Pain is a very common problem for older persons, with persistent (i.e. chronic) pain affecting more than 50% of older persons living in the community setting, and more than 80% of nursing home residents (Ferrell et al. 1995, Helme & Gibson 2001). Older persons are more likely to suffer from chronic pain than younger persons.
Pain is the most frequently reported symptom by older persons, being reported by 73% of community-dwelling older persons (Brody & Kleban 1983).
In older persons, pain tends to be constant, of moderate to severe intensity, lasting for several years, multifocal and multifactorial (Brattberg et al. 1996).
45.8% of older persons admitted to the hospital report pain; 19% have moderately or extremely severe pain; 12.9% are dissatisfied with their pain control (Desbiens et al. 1997).
Dr. A. Krakovsky, a well-known professor of the College of Medicine and Surgery and a renowned physician in interventional pain management of the International Pain Institute in California, USA, asserts that the elders are one of the most difficult patients to cure as there are far too many obstacles in addressing their sicknesses. The reality is that age-old patients or what we call the ‘elderly patients’ are oftentimes the ones suffering heavily from hearing and vision impairment as well as cognition impairment. These, as attested by many pain management physicians, are considered to be huge barriers to identifying the main causes or triggers of their sicknesses, as because of these impairments, they are unable to communicate the amount of pain they often experience and the usual triggers of these types of pains.
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A typical elderly patient often suffers from diabetes, hypertension, various types of pulmonary diseases, heart failure as well as chronic renal failure. These sicknesses or co-morbidities are not only physically but also psychologically being experienced by most elderly patients. The reality is that while most young people perceive the elders as mere complainers, the truth is that they are just not aware that elderly patients indeed experience psychological changes and or co- morbidities such as anxieties, depression, lack of vitality and the lack of capacity to socialize. These, accompanied by other physical co- morbidities continue to make most elders of today suffer extreme pain every single day of their lives (Krakovsky, A. 2007).
Chronic pain, defined as the type of pain that usually takes a long period of time to be resolved, is also the type of pain usually associated with various elderly sicknesses or conditions like cancer, osteoarthritis, and neuropathy, to name a few. The current reality is that chronic pain, mostly being experienced by elders aged 60 and above often results to change in lifestyle of elderly. Because of extreme pain, most elders do not anymore enjoy the usual recreational activities and other physical activities that they used to enjoy when they were younger. This also increases their aloofness and the chances of them isolating themselves from other people, losing their ability to work as well as increase their bond with other family members (Krakovsky, A. MD. 2007).
Alongside this current reality is the more alarming truth that most people are unaware of, is the growing percentage of the elderly, continuously suffering from chronic pain every single day of their lives to be only under treated by most physicians as well as healthcare providers even when they seek for medical assistance or aid from these so-called ‘doctors’. The truth about many elderly being under-treated is a sad reality that unfortunately has not been addressed until today. Apparently, physical and psychological impairments being experienced by the elderly are not the only reason for the under-treatment and the lack of proper medical aid for chronic pain relief. Current assessment tools for pain appear to provide inadequate information with regard to the intensity, frequency and location of the pain being experienced by an elderly. Unfortunately, these pain assessment tools merely look at observable reactions or behaviors of the elderly which can only give minimal and inaccurate indications of pain. Furthermore, many healthcare professionals possess this erroneous belief that the elderly are insensitive or numb to pain, thus giving them only few or weaker doses of pain treatments. This is also driven by the inaccurate belief that the elderly cannot endure the effects of opioids analgesics which can cause addiction or other negative effects on an elder’s weak body. In many nursing homes, healthcare staff and the availability of drugs meant for pain relief are also very limited that’s why many elders remain enduring the pain. Indeed, the reality of chronic pain among the elderly, as attested and proven by the American Geriatrics Society (AGS), is indeed very prevalent yet is mostly under-treated as well as under-recognized (Pain Management. 2008)
Assessment of pain in older persons requires a multifaceted and comprehensive assessment, including pain characteristics (intensity, quality, variations over time and situation), pain impacts (degree of psychological/affective disturbance, degree of functional limitations in activities of daily life, social impact), use of coping strategies, beliefs and attitudes toward pain, other medical illnesses, and cognitive functions.
Pain assessment often is more difficult in certain older populations, such as those in residential aged care, those with sensory loss (impaired vision or hearing), or those with cognitive impairment. For those who cannot communicate their pain, one must rely on nonverbal signs of pain (e.g., grimacing, guarding, agitation, frown eyebrows).
