Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study

Abstract

Background

Evidence to guide clinical decision making for pain management in nursing home residents is scant.

Objective

Our objective was to explore the extent of consensus among expert stakeholders regarding what analgesic issues should be prioritized for comparative-effectiveness studies of beneficial and adverse effects of analgesic regimens in nursing home residents.

Methods

Two stakeholder panels (nurses only and a mix of clinicians/researchers) were engaged (n = 83). During a three-round online modified Delphi process, participants rated and commented on the need for new evidence on nonopioid analgesic regimens and opioid regimens, short-term adverse effects, long-term adverse effects, comorbid conditions, and other factors in the nursing home setting (9-point scale; 1 = not essential to 9 = very essential to obtain new evidence). The quantitative data were analyzed to determine the existence of consensus using an approach from the RAND/UCLA Appropriateness Method User’s Manual. The qualitative data, consisting of participant explanations of their numeric ratings, were thematically analyzed by an experienced qualitative researcher.

Results

For nursing home residents, evidence generation was deemed essential for opioids, gabapentin (alone or with serotonin norepinephrine reuptake inhibitors [SNRIs]), and nonsteroid anti-inflammatory drugs with SNRIs. Experts prioritized the following outcomes as essential: long-term adverse effects, including delirium, cognitive decline, and decline in activities of daily living (ADLs). Kidney disease and depression were deemed essential conditions to consider in studies of pain medications. Coprescribing analgesic regimens with benzodiazepines, sedating medications, serotonergic medications, and non-SNRI antidepressants were considered essential areas of study. Experts noted that additional study was essential in residents with moderate/severe cognitive impairment and limitations in ADLs.

Conclusions

Stakeholder priorities for more evidence reflect concerns related to treating medically complex residents with complex drug regimens and included long-term adverse effects, coprescribing, and sedating medications. Carefully conducted observational studies are needed to address the vast evidence gap for nursing home residents.

This is a preview of subscription content, access via your institution.

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

References

  1. 1.

    Barkin RL, Barkin DS. Perception, assessment, treatment, and management of pain in the elderly. Clin Geriatr Med. 2005;21(0749–0690 (Print)):465–90.

    Article  Google Scholar 

  2. 2.

    Flock P, Terrien JM. A pilot study to explore next of kin’s perspectives on end-of-life care in the nursing home. J Am Med Dir Assoc. 2011;12(1538–9375 (Electronic)):135–42.

    Article  Google Scholar 

  3. 3.

    American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8):1331–1346. https://doi.org/10.1111/j.1532-5415.2009.02376.x

  4. 4.

    Dube CE, Mack DS, Jesdale BM, Nunes AP, Liu SH, Lapane KL. Prevalence of pain on admission by level of cognitive impairment in nursing homes. J Pain Res. 2020;13:2663–72.

    Article  Google Scholar 

  5. 5.

    Lamy P. Physiological changes due to age. Pharmacodynamic changes of drug action and implications for therapy. Drugs Aging. 1991;1(1170–229X (Print)):385–404.

    CAS  Article  Google Scholar 

  6. 6.

    Beers H. Defining Inappropriate Medication Use in the Elderly. Annu Rev Gerontol Geriatr. (1):29-40.

  7. 7.

    Lapane KL, Hume AL, Morrison RA, Jesdale BM. Prescription analgesia and adjuvant use by pain severity at admission among nursing home residents with non-malignant pain. Eur J Clin Pharmacol. 2020;76(1432–1041 (Electronic)):1021–8.

    Article  Google Scholar 

  8. 8.

    Shrank WH, Polinski JM, Avorn J. Quality Indicators for Medication Use in Vulnerable Elders. J Am Geriatr Soc. 2007;55:S373–82.

    Article  Google Scholar 

  9. 9.

    Robinson OC. Sampling in interview-based qualitative research: a theoretical and practical guide. Qual Res Psychol. 2014;11(1):25–41.

    Article  Google Scholar 

  10. 10.

    Khodyakov D, Hempel S, Rubenstein L, Shekelle P, Foy R, Salem-Schatz S, et al. Conducting online expert panels: a feasibility and experimental replicability study. BMC Med Res Methodol. 2011;23(1471–2288 (Electonic)):174.

    Article  Google Scholar 

  11. 11.

    Dalal S, Khodyakov D, Srinivasan R, Straus S, Adams J. ExpertLens a system for eliciting opinions from a large pool of non-collocated experts with diverse knowledge. Rand Corp. 2010;78:1426–44.

    Google Scholar 

  12. 12.

    Barber CE, Marshall DA, Alvarez N, Mancini GB, Lacaille D, Keeling S, et al. Development of cardiovascular quality indicators for rheumatoid arthritis: results from an international expert panel using a novel online process. J Rheumatol. 2015;42(0315–162 (Print)):1548–55.

    Article  Google Scholar 

  13. 13.

    Claassen CA, Pearson JL, Khodyakov D, Satow PM, Gebbia R, Berman AL, et al. Reducing the burden of suicide in the U.S.: the aspirational research goals of the National Action Alliance for Suicide Prevention Research Prioritization Task Force. Am J Prev Med. 2014;47(1873–2607 (Electonic)):309–14.

