prevalence

CLINICAL INVESTIGATION

Prevalence and Characteristics of Moderate to Severe Pain
among Hospitalized Older Adults

Lisa X. Deng, BS,* Kanan Patel, MBBS, MPH,* Christine Miaskowski, PhD, RN,†

Ingrid Maravilla, BA,* Sarah Schear, BA,* Sarah Garrigues, BA,* Nicole Thompson, BA,*
Andrew D. Auerbach, MD, MPH,‡ and Christine S. Ritchie, MD, MSPH*

OBJECTIVES: To investigate the prevalence, characteris-
tics, and management of pain in older hospitalized medical
patients.
DESIGN: Medical record aggregate review.
SETTING: Tertiary care hospital.
PARTICIPANTS: Individuals aged 65 and older admitted
to the medicine service between November 28, 2014, and
May 28, 2015.
MEASUREMENTS: Demographic characteristics, comor-
bidity burden, pain characteristics, and analgesics during
index hospitalization were assessed in individuals with
moderate to severe pain (�4 on 0–10 Numeric Pain Rat-
ing Scale).
RESULTS: Of 1,267 patients admitted to the medicine
service, 248 (20%) had moderate to severe pain on admis-
sion (mean age 75 6 8, 57% female, 50% white).

During

hospitalization, most participants received opioids (80%)
and acetaminophen (74%), and few received nonsteroidal
antiinflammatory drugs (9%). Participants with chronic
pain had less reduction in pain intensity score from admis-
sion to discharge than those without a history of chronic
pain (mean change score 3.7 vs 4.9, p5.002) and were
more likely to receive opioids, adjuvant analgesics, and
other analgesics (all p<.05). CONCLUSION: Twenty percent of older adults admitted to a general medicine service had moderate to severe pain. Further research about optimal pain management in hospi- talized older adults, particularly those with chronic pain, is necessary to improve care in this population. J Am Ger- iatr Soc 2018.

Key words: pain; pain management; older adult; hospi-
tal; opioids

P
ain is a common and disabling condition in older
adults. Twenty-four percent to 72% of community-

dwelling older adults and 60% to 80% of older long-term
care facility residents report or have been observed to have
pain.1–4 Unrelieved pain is associated with adverse out-
comes in older adults, including poor physical functioning,
sleep disturbance, and falls.5–7 Studies have found that pain
is often inadequately treated in older adults in various care
settings.8–10 Multimorbidity complicates pain management
in older adults, with 65% of older adults having 2 or more
chronic conditions and 24% having 4 or more.11 High rates
of polypharmacy in older adults increase the risk of drug–
drug interactions and adverse effects.12,13

Despite accounting for 13% of the U.S population in
2008, more than 40% of all hospitalized adults were aged
65 and older.14 There is limited research about the occur-
rence and management of pain in older adults in the hospi-
tal. Studies have focused on overall admission pain
prevalence, pain in the emergency department, and hip frac-
ture pain.15–18 The prevalence and management of pain in
older adults on general medicine services is unknown.

The objectives of this study were to determine the
prevalence of pain in older adults admitted to a medicine
service, examine the pain characteristics and management
of moderate to severe pain in these individuals, and inves-
tigate differences in pain and pain management in differ-
ent subgroups of individuals.

METHODS

Study Population

This retrospective cohort study included individuals aged
65 and older admitted with moderate to severe pain to

From the *Division of Geriatrics, Department of Medicine, University of
California; †Department of Physiological Nursing, School of Nursing,
University of California; and the ‡Division of Hospital Medicine,
Department of Medicine, University of California, San Francisco, San
Francisco, California.

Address correspondence to Christine Ritchie, MD, MSPH, 3333 Califor-
nia Street, Suite 380, San Francisco, CA 94143. E-mail: christine.ritchie@
ucsf.edu

DOI: 10.1111/jgs.15459

JAGS 2018
VC 2018, Copyright the Authors

Journal compilation VC 2018, The American Geriatrics Society 0002-8614/18/$15.00

http://crossmark.crossref.org/dialog/?doi=10.1111%2Fjgs.15459&domain=pdf&date_stamp=2018-08-10

the medicine service of a tertiary medical center in San
Francisco between November 28, 2014, and May 28,
2015. Moderate to severe pain was defined as a first
documented pain intensity score of 4 or greater within 24
hours of admission as assessed using the 0 to 10 Numeri-
cal Pain Rating Scale (NPRS) or a Checklist of Nonverbal
Pain Indicators (CNPI) score of 1 or greater.19,20 The
NPRS is a reliable, commonly used tool to assess pain in
older adults, and the CNPI is frequently used to assess
pain in cognitively impaired elderly adults.21 For individ-
uals with multiple admissions during the 6 months of
enrollment, the most recent admission was considered.
Ethics approval was obtained from the local institutional
review board.

