Vol. 285 No. 16,

April 25, 2001

Letters

RESEARCH LETTER

Persistent Pain in Nursing Home Residents

To the Editor: More than 1.5 million people in the United States reside in

nursing homes and an estimated 43% of adults 65 years and older will enter

a nursing home prior to death.1 Previous research using an early version

of the Minimum Data Set (MDS), a nationally mandated nursing home resident

assessment instrument, noted that daily pain was prevalent among nursing

home residents diagnosed with cancer who had been discharged from a

hospital, as well as among the residents of nursing homes in general.2

Prior research was restricted by a limited MDS pain frequency measure of

"none" or "daily," but since 1998, information on both frequency (none,

daily, or less than daily) and severity of pain (mild, moderate, or

excruciating at times) has been collected. We report the rates of

persistent severe pain among US nursing home residents by analyzing a

national repository of MDS data, which represents all nursing home

residents in all 50 states.

Methods

We determined the rate of persistent severe pain among all 2.2 million

residents of US nursing homes within 60 days of April 1, 1999. The term

"persistent pain" indicates residents with pain at an assessment around

that time who were also reported to be in daily moderate or excruciating

pain at a second assessment, 60 to 180 days later. Using state as the unit

of analysis, we adjusted observed rates of persistent severe pain for the

nursing home discharge rate and the prevalence of severe pain among all

1999 admissions.

Results

Nationwide, 14.7% of residents in a nursing home for 2 assessments were in

persistent pain and 41.2% of residents in pain at first assessment were in

severe pain 60 to 180 days later. This rate varied from 37.7%

(Mississippi) to 49.5% (Utah). Forty-one states had rates of persistent

pain between 39.5% and 46.1%. Individual state reports are available

online at http://www.chcr.brown.edu/dying/factsondying.htm.

Comment

We believe that these results underestimate the true pain burden

experienced by nursing home residents because the data were reported by

nursing home staff rather than by patients. States in which pain is not

adequately assessed may report lower rates of persistent pain. Although

facilities in states with higher rates of reported pain may be doing a

better job of recognizing pain, nearly half of these residents were

apparently not afforded adequate palliation. The high rate of persistent

pain is consistent with previous research noting that pain is often not

appropriately treated in nursing home residents.2, 3 Untreated pain

results in impaired mobility, depression, and diminishes quality of

life.3-5 These population results indicate that pain control represents an

often neglected need of this vulnerable population.

Joan M. Teno, MD, MS

Sherry Weitzen, MS

Terrie Wetle, PhD

Vincent Mor, PhD

The Center for Gerontology and Health Care Research and Department of

Community Health

Brown Medical School

Providence, RI

1. Kemper P, Murtaugh CM. Lifetime use of nursing home care. N Engl J Med.

1991;324:595-600. MEDLINE

2. Bernabei R, Gambassi G, Lapane K, et al. Management of pain in elderly

patients with cancer: SAGE Study Group: Systematic Assessment of Geriatric

Drug Use via Epidemiology. JAMA. 1998;279:1877-1882. [published erratum

appears in JAMA. 1999;281:136]. MEDLINE

3. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing

home patients. J Pain Symptom Manage. 1995;10:591-598. MEDLINE

4. Sengstaken EA, King SA. The problems of pain and its detection among

geriatric nursing home residents. J Am Geriatr Soc. 1993;41:541-544.

MEDLINE

5. Parmelee PA, Smith B, Katz IR. Pain complaints and cognitive status

among elderly institution residents. J Am Geriatr Soc. 1993;41:517-522.

MEDLINE

© 2001 American Medical Association. All rights reserved.

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