Pain Management in Long-Term Care Residents with Cognitive Impairment

The Centers for Medicaid and Medicare Services (CMS) began the Nursing Home Quality Initiative (NHQI) to improve services in nursing facilities.   Concerning pain management and the cognitively impaired, it has identified five essential systems for quality of care:

  • initial screening for pain,
  • comprehensive assessment for pain,
  • development of a plan of care,
  • ongoing screening and monitoring for pain, and
  • organizational commitment to pain management.

Pain management for persons with cognitive impairments is a complex team process, with the team consisting of healthcare professionals and informal family caregivers—each adding unique information to assessing, treating, reassessing, and monitoring pain in patients with dementia.  Assessment of pain in cognitively impaired older adults is complicated by changes in memory, language skills, and their ability to identify pain. Some indicators of pain may be changes in sleep cycle, changes in mood, decline in function, instability, weight loss, and skin conditions.

Dementia impairs an individual’s perception of pain and ability to report pain, to remember pain to evaluate relief, and to communicate about relief.  While the individual with dementia shows impaired cognition and impaired verbal communication, their pain threshold is not impaired so they feel pain but have difficulty communicating it.  Pain itself can impair cognition.  Many residents have more than one active medical condition and may experience pain from several different causes.  Some medical conditions that may be painful are pressure ulcers, diabetes with neuropathic pain, immobility, amputation, post-cardiovascular event, venous and arterial ulcers, multiple sclerosis, oral health conditions, and infections.  In addition, everyday procedures, such as moving a resident, performing physical or occupational therapies or changing a wound dressing may cause pain.

Expressions of pain may be verbal or nonverbal.  A resident may avoid the use of the term “pain.” Other words used to report or describe pain may differ by culture, language and/or region of the country. Examples of descriptions may include heaviness or pressure, stabbing, throbbing, hurting, aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms, soreness, tenderness, discomfort, pins and needles, feeling “rough,” tearing or ripping. Verbal descriptions of pain can help a practitioner identify the source, nature, and other characteristics of the pain.  Possible nonverbal indicators of pain may include:

  • Negative verbalizations and vocalizations (e.g., groaning, crying/whimpering, or screaming);
  • Facial expressions (e.g., grimacing, frowning, fright, or clenching of the jaw);
  • Changes in gait (e.g., limping), skin color, vital signs (e.g., increased heart rate, respirations and/or blood pressure), perspiration;
  • Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities;
  • Loss of function or inability to perform Activities of Daily Living (ADLs), rubbing a specific location of the body, or guarding a limb or other body parts;
  • Difficulty eating or loss of appetite; and
  • Difficulty sleeping (insomnia).

Care Process for Pain Management

 Processes for the prevention and management of pain in the cognitively impaired include:     

  • Assessing the potential for pain, recognizing and assessing the onset or presence of pain;
  • Addressing/treating the underlying causes of the pain, as much as possible;
  • Developing and implementing interventions/approaches to pain management;
  • Identifying and using specific strategies for different levels or sources of pain including:
    • Identifying interventions to address the pain based on the resident-specific assessment, a pertinent clinical rationale, and the resident’s goals;
    • Trying to prevent or minimize anticipated pain;
    • Considering non-pharmacological interventions; or, if necessary:
    • Using pain medications judiciously to balance the resident’s desired level of pain relief;
    • Monitoring appropriately for effectiveness and/or adverse consequences
    • Modifying the approaches, as necessary.

 For additional information, see the full list of Regulations and Guidance on the Centers for Medicare and Medicaid Services at:

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