Study Measures

Trained clinical and research personnel conducted struc-
tured medical record reviews. Demographic data such as
age at hospitalization, sex, race, ethnicity, marital status,
insurance type, and language preference were abstracted
electronically. Abstracted index admission information
included length of hospital stay and admission and dis-
charge locations. Pain characteristics included pain sites
and relevant pain-related diagnoses from the electronic
health record problem list (e.g., chronic pain, dementia,
depression).

On admission, the first documented NPRS or CNPI
score was recorded. At discharge, the last documented
NPRS, CNPI, or Verbal Descriptor Scale (VDS) score was
recorded. A subset of participants completed pain assess-
ments at discharge using the VDS, a valid, reliable tool
that elicits a verbal description of pain intensity (none,
mild, moderate, severe, very severe).22 Individuals who did
not have documented pain scores within 24 hours of
admission or within 48 hours of discharge were excluded.
To harmonize the 3 pain scales, CNPI scores were con-
verted to NPRS scores using the following algorithm: 1–2
! 5, 3–4 ! 8. VDS scores were converted to equivalent
NPRS scores using the following algorithm: none ! 0,
mild ! 2, moderate ! 5, severe ! 8, very severe ! 10.23

We recorded data about analgesics at 3 time points:
before hospitalization, during hospitalization, and at dis-
charge. We categorized analgesics into 4 types: nonopioids
(acetaminophen, nonsteroidal antiinflammatory drugs
(NSAIDs)), opioids, co-analgesics (e.g., antidepressants,
anticonvulsants), and other analgesics (e.g., lidocaine,
baclofen).24 We noted nonpharmacological methods of
pain treatment (e.g. repositioning, hot or cold application,
emotional support). Morphine equivalent daily dose
(MEDD) was calculated for opioid intake on the first and
last day of admission. A high MEDD was defined as 50
mg or more based on dosing recommendations in the
2016 Centers for Disease Control and Prevention guide-
lines.25 To verify accuracy of chart abstraction, an inde-
pendent abstractor re-evaluated and adjudicated data for
10% of the sample.

We assessed comorbidity burden using the Cumulative
Illness Rating Scale for Geriatrics (CIRS-G),26,27 a vali-
dated tool in older adults that assigns ratings from 0 to 4
based on severity for 14 organ systems. Total score ranges

from 0 to 56, with higher scores indicating greater burden
of disease. The 1991 CIRS-G manual was the main refer-
ence for score calculation,28 and the 2008 CIRS-G man-
ual29 was used to clarify ambiguous scoring scenarios.
Trained clinical personnel completed CIRS-G scoring. To
check interrater reliability, a trained research team mem-
ber scored a subset of the first 100 charts. All discrepan-
cies were resolved through consultation with the senior
author (CSR).

Statistical Analysis

We calculated descriptive summary statistics related to
pain prevalence and treatment characteristics using the
chi-square test for categorical variables and the Student t-
test for continuous variables. Pain prevalence, characteris-
tics, and management were examined in different sub-
groups of participants. These variables were determined a
priori based on previously identified factors associated
with pain and included age, sex, race, history of chronic
pain, depression, and dementia.2,17,30 We examined outpa-
tient treatment characteristics before hospitalization and at
discharge using the McNemar test or Wilcoxon rank sum
test and paired t-test as appropriate. To adjust for signifi-
cant factors based on previous research, multivariate logis-
tic regression analysis was used to determine variables
independently associated with history of chronic pain.31–33

All analyses were conducted using SAS version 9.4 (SAS
Institute, Inc., Cary, NC).

