(P11) Importance of Person-Centered Care for Pain Management in Nursing Home

Introduction: Pain is very common among post-acute Nursing Home (NH) patients. Balancing appropriate pain management in NHs is a challenge due to concerns for potential adverse pharmacologic effects, high prevalence of multimorbidity and polypharmacy. Prescribing, dispensing and administering pro re nata (PRN) medicines is a very common approach, and a potential area for medication errors and delay in administration. We chose two post-acute care patients to discuss how a person-centered approach may improve pain management.

Case Description: The first case is an 82-year-old, previously independent, cognitively intact and euthymic female, who developed pain after a trauma to her left hip, without associated fracture. During the first 7 days at the NH, her average pain score was 8.5 (on a scale of 10) and she received 49 doses of PRN medication during this time. The pharmacological management included a PRN prescription for acetaminophen and oxycodone-acetaminophen combination, in addition to regular Gabapentin 300mg three times daily. During days 8-15 at the NH, after titration of oxycodone-acetaminophen combination dosing and addition of regular local diclofenac gel, her average pain reported was 6.75 and she received 36 doses of PRN medication. At the time of discharge, although less intense, she still complained of pain, did not completely achieve therapy goals, and required a home health caregiver for support with activities of daily living. The second case is an 81-year-old, previously independent, cognitively intact and euthymic female, admitted to the NH after elective right shoulder surgery. During her first 4 days of stay, her average pain score was 6 with PRN tramadol, acetaminophen and oxycodone-acetaminophen combination. She received 14 doses of PRN medications for pain control. During days 5-9, after starting fixed acetaminophen dosing, her average pain score was still 6 but she needed fewer doses of PRN medication (10) for pain control. The patient’s dissatisfaction with her treatment led her to ask for an earlier discharge from NH. At the time of discharge, she did not achieve therapy goals, and required a home health caregiver for support with activities of daily living.

Discussion: These cases illustrate how pain management contingent on only standard pain scale assessment and PRN medication administration is not optimal in NH patients, and can lead to complications including functional decline and lost independence, as well as dissatisfaction with care and premature discharge. The need for frequent PRN medications should prompt reconsideration of the pain regimen. For continuous pain, medications are best given on a regular basis. PRN medications, while useful for breakthrough pain, can result in delay in administration and prolongation of the patient's pain, in addition to being a burden to nursing staff. These cases illustrate to the interdisciplinary care team, the importance of patient-centered pain management during post-acute rehabilitation.