Pain prevalence and risk factors based on self-reported data from nursing home residents: a multicentre cross-sectional study

The number of older people is steadily rising, both internationally (United Nations Department of Economic and Social Affairs 2019) and nationally in Switzerland (Bundesamt für Statistik 2023). As life expectancy increases, so do the risks of chronic disease and multimorbidity. As a consequence, more people are becoming dependent on help from their relatives or on professional help from outpatient services or residential institutions (Maresova et al. 2019), thus continuously increasing the number of people living in nursing homes (Eurostat 2021). For nursing homes, this translates into residents becoming older and more dependent on care. The existing and worsening shortage of qualified healthcare professionals (Organisation for Economic Co-Operation and Development (OECD) 2019; Schweizerisches Gesundheitsobservatorium (Obsan) 2021) and increasingly restrictive funding for long-term care (Eling and Elvedi 2019) exacerbate the challenge of ensuring a high quality of care and quality of life for nursing home residents.

Physical pain plays an important role in the quality of life of nursing home residents (Bjork et al. 2016; Sjölund et al. 2021; van Kooten et al. 2017). In the context of this article, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage” (Raja et al. 2020). Pain affects all areas of nursing home residents’ lives, such as activities of daily living, mood, participation in activities and social integration. In residents with severe pain, these aforementioned negative effects are particularly present (Brunkert et al. 2020).

Even though more attention has been paid to the issue of pain in nursing home residents in recent years, the situation has not yet improved sufficiently, with pain prevalence rates still ranging between 43 and 84% (Damsgard et al. 2018). These rates indicate considerable potential for quality improvement with regard to the quality of care. Pain is frequently under detected and, accordingly, undertreated (Veal et al. 2018). This is due, for instance, to a lack of training in assessing and treating pain among healthcare professionals (Damsgard et al. 2018) and insufficient cooperation between medical and nursing staff (Veal et al. 2018). Moreover, residents with limited cognitive or communicative abilities cannot adequately express themselves (Miu and Chan 2014) and, last but not least, many residents and staff believe that pain is an expected part of ageing (Bae et al. 2020).

A first important step towards quality improvement is to understand more precisely which residents are affected by pain. Once those in pain are identified, it is particularly significant to understand who is affected by severe pain and undertreatment (Reid et al. 2015). International studies have explored the characteristics of residents who experience pain. Residents with more severe depressive symptoms reported increased severity and consistency of pain (Chen et al. 2020). In residents with impaired cognitive function, the results were mixed: Bae et al. (2020) reported less pain, which was attributed to the fact that these residents are less able to express pain. Sjölund et al. (2021) found no significant difference based on cognitive levels. In addition to resident characteristics, nursing home characteristics were evaluated. Residents in large nursing homes and in homes located in urban areas were more likely to suffer from pain (Sjölund et al. 2021; van Herk et al. 2009).

In the literature, the presence of pain and the characteristics that influence pain have usually been determined by nursing documentation or by interviewing healthcare professionals (Bae et al. 2020; Bjork et al. 2016). However, it has been conclusively shown that the assessment of residents’ pain by staff is not identical to the self-assessment of pain by residents (Sjölund et al. 2021; van Herk et al. 2009), and the gold standard and desirable goal is to ask the residents themselves, whenever possible. This is further underscored by the intended transformation in nursing homes away from task-oriented care and towards person-centred care. In this context, it is essential to focus on the needs, wishes and preferences of residents and to take their perspective into account (Sion et al. 2020).

A total of 49 nursing homes took part in the study. Most of the participating nursing homes were medium sized, with 50–99 beds (42.9%). A clear majority of the nursing homes were located in urban areas (71.4%) and in the German-speaking part of Switzerland (85.7%). A comparable number of nursing homes were private (38.2%) and public (36.7%). Table 3 provides an overview of the participating nursing homes.

The general characteristics of the 1198 residents included in the present study are shown in Table 4. The majority of participants were women (71.5%). Over half of the participants (54.2%) were 85–94 years old, another quarter (26.0%) were 75–84 years old. Cognition of half of the participants was intact (31.5%) or borderline intact (23.5%), 27.3% were mildly impaired and 17.8% were moderately impaired. Most of the participants were care independent (38.2%) or to a great extent independent (32.0%). Only a few residents who were to a great extent dependent or care dependent (6.9%) could be interviewed. The vast majority of participants were able to completely (56.9%) or partially (9.1%) choose the nursing home they wanted to go to. Most participants rated their overall health as good or very good (56.1%) or as mediocre (37.8%).

Our study investigated the frequency and intensity of pain among residents of Swiss nursing homes by directly interviewing the residents. Further factors associated with pain, such as which residents were affected by pain and in particular by severe pain on average over the past week and which residents showed indications of undertreatment, were explored. Approximately 60% of nursing home residents reported experiencing a median pain intensity of 5 (moderate), with women and those in poorer health having significantly higher odds of both pain and higher pain intensity. Indications of undertreatment were found in that 12.6% of residents with pain reported not receiving pain medication and 15.9% of residents who reported receiving pain medication nevertheless reported severe pain intensity (7–10).

The results of our study confirm that pain remains a major topic in nursing homes in Switzerland among cognitively intact or slightly impaired residents, despite all efforts in recent years to reduce it (Damsgard et al. 2018). Of the 1198 residents interviewed, just under two-thirds reported experiencing pain. In general, pain prevalence is described as varying internationally, but the number found in our study ranks among the higher values (Cole et al. 2023). This is consistent with the finding that higher levels of pain are found when residents themselves or their relatives are interviewed as opposed to when pain data are taken from documentation (Cole et al. 2023).