    Article  Google Scholar 

  14. 14.

    Khodyakov D, Mikesell L, Schraiber R, Booth M, Bromley E. On using ethical principles of community-engaged research in translational science. Transl Res. 2016;171(1878–1810 (Electonic)):52–62.

    Article  Google Scholar 

  15. 15.

    Khodyakov D, Ochoa A, Olivieri-Mui BL, Bouwmeester C, Zarowitz BJ, Patel M, et al. Screening tool of older person’s prescriptions/screening tools to alert doctors to right treatment medication criteria modified for U.S. nursing home setting. J Am Geriatr Soc. 2017;365(1532–5415 (Electonic)):586–91.

    Article  Google Scholar 

  16. 16.

    Fitch K, Bernstein S, Aguilar M, Burnand B, LaCalle J, Lázaro P, et al. The RAND/UCLA Appropriateness method user’s manual. Rand Corporation. 2001.

  17. 17.

    Strauss A, Corbin J. Grounded theory methodology. Thousand Oaks: Sage Publications; 1994.

    Google Scholar 

  18. 18.

    Hunnicutt JN, Chrysanthopoulou SA, Ulbricht CM, Hume AL, Tjia J, Lapane KL. Prevalence of long-term opioid use in long-stay nursing home residents. J Am Geriatr Soc. 2018;66(1532–5415 (Electronic)):48–55.

    Article  Google Scholar 

  19. 19.

    Hunnicutt JN, Hume AL, Liu SH, Ulbricht CM, Tjia J, Lapane KL. Commonly Initiated opioids and risk of fracture hospitalizations in United States Nursing homes. Drugs Aging. 2018;35(1179–1969 (Electronic)):925–36.

    Article  Google Scholar 

  20. 20.

    Lapane K, Quilliam B, Chow W, Kim M. Pharmacologic management of non-cancer pain among nursing home residents. J Pain Symptom Manag. 2013;45(1873–6513 (Electonic)):33–42.

    Article  Google Scholar 

  21. 21.

    Zhao D, Shridharmurthy D, Alcusky MJ, Yuan Y, Nunes AP, Hume AL, et al. The prevalence and factors associated with antiepileptic drug use in U.S. nursing home residents. Drugs Aging. 2020;37(2):137–45.

    Article  Google Scholar 

  22. 22.

    Gurwitz J, Field T, Avorn J, McCormick D, Jain S, Eckler M, et al. Incidence and preventability of adverse drug events in nursing homes. Am J Med. 2000;109(0002–9343 (Print)):87–94.

    CAS  Article  Google Scholar 

  23. 23.

    Kosar C, Thomas K, Inouye S, Mor V. Delirium during postacute nursing home admission and risk for adverse outcomes. J Am Geriatr Soc. 2017;65(1532–5415 (Electonic)):1470–5.

    Article  Google Scholar 

  24. 24.

    Inouye S, Charpentier P. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(0098–7484 (Electonic)):852–7.

    CAS  Article  Google Scholar 

  25. 25.

    Berry S, Lee Y, Zullo A, Kiel D, Dosa D, Mor V. Incidence of hip fracture in U.S. nursing homes. J Gerontol A Biol Sci Med Sci. 2016;71(1758–535 (Electonic)):1230–4.

    Article  Google Scholar 

  26. 26.

    Berry SD, Samelson E, Bordes M, Broe K, Kiel D. Survival of aged nursing home residents with hip fracture. J Gerontol A Biol Sci Med Sci. 2009;64(1758–535X(Electronic)):771–7.

    Article  Google Scholar 

  27. 27.

    Neuman M, Silber J, Magaziner J, Passarella M, Mehta S, Werner R. Survival and functional outcomes after hip fracture among nursing home residents. JAMA. 2014;174(2168–6114 (Electronic)):1273–80.

    Google Scholar 

  28. 28.

    Morris J, Berg K, Fries B, Steel K, Howard E. Scaling functional status within the interRAI suite of assessment instruments. BMC Geriatr. 2013;13(1471–2318 (Electronic)):128.

    Article  Google Scholar 

  29. 29.

    Denkinger M, Lukas A, Nikolaus T, Peter R, Franke S. Multisite pain, pain frequency and pain severity are associated with depression in older adults: results from the ActiFE Ulm study. Age Ageing. 2014;43(1468–2834 (Electronic)):510–4.

    Article  Google Scholar 

  30. 30.

    Walid M, Zaytseva N. Pain in nursing home residents and correlation with neuropsychiatric disorders. Pain Phys. 2009;12(2150–1149 (Electronic)):877–80.

    Article  Google Scholar 

  31. 31.

    Cohen-Mansfield J, Marx M. Pain and depression in the nursing home: corroborating results. J Gerontol. 1993;48(0022–1422 (Print)):P96–7.

    CAS  Article  Google Scholar 

  32. 32.

    Parmelee P, Katz I, Lawton M. The relation of pain to depression among institutionalized aged. J Gerontol. 1991;46(0022-1422 (Print)):P15-21.