Older persons with dementia or communication problems are even more at risk of under-treatment of pain, due to difficulties communicating their pain. They are known to receive fewer analgesics than others of similar age and pathology (Parmalee et al. 1993; Pickering et al. 2006)
On initial presentation or admission of any older person to any healthcare service, a healthcare professional should assess the patient for evidence of persistent pain (AGS Panel 2002).
Any persistent pain that has an impact on physical function, psychosocial function, or other aspects of quality of life should be recognized as a significant problem (AGS Panel 2002).
Despite the fact that persistent pain is more common in the older segments of the population, the overwhelming majority of pain treatment studies and intervention trials have been conducted in young adult populations. Age differences in treatment efficacy have rarely been considered. There is a manifest lack of scientific evidence to support most of the currently accepted treatment approaches for the management of pain as applied to older adults (Gibson 2006).
Multidisciplinary pain programs that combine several modes of pharmacological and non-pharmacological treatment have demonstrated efficacy for the management of persistent pain in older adults. However, this approach appears to be underused at present because older patients are underrepresented in pain management clinics, are less likely to be offered this treatment, and receive fewer treatment options when attending such clinics (Kee et al. 1998).
2. Problem Statement and Research Question:
While chronic pain has long been a prevalent phenomenon constantly being experienced by many elderly patients both inside and outside the nursing homes, too little time and money spent rather on medical research and studies was being allocated and was being undertaken by professional practitioners in the field of medicine to lessen if not totally eradicate the chronic pain suffering of many elderly patients.
This research is meant to find a solution and to break down the barriers to the total minimization and eradication of the chronic pain phenomenon among the elderly. Basically, at the end of the study, three significant and relevant questions will be answered to address the problem statement above and these are:
How active and how progressive are the medical practitioners and healthcare professionals in finding solutions to address the under treatment and experience of pain among the elderly
How effective are the current available chronic pain medications and what are the risks and benefits of each chronic pain treatment to each elderly patient? And:
What are other possible safe and reliable chronic pain treatment alternatives currently not being tapped or utilized by medical practitioners who are intended to address the fast growing rate of elderly in need of chronic pain medications?
This research which focuses on the current reality of the chronic pain phenomenon among the elderly aims to look into two major hypotheses which could possibly resolve the ultimate objective of minimizing if not totally eliminating the chronic pain suffering as evidently and prevalently experienced by many elderly patients both inside and outside the nursing homes. Below are the two possible hypotheses that can be drawn out of the research study.
Hypothesis 1: Current chronic pain medications available in the market, if carefully assessed, properly utilized and patiently monitored by most healthcare providers and medical practitioners are enough to resolve the total minimization and eradication of the chronic pain phenomenon among the elderly.
Hypothesis 2: Current chronic pain medications available in the market, even if carefully assessed, properly utilized and patiently monitored by all healthcare providers and medical Practitioners would not suffice for the total minimization and eradication of the chronic pain phenomenon among the elderly. Hence, a need to source out other possible chronic pain medication alternatives would provide the most effective way to lessen if not totally eliminate unnecessary chronic pain suffering among the elderly.
4. Aim and Specific Objectives:
This research protocol intended to look into the most effective means to minimize, if not completely eliminate the chronic pain phenomenon among the elderly and aims to accomplish three major objectives which are the following:
To carefully and accurately assess extent of under-treatment among elderly.
To be able to design a suitable assessment tool to be more accurate indications of pain.
To source out other possible safe and reliable chronic pain treatment alternatives currently not being tapped or utilized by medical practitioners, intended to address the fast growing rate of elderly in need of chronic pain medications
A. Research Design
A quantitative study for this research with the aim of identifying the most effective and feasible means to minimize if not completely eliminate the unnecessary suffering of many elderly patients due to the chronic pain phenomenon, will be accomplished using a substantial amount of respondents, both residing in nursing and non-nursing homes. A pool of 1000 respondents, all qualified as suffering from chronic pain, will be randomly selected. Half of the total respondents will come from the nursing homes and the other half those residing outside the nursing homes. Data gathering will involve data of respondents who had taken medications to resolve chronic pains vs. data of respondents who did not take medications to minimize chronic pains. The quantitative study will identify which among the medications are most commonly taken by respondents, which ones are prescribed by medical professionals and which ones are most effective and least effective in treating chronic pains. Furthermore, the quantitative study will look into other alternative means of chronic pain medications which the respondents have tried in the past to alleviate the pain they have been experiencing.