In order to better address pain in nursing home residents, it is important to know which characteristics residents with pain share. The results from our models 1 and 2 about pain frequency and pain intensity show that women experience more pain than men, which is confirmed in the international literature (Brandauer et al. 2020; Cole et al. 2023; Lukas et al. 2013). Various reasons, such as biological processes related to sex-specific hormones or the different nature of male and female brain structure and function, are discussed (Wranker et al. 2016). It is also conceivable that cultural norms may give an older generation of women a feeling that they do not have the right to express their needs. Our results show that in women, poor overall health is also more often accompanied by severe pain, which is not the case in men. Essentially, pain status needs to be determined more precisely and carefully in female nursing home residents so that a better response can be made when pain is present.

Another indication of residents in pain can come from looking at their overall health. Residents were asked to self-assess their overall health. The results of our models 1 and 2 about pain frequency and pain intensity show that residents who rated their overall health as moderate and poor or very poor were more likely to have pain than residents who self-assessed their overall health as good or very good, which is confirmed in the literature (Axon and Maldonado 2023). It seems reasonable that there is a link between poor overall health and pain, since a poorer health status is associated with illness, and this may be a reason for pain. However, it could not be determined whether residents perceived their overall health to be worse because they were in pain or whether their poor health was leading to pain. Interestingly, model 3 regarding pain with no medication reported shows that residents with good or very good overall health had higher odds of being in pain without reporting receiving medication against it than residents with poor or very poor overall health. In residents with good or very good overall health, pain is probably less expected than in residents with poor or very poor health, so the residents with good overall health might not be asked about pain at all. The same hypothesis may be true for younger versus older residents. In contrast, model 4 about pain despite reporting receiving pain medication showed that residents with moderate as well as poor or very poor overall health had higher odds of reporting pain despite reporting receiving pain medication compared to residents with good or very good overall health. It is conceivable that both residents and healthcare staff in nursing homes simply view pain as an irrevocable given when the chosen pain medications do not seem to work sufficiently, rather than considering a change in therapy.

The descriptive analyses related to the third outcome showed that more than 12% of residents interviewed who were suffering from pain were subjectively not receiving any kind of pain medication. Although this is a lower rate than in previous international studies (Boonstra et al. 2016; Scottish Intercollegiate Guidelines Network (SIGN) 2013, Revised August 2020), it still deserves closer attention. Apart from the aforementioned association with overall health, this specific group presented additional characteristics. Residents of medium-sized nursing homes were more likely to suffer from pain without reporting receiving pain medication than residents from small nursing homes. A reason could be that in medium-sized nursing homes it is less possible to know each resident personally than in small nursing homes (Spangler et al. 2019). On the other hand, medium-sized homes might have fewer resources to have a specific expert group responsible for pain management in comparison to large nursing homes. Experts in pain management can identify pain in residents more effectively and ensure regular training on pain management in the nursing homes (Ersek et al. 2020). Model 4 about pain despite reporting receiving pain medication shows that even if residents receive pain medication, it does not always seem to work sufficiently. This takes on even greater significance considering that 15.9% of residents who stated that they were given pain medication still rated their pain as severe. According to current guidelines, the pain management of these residents must be evaluated regularly (Boonstra et al. 2016; Scottish Intercollegiate Guidelines Network (SIGN) 2013, Revised August 2020). As pain is a highly complex biopsychosocial construct (European Pain Federation 2022), this pain management must not only include pharmacological measures but also other important aspects that can have an impact on pain (e.g. nonpharmacological measures or the overall circumstances of the residents). This knowledge must be firmly established in nursing homes so that pain is regularly recorded and successfully treated.

In contrast to other studies (Bae et al. 2020; Cole et al. 2023), our results showed no association between cognitive impairment and pain or its severity. This might be related to the fact that only residents with intact or mildly to moderately impaired cognition could be included in our study. Care dependence was another characteristic we tested, but it showed no relevant associations with the outcomes in the models and, accordingly, was not selected into the model. This is in contrast to other research, as internationally, higher care dependency was shown to have a negative impact on pain (Hoedl and Bauer 2020). However, in our study, only a minority of those we interviewed were highly care dependent, which might have had an influence on our results. The characteristic of choice of nursing home was selected in one model, but the association did not reach a statistically significant level. There was not much variability between nursing homes. Whether someone is in pain seems to depend more on the person than on which nursing home they live in. Another possible interpretation is that the quality of care in Swiss nursing homes is homogeneous in terms of pain management and that improvements are therefore needed at national level.

The problem of pain is prevalent in nursing homes in Switzerland among cognitively intact or slightly impaired residents, with many residents experiencing high levels of pain intensity and a significant percentage who still report pain even though they report receiving pain medication. Our results indicate that women and residents with poor or very poor overall health conditions are particularly vulnerable to experiencing pain. Therefore, optimising pain management should be a priority in general, but with special attention to these at-risk groups. It is important for nursing homes to regularly evaluate and monitor pain in their residents, preferably by asking them directly. In particular, it is important to check whether residents who are already receiving pain medication find it sufficiently effective. Inadequate pain treatment is a complex issue that requires attention to pain assessment and management concepts.