in the treatment group, making it unlikely that residents were excessively sedated from the opioids that were administered. ³⁴

Staff Education

Whereas lack of staff education regarding pain management practice has been a key barrier to quality care in nursing homes, educational interventions have shown varying success when used alone.^35-37 Jones and associates³⁵ assessed the use of an intervention strategy involving educational and behavioral changes in six Colorado nursing homes. They found no change in the percentage of residents reporting pain before and after the intervention, but there was a statistically significant decrease in the number of residents reporting constant pain as well as improvements in the non–MDS pain assessments. This educational initiative was only somewhat successful in changing pain practices, however, partly because of staff and leadership turnover, poor physician attendance at the educational seminars, and the overwhelming amount of information that was given to participants.³⁵

Stein and colleagues³⁶ found that an educational program for nursing home physicians and staff focused on reducing use of nonsteroidal anti-inflammatory drugs in residents was more successful at changing the prescribing practices of primary care physicians, likely because a study physician either personally visited the institution or contacted LTC clinicians by phone to deliver the educational message. Another study found success targeting key nursing home physicians using an educational outreach program with interactive learning sessions, audit feedback, and a review of consensus-developed guidelines on end-of-life care.³⁸

Multifaceted Approaches to Pain Management

While targeting physicians and staff in educational programs has shown some success, multifaceted approaches to pain management interventions that employ additional strategies, such as audit, feedback, and quality improvement initiatives, seem to be the most successful.^12,38-40 Baier and colleagues³⁹ used a collaborative intervention involving education on pain management, audit, and feedback with a quality improvement approach using the Plan-Do-Study-Act (PDSA) paradigm to improve practices in Rhode Island nursing homes. They found that this collaborative quality improvement model significantly reduced the prevalence of pain and improved adherence to recommended clinical care guidelines.

Another study that included four nursing homes in North Carolina implemented a chronic pain assessment and management initiative in which a quality improvement team reviewed current clinical practice guidelines on pain management, updated the institutions’ policies and procedures, developed tools for pain assessment, and educated the staff in pain assessment and management principles.⁴¹ The study measured the efficacy of these interventions by assessing the staff’s pain-related knowledge using a multiple-choice test before and after the educational program; evaluating the completeness of documentation upon conducting a pain assessment; and measuring patient and family satisfaction with pain assessment and management both before and after the intervention. The authors found improvements in all of these measures following implementation of their quality improvement project.

Hanson and colleagues⁴² studied a quality improvement intervention that focused on staff education in seven nursing homes in North Carolina, with two additional nursing homes serving as controls in the study. The intervention included recruitment and training of palliative care leadership teams, followed by six educational sessions for staff members that examined hospice care, pain management, and advance care planning. Feedback of performance data on hospice enrollment, pain management, and advance care planning were collected at 0, 3, and 6 months. Following this quality improvement intervention, there were statistically significant increases in hospice enrollment, number of pain assessments conducted, use of nonpharmacologic pain treatments, and advance care planning discussions at the intervention facilities. No significant changes in these measures were observed at the control facilities.

Horner and associates⁴³ also used a quality improvement intervention in nine North Carolina nursing homes, providing nursing home staff leaders with education in pain management, feedback on pain quality indicator data, and assistance with the PDSA model. Five months following the intervention, pain assessments and nonpharmacologic pain treatments significantly increased for those residents experiencing pain, providing further support that quality improvement with a strong educational component can be an effective strategy for improving pain management.

Weissman and colleagues^11,12 demonstrated that enacting change at an institutional level might lead to greater success than relying on the behavior of individual clinicians or staff in LTC settings. The study enrolled 87 LTC facilities in a multifaceted role model program that included educational workshops, formation and education of a pain quality team, and site visits from project team members. Support was provided for completing facility-specific action plans for change structured around 14 national practice indicators of an institutional commitment to pain management. Chart reviews were also performed, and regular follow-up with role models and mentoring were provided.^11,12 “Buy-in” from facility administrators was key to the program’s success. The 14 target outcome indicators, which were based on guidelines by the US Agency for Healthcare Research and Quality and the American Pain Society, were similar to those outlined in the 1998 AGS pain guidelines.¹¹ This program was effective over time, and project faculty made a commitment to continue meetings with participating facilities after the study’s end.¹²                  