RESULTS

Patient Sample

Of the 1,267 individuals admitted to the medicine service
for nonelective procedures, 938 (74.0%) had no pain, 81
(6.4%) had mild pain, and 248 (19.6%) had moderate to
severe pain. The current analysis is restricted to the 248
whose admission records reported moderate to severe pain
(Figure 1). The mean age of those with moderate to severe
pain was 75.068.3, 56.5% were female, 50.4% were
white, and 89.5% were non-Hispanic; 71.4% reported
English as their primary language, 82.7% had Medicare
insurance coverage, and 45.2% had Medicaid coverage.
Mean length of hospitalization was 5.766.4 days, and
mean CIRS-G total score was 17.365.6 (Table 1).

Pain Characteristics and Management

At the time of admission, mean NPRS score was 6.361.8;
55.2% reported moderate pain (NPRS 4–6), and 44.8%
reported severe pain (NPRS 7–10); 39.9% had a docu-
mented history of chronic pain. The most common sites of
pain upon admission were back, knee, hip, and shoulder
(26.6%); abdomen (23.4%); and arm, hand, wrist, leg,
and foot (21.8%) (Table 1). A significant reduction in
mean NPRS score occurred from admission to discharge
(4.462.9, p<.001).

During hospitalization, 80.2% of participants received
opioids, 74.2% received acetaminophen (Figure 2), and
60.5% received acetaminophen and opioids; 8.9%

2 DENG ET AL. 2018 JAGS

received NSAIDs. Intravenous self-controlled analgesia
was prescribed for 3.6%, and 49.6% received nonpharma-
cological pain interventions. Of those prescribed opioids
during admission, 23.6% received a high MEDD (�50
mg). Significantly more were prescribed opioids at dis-
charge than before hospitalization (57.3% vs 50.8%,
p5.04, Figures 2, 3), 14.1% received new opioid prescrip-
tions at discharge, and 43.1% were prescribed opioids
before hospitalization and at discharge (Figure 3). No dif-
ferences were observed in other outpatient analgesic pre-
scriptions prior to hospitalization compared to at
discharge (Figure 2).

Association Between Participant Characteristics, Pain,
and Pain Management

Age

Participants aged 65 to 79 reported higher pain scores at
discharge than those aged 80 and older (2.2 6 2.7 vs 1.3
6 2.4, p5.02; NPRS �1, 49.2% vs 31.9%, p5.01). No
differences were found in pharmacological or nonpharma-
cological pain management according to age (all p>.05).

Sex

No differences were observed in admission and discharge
pain scores according to sex (all p>.25). Women were
more likely than men to be prescribed nonopioids before
hospitalization, during hospitalization, and at discharge
(all p<.05) and more likely to be prescribed other analge- sics during hospitalization and at discharge (all p<.05). There was no difference in nonpharmacological pain man- agement according to sex (p5.15).

Race

Admission and discharge pain scores between white and
nonwhite participants were not significantly different (all
p>.25), although white participants were more likely to
be prescribed opioids before and during hospitalization
(all p<.05) and less likely to be prescribed acetaminophen at discharge (p5.02). No differences were observed in nonpharmacological interventions according to race (p5.80).

Chronic Pain

Participants with a history of chronic pain were more
likely to live alone (63.6% vs 43.6%, p5.002) and have a
history of depression (33.3% vs 20.1%, p5.02) and sleep
apnea (18.2% vs 8.1%, p5.02). In an a priori logistic
regression model, depression was the only factor associ-
ated with a history of chronic pain (odds ratio51.94,
95% confidence interval51.05–3.59, p5.03), after adjust-
ing for age, sex, and body mass index.

No differences were found in admission pain scores
between participants with and without a history of
chronic pain (p5.83), but at discharge, participants with
chronic pain reported less reduction in pain than those
without chronic pain (mean change score 3.762.9 vs
4.962.8, p5.002). Participants with a history of chronic
pain were significantly more likely to receive opioids, co-
analgesics, and other analgesics before and during hospi-
talization and at discharge (all p<.05). Although no differ- ences were found between participants with and without chronic pain in nonpharmacological interventions (50% in each group) and nonopioid prescriptions during hospitali- zation, participants with chronic pain were more likely to

Figure 1. Flow chart of study participants. [Color figure can be viewed at wileyonlinelibrary.com]

JAGS 2018 PAIN IN HOSPITALIZED OLDER ADULTS 3

wileyonlinelibrary.com

receive nonopioids before hospitalization and at discharge
(all p<.05, Table 2); 38.9% of participants without chronic pain received opioid prescriptions before admis- sion, of whom 51.7% had a history of a cancer diagnosis.

