- Learn more about the Robert Wood Johnson Foundation Executive Nurse Fellows Program.
- Geriatric Care Web site.
- Iowa John A. Hartford Center of Geriatric Nursing Excellence
- Interdisciplinary Nursing Quality Research Initiative
Problem: Many older adults experience pain, but health providers often don’t know how to evaluate or treat pain in this population, especially when the patients have cognitive impairments. Even though research is providing new information about how best to manage pain among older patients, many health providers have yet to put that information into practice.
Background: Keela Herr, now a pioneering nurse scientist, a leading nurse educator and nationally renowned geriatric health leader, had just started her nursing career when her grandmother fell ill with pancreatic cancer more than three decades ago. Shortly after learning of the diagnosis, she decided to leave her new job in Missouri and move back to her childhood home in rural Iowa to help her mother care for her ailing grandmother.
Herr’s grandmother coped with the disease with strength and grace but also, to Herr’s dismay, with fear and stoicism. Like many older people, Herr’s grandmother didn’t feel comfortable talking openly with her doctors about her pain, perhaps because, as a child of the Great Depression, she viewed the articulation of pain and suffering as a sign of weakness. She was also reluctant to accept treatment.
Many older adults have other deeply rooted fears about pain that can prevent them from getting relief, Herr says. They may be afraid of adverse side effects, afraid of being hospitalized, and afraid that diagnostic testing will be uncomfortable and expensive. Also, thanks to a massive public relations campaign against illicit drugs in the 1980s, many older people may fear becoming addicted to pain medication. Addiction to pain medication, Herr notes, is not common in older adults and happens mostly to people with a history of substance abuse or mental illness—not those who are only struggling with pain.
“My grandmother had only a few months left to live, and she was afraid of getting addicted to opioids,” Herr says. “That’s crazy! Particularly at the end of life, the ultimate goal is comfort and the prevention of suffering, not concern over dependency and addiction to medications”
Herr’s grandmother’s physician also was reluctant to treat her pain and provided minimal pain analgesia. Instead of taking the recommended dose of weak pain medication, Herr’s grandmother instead chose to ration her medication use—and suffered in silence for the short remainder of her life.
Herr, Ph.D., R.N., F.A.A.N., was greatly distressed by what she witnessed. But she was not able to effectively intervene because she had received little instruction on pain management in nursing school. She wondered what could be done to help her grandmother—and the millions of other seniors in this country and around the world—manage intense and sometimes debilitating pain. The experience motivated her to learn more about how to better manage pain in older people.
Herr took the first step toward answering this question early in her career when she began researching valid and reliable ways to assess pain in older people as an assistant professor at the College of Nursing at the University of Iowa in Iowa City.
The answer, she knew, had tremendous potential to improve the health of a great number of people, especially in our rapidly aging society. Treating pain effectively can prevent adverse consequences such as fatigue, impaired mobility, depression and delirium, she says. It can also improve physical, psychological and social function. But, she notes, it has to be recognized and assessed before it can be treated.
To begin her research program Herr reviewed the literature on ways to measure pain and found nothing about older adults in particular. “There wasn’t a reliable and objective way to evaluate, measure, and monitor pain over time in older adults,” Herr says. “And there were few studies to support pain management approaches in this population. Pain treatment was hit or miss.”
Solution: Herr’s first attempt to solve the problem was to conduct a series of studies evaluating pain scales used to assess pain severity in older people. The findings of her work have been incorporated into clinical practice guidelines for assessing and treating pain in this population.
To better evaluate pain in older adults, health providers, she says, should take time to explain the negative consequences of untreated pain and the benefits of pain management. Pain scales have been validated that are appropriate for use by older adults, but health providers should repeat instructions, help patients to process new information, and adjust for sensory impairments (by using scales with large text and pictures, for example, or by providing hearing aids if needed). They should also focus on pain in the present instead of relying on patient memories of earlier pain levels. Seniors, she also found, prefer assessing their pain with verbal descriptor tools rather than numeric scales.
Herr’s next step in her career was to lead the development of guidelines for pain assessment in older adults with cognitive disorders such as dementia. If patients can’t self-report, she notes, health providers should look for medical diagnoses and conditions known to be painful, seek information from patient caregivers and family members, observe for behaviors suggestive of pain, and treat behavior changes that could possibly be related to pain to determine if patients respond to pain treatment.
In patients who cannot self-report pain, health care providers should consider how older persons with similar conditions and diagnoses experience pain—and assume the pain levels are similar, she adds. “If a patient who has a fractured hip or osteoarthritis reports moderate to severe pain, we have to assume the same kind of pain is present in patients with advanced cognitive impairment.”
Herr’s seminal work has garnered widespread attention and professional acclaim. She has received awards from organizations including the American Society for Pain Management Nursing (2006), the American Pain Society (2005), the Iowa Board of Regents (2005) and the Midwest Nursing Research Society (2009, 2011).
Yet despite its profound implications for the health of older people, her research has yet to be widely adopted by health care providers—even though the problem has persisted. At the onset of her career, Herr says, as many as one in two older adults and as many as four in five older adults in long-term care facilities reported problems with pain. Those numbers have remained fairly constant over the last two decades. “There is still a high prevalence of pain. Treatment, and even recognition of the need for treatment, is still not where we need it to be.”
Herr continues to study approaches to assessing pain, but she has broadened her focus to exploring ways to disseminate research and facilitate changes in practice.
One way she did that was as a Robert Wood Johnson Foundation (RWJF) Executive Nurse Fellow (2007-2009). The program helped provide the resources and support she needed to lead the development of a national Web site to spread knowledge about how to evaluate and treat pain in older patients. Herr has also disseminated her research findings in various publications and her work has been incorporated into professional consensus statements and guidelines used in the United States and around the world.
As the new co-director of the Iowa John A. Hartford Center of Geriatric Nursing Excellence at the University of Iowa’s College of Nursing and the newly named associate dean for faculty at the College of Nursing at the University of Iowa, she is exploring ways to promote practice changes and address barriers to adoption of pain assessment and management “best practices.” She is also working to recruit more students into the field of geriatric health, increase the number of faculty teaching the subject, and help students and faculty develop pilot grants and support for research into the health of older Americans.
Although pain in older adults is still prevalent, there are encouraging signs that knowledge of Herr’s seminal research and the importance of improving pain care is beginning to permeate the health care industry. The National Institute on Aging and the National Institute of Nursing Research have made pain management a research priority, she says. And the National Institute on Aging, the National Institutes of Health and the Food and Drug Administration held meetings in 2010 that resulted in a research agenda and strategies for promoting safe and effective pharmacologic management of pain in older adults.
“With the Baby Boomers moving into the senior cohort, everyone is becoming aware that our society’s profile is changing,” she says. “We are going to be a more aged society, and we need effective pain assessment and management to support quality of life. The Baby Boomers are going to demand it, and it is high time that good pain management for seniors is an accepted priority by all health care providers.”
RWJF Perspective: The Robert Wood Johnson Foundation supports improving the health of all Americans, including older Americans and those with cognitive impairments. Herr is just one RWJF Executive Nurse Fellow working to improve end-of-life care. While Herr focuses on older people, Jody Chrastek, another RWJF Executive Nurse Fellow, has dedicated her career to the emerging field of pediatric palliative care.
The Foundation is also committed to advancing the spread of new health care knowledge and promoting the adoption of best health care practices. For example, the Interdisciplinary Nursing Quality Research Initiative (INQRI), also funded by RWJF, has been working in collaboration with the Donaghue Foundation to bring researchers and funders together to find solutions to challenges of translating research into practice.