Stevenson and colleagues⁴⁰ reported on how templates, faculty, and ongoing consultation from the Resource Center of the American Alliance of Cancer Pain Initiatives were used to assist with implementing a practice-changing program to improve pain management in 113 healthcare organizations, which included home health agencies, LTC facilities, and community hospitals. Each organization committed to supporting a team of two to three staff members through a 10-month pain quality improvement process, which entailed a site visit, two educational conferences, pre- and postprogram analyses of the organizational structures in place to support pain assessment and management, quality improvement work plan development, and assessment of data collected from patient surveys. Postprogram results showed statistically significant increases in the presence of key structural elements within the healthcare institution that were important for effective pain management. An example of a key element was having a tool in place for assessing pain in cognitively impaired patients. The authors also found a statistically significant decrease in the percentage of patients who reported pain of any severity.⁴⁰

Collaboration With an Interdisciplinary Team

Interdisciplinary team (IDT) participation has been shown to be beneficial in managing pain in LTC residents. Chapman and Toseland⁴⁴ used IDTs in their study of advanced illness care teams for nursing home residents with dementia. Teams included members from medicine, nursing, social work, psychology, physical and occupational therapy, and nutrition. The authors addressed four domains of care: medical issues, meaningful activities, psychological problems, and behavioral concerns. Through collaboration in weekly meetings, the teams were effective in reducing agitated behavior and pain compared with the control group.⁴⁴

Long and colleagues¹⁰ described an interdisciplinary audit, feedback, and quality improvement intervention that educated staff from all key departments in their facility. The training used an IDT approach that included disciplines of management, nursing, social service, pastoral care, physical and occupational therapy, and even environmental and food services. There were no statistical controls in this study, but a percentage reduction in the incidence of chronic pain was observed and fewer short-stay residents reported experiencing moderate to severe pain.¹⁰

Pain Management in Hospice

Although pain control is one of the primary goals of hospice care, and federal and state guidelines regulating hospices require every reasonable effort to be made to ensure patients’ pain is well controlled, there are conflicting data regarding whether hospice care consistently improves pain management interventions for LTC residents at the end of life.^19,45 Miller and associates¹⁹ found that many dying nursing home residents received either no medications for their pain or analgesics that were inconsistent with the AMDA and AGS guidelines, although those enrolled in hospice were significantly more likely to receive regular treatment for daily pain than those residents not in hospice care at the end of life. Munn and colleagues⁴⁵ saw no appreciable difference in pain management at the end of life between patients in hospice and nonhospice care. The authors noted that the rates of hospice use were high in their patient population (22% of the study group), and hospice enrollees more often had moderate to severe pain than those not in hospice care. As these studies demonstrate, more research is needed on the effects of hospice care on pain management among LTC residents.

Conclusion

Effective pain management requires careful thought and collaboration between providers, as nursing home residents often have many other conditions that may confound pain assessments. More research is needed to determine if strict adherence to the AGS, AMDA, or any other pain guidelines can effectively address pain in the setting of complex patient needs. Research is also needed to better understand the optimal assessment and management of all types of pain for patients in LTC settings. The available recommendations for pain assessment would benefit from additional testing in prospective clinical trials in nursing homes to ensure their validity and effectiveness before they are implemented in LTC facilities nationwide. Studies that determine the most effective interventions for persistent pain in older adults in general and in the LTC setting in particular are needed as well. In addition, more randomized controlled trials should be undertaken to evaluate pharmacologic, nonpharmacologic, and combined therapies in this often complex population with comorbidities.

Based on our review of the literature, multifaceted approaches and quality improvement initiatives to integrate pain management changes at the institutional level are most likely to be helpful. Patients and families should engage in decision-making with providers regarding potential pharmacologic treatments whenever possible, weighing the benefits and burdens of therapies, and informing providers about their personal values and concerns. Appropriate patient and family involvement will ensure that patient goals remain at the center of care.

This study was supported in part by grants awarded to Dr. Ritchie from the US Agency for Healthcare Research and Quality, the National Institutes of Health, the Health Resources and Services Administration, and the Donald W. Reynolds Foundation.