Dementia

In this sample, 10.1% of participants had a documented
history of dementia. Those with dementia were more
likely to be older (79.5610.8 vs 74.567.8, p5.03) and
have a higher CIRS-G score (19.865.7 vs 17.065.5,
p5.02). Participants with dementia had pain scores on
admission similar to those of individuals without dementia
(p5.45) but reported lower pain scores on discharge
(0.561.4 vs 2.162.7, p<.001) and achieved greater reduc- tion in pain from admission to discharge (mean change score 5.662.2 vs 4.363.0, p5.03). Participants with dementia were less likely to be prescribed opioids before (32.0% vs 52.9%, p5.047) and during (64.0% vs 82.1%, p5.03) hospitalization. Nonpharmacological interventions during hospitalization and prescription of nonopioids, co- analgesics, and other analgesics before and during

hospitalization and at discharge did not differ between
participants with and without dementia.

Depression

Sixty-three (25.4%) participants had a documented history
of depression. No differences were found in pain scores at
admission (p5.45) or reduction in pain from admission to
discharge (p5.23) between participants with and without
depression. Participants with depression were more likely
to receive opioid prescriptions before (63.5% vs 46.5%,
p5.02) and during (93.7% vs 75.7%, p5.002) hospitali-
zation but not at discharge (65.1% vs 54.6%, p5.15).
Participants with depression were more likely to receive
co-analgesics (34.9% vs 21.6%, p5.03) before hospitaliza-
tion and more likely to be discharged with other analge-
sics (39.7% vs 21.6%, p5.005). There were no differences
in nonpharmacological interventions between participants
with and without depression (p5.42).

Because CNPI scores were converted to NPRS scores,
we conducted a sensitivity analysis in which participants
with CNPI scores on admission (8.5%) were excluded.

Table 1. Demographic and Clinical Characteristics of Older Adults Admitted to Medicine Service with Moderate to
Severe Pain, Overall and According to Age

Characteristic Overall, n 5 248 < 80, n 5 179 � 80, n 5 69 P-Value

Age, mean 6 SD 75.0 6 8.3 70.7 6 4.4 86.2 6 4.9 <.001 Female, n (%) 140 (56.5) 102 (57.0) 38 (55.1) .79 White, n (%) 125 (50.4) 100 (55.9) 25 (36.2) .01 Married, n (%) 110 (44.4) 79 (44.1) 31 (44.9) .92 Preferred language English, n (%) 177 (71.4) 137 (76.5) 40 (58.0) .004 Admission source community, n (%) 224 (90.3) 165 (92.2) 59 (85.5) .11 Discharge location community, n (%) 148 (59.7) 115 (64.2) 33 (47.8) .02 Hospital length of stay, mean 6 SD 5.7 6 6.4 5.9 6 7.1 5.2 6 4.3 .37 Comorbid conditions, n (%)

Anxiety 56 (22.6) 47 (26.3) 9 (13.0) .03
Cancer 91 (36.7) 74 (41.3) 17 (24.6) .01
Cerebrovascular disease 38 (15.3) 22 (12.3) 16 (23.2) .03
Congestive heart failure 55 (22.2) 30 (16.8) 25 (36.2) <.001 Dementia 25 (10.1) 14 (7.8) 11 (15.9) .06 Depression 63 (25.4) 50 (27.9) 13 (18.8) .14 Liver disease 26 (10.5) 23 (12.8) 3 (4.3) .05

History of falls, n (%) 59 (23.8) 33 (18.4) 26 (37.7) .001
Charlson Comorbidity Index, mean 6 SD 3.1 6 2.3 3.2 6 2.4 2.6 6 2.1 .06
Cumulative Illness Rating Scale for Geriatrics score, mean 6 SD 17.3 6 5.6 16.9 6 5.6 18.2 6 5.5 .10
Body mass index, kg/m2, mean 6 SD1 26.1 6 7.0 26.8 6 7.4 24.3 6 5.2 .005
Creatinine clearance on admission, mean 6 SD1 60.4 6 34.4 67.6 6 36.2 41.4 6 19.0 <.001 Admission pain score

