Life In The Slower Lane

Here is the PICO analysis for the article:

Full Article Title:

The Application of Evidence-Based Principles of Care in Older Persons (Issue 4): Pain Management

Authors: Hollenack KA, Cranmer KW, Zarowitz BJ, O’Shea T

Journal: Journal of the American Medical Directors Association (JAMDA) (2007); Supplement March: E.77–E.85

DOI: 10.1016/j.jamda.2006.12.016

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✅ PICO Analysis

Type of Study:

Expert-based narrative review with clinical pathways and guideline synthesis

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P – Population

• Setting:
  • Older adults in long-term care, primarily nursing home residents
  • Includes subgroups with cognitive impairment, chronic disease, cancer, or post-acute conditions
• Patient Characteristics:
  • Aged ≥65 years
  • High prevalence of comorbidities (e.g. osteoarthritis, cancer, diabetic neuropathy, vertebral fractures)
  • 45–80% reported to have persistent or chronic pain in the nursing home setting

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I – Intervention

• Application of Evidence-Based Pain Management Principles, including:
  1. Comprehensive pain assessment, even for cognitively impaired residents
  2. Multidisciplinary management and stepwise pharmacologic therapy tailored to pain type (e.g., osteoarthritis, neuropathic, cancer, post-fracture)
  3. Use of standardised clinical pathways:
     • Acute pain and inflammation (Fig. 1, p. E.80)
     • Chronic nonmalignant pain (Fig. 2, p. E.80)
     • Cancer pain (Fig. 3, p. E.81)
     • Chronic back pain (Fig. 4, p. E.83)
     • Osteoarthritic pain (Fig. 5, p. E.83)
     • Neuropathic pain (Fig. 6, p. E.84)
• Medication Guidance:
  • Use of acetaminophen as first-line for most pain
  • Cautious use or avoidance of certain medications in older adults (e.g., propoxyphene, meperidine, long half-life NSAIDs)
  • Integration of adjuvant therapies (e.g., anticonvulsants, antidepressants) for neuropathic pain

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C – Comparison

• Comparator:
  • Not a comparative study. However, the article compares recommended practices versus common patterns of inadequate or inappropriate prescribing in long-term care settings
• Examples of suboptimal care cited:
  • 25% of nursing home residents with persistent pain received no analgesics
  • Overuse of potentially inappropriate medications (e.g., propoxyphene) despite known risks

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O – Outcomes

Person-Centred Outcomes (inferred or cited from literature):

• Untreated pain consequences:
  • Depression, social isolation, sleep disturbances, immobility, poor quality of life 
• Assessment improvements recommended:
  • Use of verbal and observational tools for residents with and without cognitive impairment
  • Avoidance of placebo use in pain assessment

Process Outcomes:

• Improved pain documentation and prescribing practices via:
  • Routine screening and assessment
  • Scheduled rather than PRN dosing
  • Use of validated scales (e.g., VDS, faces, VNS)
  • Multidisciplinary care plans
• Specific clinical pathways standardise care:
  • For acute pain: start low, titrate slowly, use oral route if possible
  • For chronic or neuropathic pain: incorporate non-drug approaches, topical agents, adjuvants

System-Level Outcomes (recommended or implied):

• Reduced inappropriate prescribing (e.g., meperidine, indomethacin)
• Safer pain control with fewer adverse drug reactions
• Improved alignment with AMDA and AGS guidelines
• Recommendations support institutional quality assurance programs for pain management

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Summary Conclusion

This expert-based review provides an evidence-informed, practical guide for improving pain management in nursing home residents. The article outlines condition-specific clinical pathways, emphasises comprehensive pain assessment (even for cognitively impaired patients), and offers guidance on appropriate analgesic selection. It addresses prevalent deficiencies in long-term care—including under-treatment, inappropriate drug use, and regulatory fear—and provides concrete steps to implement safer, more effective, and resident-centred pain care .

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