Best Practices for Pain Management in Assisted Living

Written by Karina Christensen for ALFA Update

There are many myths about pain. Assisted living administrators and long-term care providers should be alert for caregivers who believe in these myths and deliver inappropriate care because of such misconceptions. 

In response to this, the Wisconsin Assisted Living Association (WALA) offered a new course this fall titled Pain Management in Assisted Living. The course tests attendees’ knowledge, discusses the importance of pain management in assisted living, and provides valuable resources to those who strive to provide the best care possible for their residents.

If we ask caregivers, “What is pain?” we will not always get the same answer. Pain is often difficult to define and describe. Perception and tolerance of pain vary widely from individual to individual. Practice shows that even people with identical injuries or illnesses experience different manifestations of pain and express it in different ways.

Pain can be described as the way a person’s brain interprets information about a particular sensation the body is experiencing. To fully understand pain, it is important to be aware of the complexity of the issue. As senior living providers, we need to take the following variables into consideration when discussing pain:

• Barriers to pain
• Ethical and legal concerns related to pain
• Acute vs. chronic pain
• Classification and types of pain
• Ways to approach pain: curative vs. palliative
• Holistic approach to pain management
• Pain assessments and tools
• Pharmacological and nonpharmacological treatment
• Types of pain medication
• Addiction

When addressing pain with senior living providers, families, and residents, it is important to start with a discussion about the barriers to pain management. One of the main barriers is a failure of  providers to identify pain management as a priority. Neglect of pain issues in health care and long-term care settings can occur when there is inadequate knowledge about pain management. This could be due to lack of available curriculum, with the result being a lack of emphasis placed on a individual’s subjective pain experience.

To treat pain to the best of their abilities, providers need to understand the physiology and pathology of pain. It is critical to understand the difference between acute and chronic pain, as well as to have in-depth knowledge of nociceptive, inflammatory, and pathological pain. While making use of academic knowledge about pain, assisted living staff also need to have hands-on experience with different types of pain, including visceral, bone, neuropathic, peripheral nervous system, phantom, breakthrough, and incident types of pain, as well as persistent somatic form pain disorder.

Pain assessments are one of the centerpieces of pain management. It is especially important to address the challenge of accurately assessing and managing the pain of residents who have communication challenges. Educate assisted living staff about nonverbal assessments and indicators, as well as ways to recognize nonverbal signs of pain. Some primary indicators of pain in nonverbal residents may be changes in gait, loss of function, decreased activity levels, resisting certain movements during care, bracing, guarding, and rubbing certain areas; these are just a few examples.

Some of the pain assessment questions providers should seek to answer are:

• Is the resident having increased difficulty walking or balancing? Is the resident limping? Has there been a fall?
• Is the resident having difficultly carrying out functions such as eating, bathing, dressing, or toileting? Were they able to carry them out before?
• Is the resident resting more, with less energy and endurance than they had before? Are they isolating themselves from others? Are they eating poorly?
• Does the resident cry out, become combative, resist range-of-motion activity, cringe, or stiffen when being assisted with bathing, dressing, or other functions?
• Is the resident protecting certain parts of their body from contact, or rubbing or massaging them? Is the resident holding tightly onto furniture or similar supports?

Frowning, grimacing, fearful facial expressions, and grinding of teeth can be indicators of pain as well. Changes in behavior, increasing or recurring agitation, and signs of depression are other nonverbal signs of pain that  providers need to be aware of.

Holistic approach and interventions to pain management are always a hot topic when discussing pain management. True holistic therapies must include more than just a set of symptoms to be addressed. They must consider the whole being, including the emotional, mental, and physical (both internal and external) environments in which they exist.

For example: Acupuncture and acupressure (shiatsu), yoga, and breathing techniques are ways to focus on harnessing the energy flow in the body. Meditative practices and prayer can exert physiological benefits. Cognitive behavioral therapy involves reframing beliefs and behaviors, and guided imagery techniques use the capacities of visualization and imagination to evoke sensory or affective changes. Other holistically oriented methods modify attitudes toward healthy diet and lifestyle choices, draw upon the time-honored practice of botanical medicine, use massage techniques, target shifts in body mechanics, and recondition the body using graduated exercises.

On their own or in combination, these alternative practices can make a significant difference in pain levels and pain threshold. Taken together with conventional modalities, the holistic approach to pain management offers a viable, effective alternative that builds on traditional methods of therapy. When a resident chooses a holistic approach to pain relief, it is important for senior living providers to respect that decision, regardless of whether staff holds the same beliefs.

WALA has created the Pain Management in Assisted Living course to give participants the awareness and educational resources to understand the principles of pain management. We hope this course will assist senior living providers in improving the quality of life of our seniors through improved pain management.

Karina Christensen, RN, PhD
Wisconsin Assisted Living Association Member 
CaRiNg4U Training and RN Consulting

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