Mean 6 SD (range) 6.3 6 1.8 (4–10) 6.4 6 1.9 (4–10) 6.2 6 1.7 (4–10) .45
Median (IQR) 6 (5–8) 6 (5–8) 6 (5–8) .45

Discharge pain score
Mean 6 SD (range) 1.9 6 2.7 (0–10) 2.2 6 2.7 (0–10) 1.3 6 2.4 (0–10) .02
Median (IQR) 0 (0–4) 0 (0–4) 0 (0–2) .02
History of chronic pain, n (%) 99 (39.9) 73 (40.8) 26 (37.7) .66

Sites of pain on admission, n (%)
Abdomen 58 (23.4) 47 (26.3) 11 (15.9) .09
Chest 40 (16.1) 32 (17.9) 8 (11.6) .23
Back, knee, hip, shoulder 66 (26.6) 45 (25.1) 21 (30.4) .40
Arm, hand, wrist, leg, foot 54 (21.8) 40 (22.3) 14 (20.3) .73
Generalized 17 (6.9) 15 (8.4) 2 (2.9) .13

1Data missing as follows: body mass index (n 5 16), creatinine clearance at admission (n 5 14).

SD 5 standard deviation; IQR 5 interquartile range.

4 DENG ET AL. 2018 JAGS

The overall results were essentially unchanged. The magni-
tude of the effect remained similar, but age group differen-
ces in discharge pain scores and CIRS-G score differences
according to dementia group were no longer statistically
significant. VDS scores at discharge (13.7% of sample)
were converted to equivalent NPRS scores.

DISCUSSION

This study expands our understanding of pain characteris-
tics and current pain management practices in older adults
admitted to a medicine service. We found that 1 in 5 older
medical patients reported moderate to severe pain. The
majority of these individuals received opioid therapy for

pain management. Although participants with chronic
pain commonly reported pain in the hospital, their pain
was often not as responsive to multiple pharmacological
agents compared to those without chronic pain.

Our study offers a unique focus on management of
moderate to severe pain in older medical patients. Other
samples of hospitalized individuals have been smaller,
investigated specific analgesics (e.g., opioids), or included
more heterogeneous groups (e.g., mixed age groups or
combined medical and surgical patients).34–37 Although
the prevalence identified in our study (20%) was lower
than estimates of pain in community-dwelling adults (24–
72%),2–4 it is likely that this difference is because we
focused on moderate to severe pain, whereas other studies

Figure 3. Flow chart of opioid prescription before hospitalization, during hospitalization, and at discharge. Percentages are calcu-
lated based on total study sample (N5248). Received new prescription at discharge, inception cohort, Received pre-
scription before hospitalization and at discharge, prevalent cohort, Died during hospital stay. [Color figure can be viewed
at wileyonlinelibrary.com]

Figure 2. Types of analgesics prescribed before hospitalization, during hospitalization, and at discharge. NSAID 5 nonsteroidal
anti-inflammatory drug. Co-analgesics 5 antidepressants, anticonvulsants, and antiarrhythmic. *p5.04. P-value represents com-
parison between frequency of opioid analgesics prescribed before hospitalization and at discharge.

JAGS 2018 PAIN IN HOSPITALIZED OLDER ADULTS 5

wileyonlinelibrary.com

reported any level of pain. If individuals with mild pain
had been included, the total prevalence would have been
26%, similar to previous estimates. In addition, because
pain was identified through chart abstraction, pain preva-
lence may have been lower than if self-reported.