    CAS  Article  Google Scholar 

  33. 33.

    Kauppila T, Pesonen A, Tarkkila P, Rosenberg P. Cognitive dysfunction and depression may decrease activities in daily life more strongly than pain in community-dwelling elderly adults living with persistent pain. Pain Pract. 2007;7(1533-2500 (Electronic)):241–7.

    Article  Google Scholar 

  34. 34.

    Mavandadi S, Have T, Katz I, Durai U, Nalla B, Durai U, et al. Effect of depression treatment on depressive symptoms in older adulthood: the moderating role of pain. J Am Geriatr Soc. 2007;55(00002-8614 (Print)):202–11.

    Article  Google Scholar 

  35. 35.

    Thomas K, Dosa D, Wysocki A, Mor V. The minimum data Set 3.0 cognitive function scale. 55. 2017;9:e68-e72.

  36. 36.

    Beloosesky Y, Nenaydenko O, Gross Nevo R, Adunsky A, Weiss A. Rates, variability, and associated factors of polypharmacy in nursing home patients. Clin Interv Aging. 2013;8(1178-1998 (Electronic)):1585–90.

    Article  Google Scholar 

  37. 37.

    Ersser S, Wiles A, Taylor H, Wade S, Walsh R, Bentley T. The sleep of older people in hospital and nursing homes. J Clin Nurs. 1999;8(0962-1067 (Elecronic)):360–8.

    CAS  Article  Google Scholar 

  38. 38.

    Lunde L, Pallesen S, Krangnes L, Nordhus I. Characteristics of sleep in older persons with chronic pain: a study based on actigraphy and self-reporting. Clin J Pain. 2010;26(1536-5409 (Electronic)):132–7.

    Article  Google Scholar 

  39. 39.

    Chen Q, Hayman L, Shmerling R, Bean J, Leveille S. Characteristics of chronic pain associated with sleep difficulty in older adults: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. J Am Geriatr Soc. 2011;59(1532-5415 (Electronic)):1385–92.

    Article  Google Scholar 

  40. 40.

    Martin JL, Dzierzewski J, Mitchell M, Constance H, Fung C, Jouldjian S, et al. Patterns of sleep quality during and after postacute rehabilitation in older adults: a latent class analysis approach. J Sleep Res. 2013;22(1365-2869 (Electronic)):640–7.

    Article  Google Scholar 

  41. 41.

    Díaz Del Campo P, Gracia J, Blasco J, Andradas E. A strategy for patient involvement in clinical practice guidelines: methodological approaches. BMJ Qual Saf. 2011;20(2044-5423 (Electronic)):779–84.

    Article  Google Scholar 

  42. 42.

    Keeney S, McKenna H, Hasson F. The Delphi technique in nursing and health research. New York: Wiley; 2010.

    Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Kate L. Lapane.

Ethics declarations

Funding

This study was funded by a grant from the National Institute for Nursing Research (5R01NR016977; Principal Investigator: Kate L. Lapane) and supported by a grant from the National Institute on Aging (K24AG068300; Principal Investigator: Jennifer Tjia).

Conflicts of interest

Drs. Kate Lapane, Anne L. Hume, Bill Jesdale, Jayne Pawasauski, and Catherine Dubé have no conflicts of interest that are directly relevant to the content of this article. Dr. Jennifer Tjia is a consultant for CVS Health and Omnicare Long Term Care Pharmacy. Dr. Khodyakov is a leader of the ExpertLens team at RAND. ExpertLens was used to collect data for this study.

Availability of data and material

We are unable to share the data used to conduct this study per our institutional review board approval. The documents used to frame the panel questions are available from the authors on request.

Ethics Approval

This study was approved by the University of Massachusetts Medical School Institutional Review Board (protocol number H00011964) and the RAND Corporation.

Consent

Not applicable.

Declarations

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Author contributions

Drs. Lapane, Dubé, and Khodyakov had full access to all data in the study and are responsible for the data integrity and the accuracy of the data analysis. Study concept and design: Drs. Lapane, Dubé, Hume, Jesdale, Tjia, Pawasauskas, and Khodyakov. Acquisition of data: Drs. Hume, Lapane, Khodyakov, Tjia, and Pawasauskas. Interpretation of data: Drs. Lapane, Khodyakov, Tjia, Hume, Pawasauskas, and Dubé. Analysis: Drs. Khodyakov and Dubé. Preparation of manuscript: Drs. Lapane, Khodyakov, Hume, Pawasauskas, Tjia, and Dubé. Critical revision of manuscript for important intellectual content: Drs. Lapane, Jesdale, Hume, Tjia, Pawasauskas, Dubé, and Khodyakov. Obtained funding: Dr. Lapane. Study supervision: Dr. Lapane. The final manuscript was read and approved by all authors.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 464 KB)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lapane, K.L., Dubé, C., Hume, A.L. et al. Priority-Setting to Address the Geriatric Pharmacoparadox for Pain Management: A Nursing Home Stakeholder Delphi Study. Drugs Aging 38, 327–340 (2021). https://doi.org/10.1007/s40266-021-00836-8

Download citation