 Dr. Farless reports no relevant financial relationships.

References

1. AGS Panel on Chronic Pain in Older Persons. The management of chronic pain in older persons. American Geriatrics Society. J Am Geriatr Soc. 1998;46(5):635-651.

2. AGS Panel on Persistent Pain in Older Persons (2002). The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(suppl 6):S205-S224.

3. AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons (2009). Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331-1346.

4.  American Medical Directors Association (AMDA). AMDA clinical practice guidelines: chronic pain management in the long-term care setting. Columbia, MD: AMDA; 1999.

5.  American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia, MD: AMDA; 2003.

6. American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia, MD: AMDA; 2009.

7.  American Medical Directors Association (AMDA). Clinical Practice Guideline: Pain Management. Revised 2012. www.amda.com/tools/guidelines.cfm#chronicpain. Accessed May 7, 2012.

8.  Fox PL, Raina P, Jadad AR. Prevalence and treatment of pain in older adults in nursing homes and other long-term care institutions: a systematic review. CMAJ. 1999;160(3):329-333.

9.  Teno JM, Weitzen S, Wetle T, Mor V. Persistent pain in nursing home residents. JAMA. 2001;285(16):2081.

10. Long C, Morgan BM, Alonzo TR, Mitchell KM, Bonnell DK, Beardsley ME. Improving pain management in long-term care: the campaign against pain. J Hosp Palliat Nurs. 2010;12(3):148-155.

11. Weissman DE, Griffie J, Muchka S, Matson S. Building an institutional commitment to pain management in long-term care facilities. J Pain Symptom Manage. 2000;20(1):35-43.

12. Weissman DE, Griffie J, Muchka S, Matson S. Improving pain management in long-term care facilities. J Palliat Med. 2001;4(4):567-573.

13. Keeney CE, Scharfenberger JA, O’Brien JG, Looney S, Pfeifer MP, Hermann CP. Initiating and sustaining a standardized pain management program in long-term care facilities. J Am Med Dir Assoc. 2008;9(5):347-353.

14.  Cohen-Mansfield J, Lipson S. The utility of pain assessment for analgesic use in persons with dementia. Pain. 2008;134(1-2):16-23.

15. Clark L, Jones K, Pennington K. Pain assessment practices with nursing home residents. West J Nurs Res. 2004;26(7):733-750.

16. Jablonski A, Ersek M. Nursing home staff adherence to evidence-based pain management practices. J Gerontol Nurs. 2009;35(7):28-34.

17. Decker SA, Culp KR, Cacchione PZ. Evaluation of musculoskeletal pain management practices in rural nursing homes compared with evidence-based criteria. Pain Manag Nurs. 2009;10(2):58-64.

18. Cramer GW, Galer BS, Mendelson MA, Thompson GD. A drug use evaluation of selected opioid and nonopioid analgesics in the nursing facility setting. J Am Geriatr Soc. 2000;48(4):398-404.

19. Miller SC, Mor V, Wu N, Gonzalo P, Lapane K. Does receipt of hospice care in nursing homes improve the management of pain at the end of life? J Am Geriatr Soc. 2002;50(3):507-515.

20. Bernabei R, Gambassi G, Lapane K, et al; SAGE Study Group. Management of pain in elderly patients with cancer. JAMA. 1998;279(23):1877-1882.

21. Stevenson K, Brown RL, Dahl JL, Ward SE, Brown MS. The Discomfort Behavior Scale: a measure of discomfort in the cognitively impaired based on the Minimum Data Set 2.0. Res Nurs Health. 2006;29(6):576-587.

22. Snow AL, Shuster JL Jr. Assessment and treatment of persistent pain in persons with cognitive and communicative impairment. J Clin Psychol. 2006;62(11):1379-1387.

23. US Centers for Medicare & Medicaid Services. Nursing home quality initiatives. Updated February 23, 2012. Accessed March 29, 2012. www.cms.gov/nursinghomequalityinits.

24. Cohen-Mansfield J, Lipson S. Pain in cognitively impaired nursing home residents: how well are physicians diagnosing it? J Am Geriatr Soc. 2002;50(6):1039-1044.

