Pain assessment and management deficiencies in nursing homes (NHs) are well documented. Unrelieved pain in this setting results in poorer resident outcomes, including depression, decreased mobility, sleep disturbance, and impaired physical and social functioning. This randomized controlled trial will evaluate the efficacy of a pain management algorithm coupled with intense diffusion strategies in improving physical function and decreasing pain and depression among NH residents.
Specific aims of the study are to: 1) Evaluate the effectiveness of a pain management algorithm (ALG) coupled with intense diffusion strategies, as compared with pain education (EDU) and weak diffusion strategies, in improving self-care, locomotion, and mobility, and decreasing pain and depression among NH residents; 2) Determine the extent to which adherence to the ALG and organizational factors are associated with changes in residents' self-care, locomotion, mobility, pain, and depression and the extent to which changes in these variables are associated with changes in outcomes; 3) Evaluate the persistence of changes in process and outcome variables at long-term follow-up and 4) Evaluate the relationships among behavioral problems (measured by the BEHAVE-AD) and discomfort (as measured by the DS-DAT) in severely cognitively impaired residents who are unable to provide self-report. The NH pain management algorithm is a series of decision-making tools that begin with regular, comprehensive pain assessment matched to residents' cognitive status and proceed through analgesic therapy appropriate to the character, severity, and pattern of pain. The algorithm is based on the investigators' earlier research and was adapted in collaboration with geriatric pain experts. Initial pilot testing demonstrated preliminary support for the effectiveness of the algorithm. Implementation of the algorithm will utilize a program that applies the principles of Roger's Diffusion of Innovations Theory. The implementation program emphasizes the education of NH staff in the use of the algorithm; practice in applying the algorithm to hypothetical and real case studies; establishment of NH pain teams comprised of opinion leaders who are experts in using the algorithm; and use of booster and supportive strategies to imbed the algorithm into everyday, ongoing pain management practices. The randomized controlled trial will involve 20 facilities, 10 ALG and 10 EDU. Facilities will be the unit of randomization, although clinical outcomes will be measured in individual residents within facilities. Clinical outcomes from 510 residents, 255 in each treatment arm, will be evaluated to determine the efficacy of the ALG. Findings from this study will assist NH staff to assess and treat pain effectively in cognitively intact and impaired residents. Long-term follow-up will establish the persistence of changes in clinical practice and resident outcomes.