B. Research Study Population
This qualitative study will involve a pool of 1000 respondents, males and females from all socio-economic levels, aged 55 and up. 500 of the total 1000 respondents are supposed to be residents of nursing homes while the remaining 500 are supposed to be non-residents of nursing homes. All 1000 respondents must have met the qualification which is an experience of chronic pain in as often as once a day at least in the past one year and experience of either a routine medication order or an alternative chronic pain medication. The sample population of elderly patients will all be selected randomly.
C. Sampling Method
The data for this quantitative study will be collected and generated via the Computer Assisted Telephone Interview (CATI) technology. Using a random generation of telephone numbers accompanied by a two-stage stratified sampling method, respondents will be selected based on the single criterion which is an experience of chronic pain at least once a day for period of over six months or one year and longer.
D. Inclusion and Exclusion Criteria
Using a two-stage stratified sampling method and the use of the CATI technology, respondents will be selected entirely at a random basis. All the respondents must have met the following criteria: Males & Females age 55 and above, from ABCD socio-economic class, and must have experienced chronic pain for the past one year at least every day or once a day for the past one year or longer. All respondents who did not meet all of the above-given criteria will not be included in the pool of 1000 respondents.
E. Study Procedures
The qualitative study in this specific research protocol will involve a huge number of respondents totalling to 1000 (500 from nursing homes and 500 from non-nursing homes). The respondents must meet the set criteria to be qualified as a respondent which are: Males & Females age 55 and above, from ABCD socio-economic class, and must have experienced chronic pain for the past one year at least every day or once a day for the past one year or longer. Using a stratified sampling procedure with two-stages, the respondents will be randomly pre-screened to determine if they will be included or excluded in the study. Upon inclusion in the qualitative study, the respondents will be interviewed by randomly assigned interviewers from an outsourced Market Research Agency to avoid possible biases in the study results. Interviews will be conducted via the Computer- Assisted Telephone Interview (CATI). Telephone numbers of the qualified respondents will be randomly generated as well using the CATI technology.
F. Description of Pilot Study
To identify the effectiveness of the qualitative study, a pilot study will first be conducted during the first three months wherein the actual study procedures will be applied as specified in the research design and methodology.
G. Data Gathering Method
The data gathering method that will be applied in the study is a two-stage stratified sampling method. This is to ensure the quality and randomness of the chosen qualified respondents and to increase the confidence of the research results.
The researchers visited the [Insert name of University Library or City Library] for journals, articles and studies needed for the research paper. The researchers gathered time-series data from different physical training institutions to assure of its validity and consistency.
The primary data will be gathered using quantitative method, as this is best useful with questionnaires. The use of quantitative method will be appropriate for the research because the results in the questionnaires consist of numerical information, mostly based from the ratings included in the questions. Quantitative methods are used to provide reference to numeric calculations and are often used with questionnaires that have a specific goal and a target to achieve. This is helpful in the research, and its instigation in the process needs to be further culminated so that the problem is solved with efficiency and precision.
In gathering data, the researcher would like to clear certain ethical issues that might hinder the processing of data. First, confidentiality will be kept at all costs. As the main reason why questionnaires will be used in the research is for the respondents to feel secure and to be assured that their answers will not be related to who they are. There may be instances wherein the respondent will divulge information that will be detrimental to the company, or to its competitors, depending on the case. Hence, there is a better chance at more responsive respondents if they can be assured of their confidentiality.
Second, the Data Protection Act will be followed at all costs. The compliance with the act will be transparently said to the respondents so that they are further assured that anything they say in response to the questions asked them will only be used for the benefit of the research and not in any other practices. It should also be clear to the researcher that any information regarding the respondents cannot be released to anyone who is not immediately connected with the research unless permission from the subject respondent has been secured beforehand.
Third, the research must always bear in mind the objectives of the study and never stray away from them. A researcher who has no definite purpose in doing the research is going nowhere and is exerting effort in a research that is not delimited properly and punctually. The purpose of the research is explicitly stated at the beginning of the research and is implied in every step of the realization of the research so as to not delineate the researcher from his goals.
Lastly, the researcher must opt to practice objectivity. As the researcher, he is expected to keep an open-minded approach to the topic, keeping from his mind and personal bias in the subject matter or on the people involved. The reason for doing research is to test existing information, validate, prove or disprove existing ideas, or to test the limits of a certain prospect. Given this simple definition, it is clearly seen that in no form is the personal opinions of the researcher expected to hinder in the subject. Any act that might be biased or subjective will hint of the research’s failure to achieve its goals.