25. Blomqvist K, Hallberg IR. Recognizing pain in older adults living in sheltered accommodation: the views of nurses and older adults. Int J Nurs Stud. 2001; 38(3):305-318.

26. Kovach CR, Weissman DE, Griffie J, Matson S, Muchka S. Assessment and treatment of discomfort for people with late-stage dementia. J Pain Symptom Manage. 1999;18(6):412-419.

27. Buffum MD, Sands L, Miaskowski C, Brod M, Washburn A. A clinical trial of the effectiveness of regularly scheduled versus as-needed administration of acetaminophen in the management of discomfort in older adults with dementia. J Am Geriatr Soc. 2004;52(7):1093-1097.

28. Herman AD, Johnson TM, Ritchie C, Parmelee PA. Pain management interventions in the nursing home: a structured review of the literature. J Am Geriatr Soc. 2009;57(7):1258-1267.

29. Chibnall JT, Tait RC, Harman B, Luebbert RA. Effect of acetaminophen on behavior, well-being, and psychotropic medication use in nursing home residents with moderate-to-severe dementia. J Am Geriatr Soc. 2005;53(11):1921-1929.

30. Manfredi PL, Breuer B, Wallenstein S, Stegmann M, Bottomley G, Libow L. Opioid treatment for agitation in patients with advanced dementia. Int J Geriatr Psychiatry. 2003;18(8):700-705.

31.Simmons SF, Ferrell BA, Schnelle JF. Effects of a controlled exercise trial on pain in nursing home residents. Clin J Pain. 2002;18(6):380-385.

32. Kovach CR, Noonan PE, Griffie J, Muchka S, Weissman DE. Use of the assessment of discomfort in dementia protocol. Appl Nurs Res. 2001;14(4):193-200.

33. Kovach CR, Logan BR, Noonan PE, et al. Effects of the Serial Trial Intervention on discomfort and behavior of nursing home residents with dementia. Am J Alzheimers Dis Other Demen. 2006;21(3):147-155.

34.  Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with
dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065.

35. Jones KR, Fink R, Vojir C, et al. Translational research in long-term care: improving pain management in nursing homes. Worldviews Evid Based Nurs. 2004; 1(suppl s1):S13-S20.

36. Stein CM, Griffin MR, Taylor JA, Pichert JW, Brandt KD, Ray WA. Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: a randomized controlled trial. Med Care. 2001;39(5):436-445.

37. Kovacs F, Abraira V, Santos S, et al; Spanish Back Pain Research Network. A comparison of two short education programs for improving low back pain-related disability in the elderly: a cluster randomized controlled trial. Spine. 2007;32(10):1053-1059.

38. Keay TJ, Alexander C, McNally K, Crusse E, Eger RE. Nursing home physician educational intervention improves end-of-life outcomes. J Palliat Med. 2003;6(2):205-213.

39. Baier RR, Gifford DR, Patry G, et al. Ameliorating pain in nursing homes: a collaborative quality-improvement project. J Am Geriatr Soc. 2004;52(12):1988-1995.

40. Stevenson KM, Dahl JL, Berry PH, Beck SL, Griffie J. Institutionalizing effective pain management practices: practice change programs to improve the quality of pain management in small health care organizations. J Pain Symptom Manage. 2006;31(3):248-261.

41. Buhr GT, White HK. Quality improvement initiative for chronic pain assessment and management in the nursing home: a pilot study. J Am Med Dir Assoc. 2006;7(4):246-253.

42. Hanson LC, Reynolds KS, Henderson M, Pichard CG. A quality improvement intervention to increase palliative care in nursing homes. J Palliat Med. 2005;8(3):576-584.

43.  Horner JK, Hanson LC, Wood D, Silver AG, Reynolds KS. Using quality improvement to address pain management practices in nursing homes. J Pain Symptom Manage. 2005;30(3):271-277.

44. Chapman DG, Toseland RW. Effectiveness of advanced illness care teams for nursing home residents with dementia. Social Work. 2007;52(4):321-329.

45. Munn JC, Hanson LC, Zimmerman S, Sloane PD, Mitchell CM. Is hospice associated with improved end-of-life care in nursing homes and assisted living facilities? J Am Geriatr Soc. 2006;54(3):490-495.