North Dakota Nurse - April 2021

April, May, June 2021 The North Dakota Nurse Page 7
Nonpharmacological Pain Management
Interventions for Older Adults
Appraised by:
Alanna Rohweller SN, Morgan Erickson SN,
Brielle Marman SN, Kyla Schock SN, Morgan
Erickson SN, (NDSU School of Nursing at Sanford
Bismarck)
Allison Sadowsky MSN, RN Assistant Professor
of Practice (Faculty)
Clinical Question:
In the elderly population, what are the health
effects of nonpharmacological interventions
on pain management compared with
pharmacological interventions.
Sources of Evidence:
Fitzgerald, S., Tripp, H., & Halksworth-Smith, G. (2017).
Assessment and management of acute pain in
older people: Barriers and facilitators to nursing
practice. Australian Journal of Advanced
Nursing, 35(1), 48-57.
Koo, V., Shicheng Jin, Wan, B. A., Ahrari, S., Lam, H.,
Rowbottom, L., Chow, S., Chow, R., Chow, E., &
DeAngelis, C. (2018). Pain management in older
adults with dementia: A selective review. Journal
of Pain Management, 11(4), 333–344.
Park, J., & Hughes, A. K. (2012). Nonpharmacological
approaches to the management of chronic
pain in community-dwelling older adults:
a review of empirical evidence. Journal of
the American Geriatrics Society, 60(3), 555–
568. https://doi-org.ezproxy.lib.ndsu.nodak.
edu/10.1111/j.1532-5415.2011.03846.x
Qi Zhang, Lufei Young, & Feng Li. (2019). Network
Meta-Analysis of Various Non Pharmacological
Interventions on Pain Relief in Older Adults with
Osteoarthritis. American Journal of Physical
Medicine & Rehabilitation, 98(6), 469–478.
Tang, S. K., Tse, M. M. Y., Leung, S. F., & Fotis, T. (2019).
The effectiveness, suitability, and sustainability
of non-pharmacological methods of managing
pain in community-dwelling older adults: a
systematic review. BMC Public Health, 19(1),
1–10. https://doi-org.ezproxy.lib.ndsu.nodak.
edu/10.1186/s12889-019-7831-9
Synthesis of Evidence:
Older adults usually receive pharmacological
treatment for pain management of chronic
pain, but because of age related changes,
older adults are at a significantly higher risk
of adverse effects from pain medications
including liver and kidney damage,
gastrointestinal bleeding, high blood pressure,
worsening of heart failure, and constipation.
Five articles were reviewed as evidence in
this report. Four of the articles were systematic
reviews that used randomized control studies,
and one article that was a systematic review
including cluster randomized trials, double
blind randomized study, double-blind doubledummy
placebo-controlled crossover study,
randomized double blind placebo controlled
crossover trial, open medication study, quasiexperimental
design, and a pilot randomized
controlled trial. Non Pharmacological
interventions may be most appropriate
for individuals who cannot tolerate pain
medications because of the side effects or are
reluctant to take pain medications and are
seeking alternative methods for controlling
chronic pain. In addition, non-pharmacological
interventions may be suitable for older adults
who are taking multiple medications for
numerous chronic diseases and who seek
to reduce dosages and frequency of pain
medications and drug-drug interactions that
can result from taking multiple medications.
Non-pharmacological pain regimens may
provide alternative therapeutic balance to pain
relieving medication, decreasing the doses of
medications needed and minimizing adverse
events and side effects (Park & Hughes, 2012).
Fitzgerald, Halksworth-Smith, and Tripp (2017)
conducted an integrative literature review of
a combination of quantitative and qualitative
studies. The review included 13 articles with a
total of 9,161 older adult patients and 756 nurses.
The aim of the review was to examine pain
management practices of nurses and identify
barriers and facilitators to assessment of pain
and management of pain for older adults in
the acute hospital setting. A total of 101 findings
were taken from the 13 studies. These findings
were synthesized into fourteen themes, which
were grouped into four categories; nursing
practice, organizational factors, knowledge
and education, and power balance. Findings
indicated that nurses need to improve their
communication and interactions with older
patients, as well as their knowledge of pain
assessment and pain management.
Koo, Shicheng, Wan, Ahrari, Lam, Rowbottom,
Chow, S., Chow, R., Chow, E., and DeAngelis
(2018) conducted a systematic review of
a variety of studies. The systematic review
included 11 different studies. The study
types consisted of cluster randomized trials,
double blind randomized study, doubleblind
double-dummy placebo-controlled
crossover study, randomized double blind
placebo controlled crossover trial, open
medication study, quasi-experimental design,
and a pilot randomized controlled trial.
The goal of this study was to examine the
different options for pain management in
older adults that have dementia. There were
a total of 1102 participants that included older
adults aged 67-91 who have dementia and
pain. The interventions included a variety of
nonpharmacological and pharmacological
methods to reduce pain. The main interventions
used were acetaminophen, stepwise protocol,
morphine, oxycodone, music therapy, ear
acupressure, massage therapy, and Namaste
care. Some of the interventions were also
carried out by leadership, proper staffing,
and quality care. This systematic review
displays data from multiple studies that show
acetaminophen, or the combination of a
stepwise program can sufficiently decrease
pain the best in elderly patients with dementia.
