• American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [22 references]

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association. Chronic pain management in the long-term care setting. Columbia (MD): American Medical Directors Association; 1999. 39 p.

Acute or chronic pain

Diagnosis
Evaluation
Management
Risk Assessment
Treatment

Family Practice
Geriatrics
Internal Medicine
Nursing
Pharmacology

Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Social Workers
Speech-Language Pathologists

• To improve the quality of care delivered to patients with acute or chronic pain in long-term care settings
• To guide care decisions and to define roles and responsibilities of appropriate care staff

Elderly residents of long-term care facilities with acute or chronic pain or who are at risk of pain

Diagnosis/Assessment

1. Regular and systematic assessment for presence of pain
2. Observation for nonspecific signs and symptoms that suggest pain
3. Use of Minimum Data Set (MDS) as a tool to aid in pain assessment.
4. Identification of characteristics and causes of pain
5. Use of a standardized scale to quantify the intensity of the patient's pain
6. Identification and addressing of risk factors for pain
7. Assessment of impact pain has on function and quality of life
8. History and physical examination
9. Diagnostic testing, as indicated
   • Laboratory testing, such as fasting glucose, blood urea nitrogen, creatinine, liver profile, urinalysis, uric acid, alkaline phosphatase;
   • Radiologic testing, such as spine x-rays, computed tomography (CT) or magnetic resonance imaging (MRI) scan
10. Consultation with pharmacist and pain specialists, as needed

Management/Treatment

1. Interdisciplinary care planning
2. Environment support to promote comfort (temperature control, minimization of background noise, clean & dry skin, comfortable positioning in bed or chair, reassuring words and touch, back rub, hot or cold compresses, whirlpool, services of a chaplain or other appropriate pastoral counselor, comforting music)
3. Pharmacologic treatment
   • Non-opioid analgesics, such as acetaminophen, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 (cox-2) inhibitors and tramadol. NOTE: The NSAIDs indomethacin, piroxicam, tolmetin, and meclofenamate are considered but not recommended for chronic use. Propoxyphene, meperidine, pentazocine, butorphanol, and other agonist-antagonist combinations are considered but not recommended.
   • Opioid analgesics (oxycodone; morphine; transdermal fentanyl; hydromorphone; methadone; combination opioid preparations, such as codeine, hydrocodone, oxycodone)
   • Other classes of drugs (corticosteroids, anticonvulsants, clonazepam, carbamazepine, anti-arrhythmics, intravenous local anesthetics, baclofen)
4. Complementary (nonpharmacologic) therapies
   • Education, cognitive/behavioral therapy, exercise
   • Other physical therapies (physical and occupational therapy, positioning, cutaneous stimulation, neurostimulation, chiropractic, magnet therapy)
   • Other nonphysical therapies (psychological counseling, spiritual counseling, peer support groups, alternative medicine, aromatherapy, music, art, drama therapy, biofeedback, meditation, other relaxation techniques, hypnosis)
5. Evaluation of response to treatment, monitoring of patient’s pain, and adjustment of treatment as needed

• Pain intensity
• Pain relief
• Mood, function, sleep, and quality of life
• Safety and side effects of medications

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

Interdisciplinary workgroups developed the guidelines, using a process that combined evidence- and consensus-based approaches. Workgroups included practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group worked to make a concise, usable guideline tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations were based on the expert opinion of practitioners in the field.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.

• This guideline recommends processes that, if followed, will help to ensure that pain among long-term care patients is adequately recognized, assessed, treated, and monitored.
• By implementing the steps described in this guideline, health care providers can meet the expectations of patients, their families, advocates, and policy makers for adequate, compassionate management of pain in the long-term care setting.

• See Table 9 in the original guideline document for a listing of possible adverse effects associated with non-opioid analgesics commonly used in the long-term care setting.
• See Table 17 in the original guideline document for a listing of possible adverse effects associated with non-analgesic drugs sometimes used for analgesia in the long-term care setting.

• This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association, their heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.
• The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
   • Identify individual responsible for each step of the CPG.
   • Identify support systems that impact the direct care.
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement.
   • Evaluate the predefined performance measures and obtain and provide feedback.

End of Life Care
Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• American Medical Directors Association (AMDA). Pain management in the long-term care setting. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [22 references]

Not applicable: The guideline was not adapted from another source.

2003

American Medical Directors Association - Professional Association

American Medical Directors Association

Steering Committee

Not stated

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association. Chronic pain management in the long-term care setting. Columbia (MD): American Medical Directors Association; 1999. 39 p.

None available

This NGC summary was completed by ECRI on July 6, 2004. The information was verified by the guideline developer on August 4, 2004. This summary was updated by ECRI on January 12, 2005 following the release of a public health advisory from the U.S. Food and Drug Administration regarding the use of some non-steroidal anti-inflammatory drug products. This summary was updated on April 15, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI Institute on January 10, 2008, following the U.S. Food and Drug Administration advisory on Carbamazepine.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. For more information, please contact the American Medical Directors Association (AMDA) at (800) 876-2632.