H. Statistical Analysis and Interpretation
The survey and all the qualitative data gathered will be inputted and carefully assessed in the SPSS or the Statistical Package for the Social Sciences for a much clearer and accurate data analysis. The measures will be carefully weighed by using this appropriate statistical tool and the measures will as well be analyzed strictly. Measures will include the type of medication being used, the effects both positive and negative of these types of medications and the overall effectiveness of each medication type to each patient. The lifestyle and overall emotional condition will also be very important factors to be considered. A percentage of subjectivity in the measures will be considered and weighed down as well.
6. Ethical Considerations
To determine the effectiveness of each of the medications taken by the elderly patients to alleviate chronic pain, a strict implementation of the qualification and requirements will be needed so as to acquire accurate results on the effect of each treatment to each individual patient. However, to answer the specific objective on sourcing out new and effective alternative medical treatments, the researcher would not recommend testing new types of medications on actual people, specifically, actual elderly patients because of the big risk involved on the possible adverse effects of new medications to people. For instance, there is a big potential risk of the negative effects of NSAIDs or non-steroidal anti-inflammatory drugs like Aleve, Celebrex and Ibuprofen. Two other drugs called Vioxx and Bextra have also been recently banned due primarily to the higher risk than benefit effect of drugs such as these to elderly patients (Barber, A. 2009).
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Because of this, the testing of each new medication must strictly not be done on individuals or if can be avoided, should not also be tested on animals. This important ethical consideration must also force medical professionals and healthcare providers to source out other safe and reliable means to address the chronic pain phenomenon among the elderly.
7. Strengths and Limitations of the Study
The scope of this qualitative study only involves addressing the three specific objectives identified as:
1. Assessing how much rate or progress the healthcare providers and medical professionals are providing when it comes to finding the right solution to address the chronic pain phenomenon
2. Identifying which current chronic pain medications are most effective and which ones are the least effective and
3. Sourcing out other alternative chronic pain treatment which is also effective to alleviate the elderly patients’ pain.
On the other hand, the study will not delve on the post-evaluation method of reassessing the risks and benefits of each medication to its patients. It will also not delve on studying the possible negative and positive effects of each type of medication on other age groups. The study will only be limited to the elderly who are suffering from chronic pain for the past one year.
8. Reporting and Dissemination of Results
Results of this qualitative study will be directly sent to the American Geriatrics Society as well as other organizations involved in improving and developing medical assistance. Doctors all over the country as well as pharmaceutical companies must also be furnished a copy of the results so as to enable them to review all the possible effects (both positive and negative) of each medication or treatment they are offering to the consuming public.
Barriers in assessing and treating pain in the elderly are the following:
â€¢ The elderly often under report pain because it is often considered a normal part of aging.
â€¢ The elderly sometimes choose to suffer in silence. This may be a culturally orientated response to pain or may be related to the high cost of medications and/or inability to access medical care.
â€¢ Caregivers’ and other’s misconceptions of the pain experience can influence the elderly person’s pain.
â€¢ Elderly persons with cognitive impairments or communication challenges may not be able to make their pain needs heard. Nurses must be observant of subtle clues such as guarding, wincing, moaning etc.
â€¢ The ability of elderly persons to swallow pills easily may be impaired due to dry mouth, swallowing difficulties or ill-fitting dentures.
There are a number of systematic, validated pain assessment tools available to assist you with your pain assessment.
The tool that you select should reflect the following basic parameters of pain:
â€¢ Location of pain
â€¢ Effect of pain on function and activities of daily living
â€¢ Level of pain at rest and during activity
â€¢ Medication usage and adverse effects
â€¢ Provoking and precipitating factors
â€¢ Quality of pain (in the resident’s words – achy, hurting)
â€¢ Radiation of pain – does it extend beyond the site?
â€¢ Severity of the pain (intensity, 0-10 scale)
â€¢ Pain related symptoms
â€¢ Timing (constant, occasional)
Tools to Assess the Intensity of Pain (established validity)
â€¢ Visual Analogue Scale (VAS)
â€¢ Numeric Rating Scale (NRS)
â€¢ Verbal Scale
â€¢ Faces Scale
â€¢ Behavioural Scale
This qualitative study must be accomplished in a maximum period of six months. After the whole six months of study, the results must be approved and sent out already to the concerned individuals such as hospitals, doctors, medical associations, pharmaceutical companies, the media and even the consumers for an increased awareness regarding the chronic pain phenomenon.
The budget needed for the said study will be for the research conduction facilities needed, the petty expenses and the specialist needed to analyze the treatments’ effetiveness will have costs too. Consultants will help in determining the right facilities needed for the study being conducted.
Transportation = $115
Supplies needed for the paper (A4 paper, printer, photocopy) = $ 54
Consultant’s fee = $ 500
Processing of permits needed for the said research = $120
TOTAL = $798
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