However, the findings were also consistent
throughout the articles stating that music
therapy, ear acupressure, massage therapy,
and Namaste care can also significantly reduce
pain in the elderly.
Park & Hughes (2012) used randomized
control trials (RCTs) of physical and psychosocial
interventions to summarize existing evidence of
nonpharmacological interventions. All of the
studies were conducted in the United States,
except for one in South Korea and one in Hong
Kong. The mean age of the participants in the
28 articles were aged 65 and older, community
dwelling older adults, and noncancer chronic
pain was a primary outcome measured in
the study. All 28 articles reviewed the Visual
Analog Scale (VAS) and the Western Ontario
and McMasters Universities Index (WOMAC).
The study looked at the effects of both physical
and psychosocial interventions. The physical
interventions included: TENS, TENS and electoacupuncture,
TENS and acupuncture, exercise,
exercise with light resistance, acupuncture,
acupuncture with exercise, acupuncture with
exercise and advice, exercise (walking) and
education, Qigong, and Qigong with exercise.
The psychosocial interventions included: selfmanagement
education, cognitive - behavioral
therapy, mindfulness meditation, music listening,
and guided imagery. This study showed
nonpharmacological interventions most
appropriate for individuals who cannot tolerate
pain medications because of side effects or
are reluctant to take pain medications and
are seeking alternative methods for controlling
chronic pain. In addition, these interventions
may be suitable for older adults who are taking
multiple medications for numerous chronic
diseases and who seek to reduce dosages and
frequency of pain medications and drug-drug
interactions that can result from taking multiple
medications. The review fell short in identifying
the most appropriate non-pharmacological
pain interventions for this population.
Zhang, Young, & Li. (2019) authored a network
meta-analysis to compare the effectiveness
of different nonpharmacological interventions
on pain relief in older adults with osteoarthritis.
They conducted this study by collecting
articles only using randomized controlled
trials. The articles were dated between 1997
through 2017. The sample sizes ranged from
21 to 454 patients. Altogether, 32 articles and
3228 patients were included. 11 of the articles
came from the United States, six from China,
three from Denmark, and the remaining from
Brazil, Israel, Japan, New Zealand, Norway,
Italy, France, Netherlands, and Canada. The
nonpharmacological interventions used were
resistance training, neuromuscular electrical
stimulation, walking, gait training, nordic
walking, targeted dynamic balance training,
cycle ergometry, whole-body vibration,
strengthening exercise, usual care, activities of
daily living, health education, yoga, stretching
exercise, acupuncture, aquatic exercise,
healing touch, heat treatment, intervention in
a heated pool, short-wave diathermy therapy,
balneotherapy, mud-bath therapy, Tai Chi,
and weight loss. Out of the interventions used
acupuncture was the least effective while
strengthening exercise had the greatest long
term effect on pain management.
Tang, Tse, Leung, and Fotis (2019) wrote a
systematic review of randomized controlled
studies. This systematic review was conducted
to evaluate the effectiveness, suitability, and
sustainability of non-pharmacological pain
management interventions for communitydwelling
older adults. The information was
collected from 10 different articles searched
on five different databases. The interventions
included acupressure, acupuncture, guided
imagery, periosteal stimulation, Qigong,
and Tai chi. The different pain rating scales
were the visual analogue scale, numeric
rating scales, and the Western Ontario and
McMaster University Osteoarthritis Index
(WOMAC). These studies compared the preintervention
mean pain intensity, compared
to the post-intervention mean pain intensity.
After implementing non-pharmacological
pain interventions, pain intensity decreased
by anywhere from one to three on a zero to
ten rating scale. The study concluded that
non-pharmacological methods of managing
pain were effective in lowering pain levels in
community-dwelling older adults and can be
promoted widely in the community.
Conclusion:
All five articles indicated success with nonpharmacological
interventions in reducing
pain in older adult populations. The articles
also mentioned that with the use of nonpharmacological
interventions, there was
a decreased need for pharmacological
interventions, therefore decreasing the risk of
side effects associated with those medications.
Another benefit was the cost effectiveness
of non-pharmacological interventions as
healthcare costs increase. The literature review
by Fitzgerald, Halksworth-Smith, and Tripp (2017)
concluded that there is a need for nursing
education, and the promotion of individualized
effective pain management within institutions,
to overcome these barriers and promote better
outcomes for the older population.
Implications for Nursing Practice:
Consistent implications that we saw within
all five articles were educating nurses to
better assess and individualize pain for each
older adult, as well as educating nurses on
ability to implement non-pharmacological
interventions. Another consistency was being
able to equip older adults with skills to improve
their self-efficacy in managing pain, taking
into consideration racial/ethnic disparities,
cognitive function, and ability to perform the
non-pharmacological interventions, rather
than solely investigating the effectiveness
of the interventions themselves. Similarly,
all articles mentioned implicating a way to
maintain sustainability of pain reductions, and
stay ahead of the pain, rather than the nonpharmacological
interventions only being
effective for a short time.