The most common analgesics in our sample were acet-
aminophen and opioids; NSAIDs were rarely used. Opioid
use has grown substantially in the general population,
including in older adults.38 One study showed that, from
1999 to 2010, outpatient opioid prescriptions for older
adults almost doubled, from 4% to 9%,38 and another
study reported a 2% annual increase in opioid prescrip-
tions for older adults without cancer between 2004 and
2013.39 In our study of hospitalized individuals, 51%
received opioids before admission, and their use increased
to 80% during the hospital stay, which was higher than a
recent study of opioid prescription in the emergency
department (35%).40 Our study also reported greater use
of opioids at discharge than admission. Of 536,767
opioid-na€ıve individuals who filled an opioid prescription
in Oregon, 5% continued with long-term use.41,42

Although not evaluated in our study, it is possible that
greater prescription of opioids in the hospital may contrib-
ute to persistent use in these older adults.42

Almost one-third of participants in our study
received high doses of opioids (MEDD �50 mg) during
admission. Although often needed to control pain
adequately, higher doses of opioids are associated with
more adverse outcomes. The 2016 Centers for Disease
Control and Prevention guidelines and other national and
state-based initiatives to curb opioid use have highlighted
concerns related to higher doses of opioids and have led
to an overall plateauing of opioid use nationally.25,43

How these new initiatives to restrict opioid use affect
older adults’ pain and pain management remains to be
determined.

Opioid therapy is one of the most frequently impli-
cated medications in adverse drug reactions in the hospi-
tal.44 A recent study showed that hospitalized older adults
who received opioids had longer hospital stays and were
more likely to be readmitted.37 In our study, participants
who had received outpatient opioids before hospitalization
experienced longer hospital stays than those who did not.
Further research is necessary to clarify the effect of opioid

use in this population and to identify nonopioid strategies
for pain management in the hospital.

More than one-third of participants in our study had
a documented history of chronic pain. Overall, these indi-
viduals received more analgesics during their hospitaliza-
tion yet reported less reduction in pain. Chronic pain is
prevalent in older adults and is often challenging to man-
age.45 Factors that contribute to chronic pain include older
age, Hispanic ethnicity, female sex, depression, anxiety,
and obesity.31–33 In our study, depression was the only
factor associated with chronic pain in multivariate analy-
sis. Depression is well studied in individuals with chronic
pain and is thought to represent a dyad in which the 2
conditions coexist and may exacerbate each other.46

Although the American Geriatrics Society guidelines rec-
ommend using nonpharmacological methods to manage
persistent pain, participants with chronic pain in our study
did not receive more nonpharmacological interventions
than those without.47 Our findings underscore the need
for better comprehensive management of older adults with
chronic pain and attention to psychiatric components of
pain in the inpatient setting.

Our study has important implications for clinical
practice. As the population ages, an increasing number of
older adults will be hospitalized with moderate to severe
pain. Healthcare providers should adopt evidence-based
approaches to manage their pain. Although our study indi-
cates that opioids are the current mainstay of hospital
pain management, their use has significant risks, and there
are limited prospective trials examining treatment out-
comes in older adults. Furthermore, the effect of opioid
administration in individuals with chronic pain in the hos-
pital is unknown. Thus, healthcare providers should exert
caution when prescribing opioids to older hospitalized
adults.

Several limitations warrant consideration. Our study
findings may be limited in generalizability because the
sample was from a single medical center with a higher
proportion of nonwhite patients than in the general pop-
ulation. Data were abstracted from medical records,
which may not reflect actual pain management practices
and may underestimate pain prevalence because of miss-
ing or incomplete pain documentation. Furthermore, reli-
ability of pain assessments may be limited in individuals

Table 2. Analgesics Prescribed to Participants with and Without a History of Chronic Pain

No History of Chronic Pain (n 5 149) History of Chronic Pain (n 5 99)

Drug Category

Before

Hospitalization

During
Hospitalization

At

Discharge

Before
Hospitalization
During
Hospitalization
At
Discharge

Nonopioid 69 (46.3)1 110 (73.8) 77 (51.7)2 67 (67.7)1 78 (78.8) 65 (65.7)2

Acetaminophen 64 (43.0)2 108 (72.5) 70 (47.0)2 60 (60.6)2 76 (76.8) 61 (61.6)2

Nonsteroidal antiinflammatory drug 13 (8.7) 15 (10.1) 13 (8.7) 16 (16.2) 7 (7.1) 12 (12.1)
Opioid 58 (38.9)1 112 (75.2)2 72 (48.3)1 68 (68.7)1 87 (87.9)2 70 (70.7)1

Co-analgesic3 24 (16.1)1 23 (15.4)1 28 (18.8)1 38 (38.4)1 37 (37.4)1 42 (42.4)1

Other analgesic 24 (16.1)2 26 (17.4)1 26 (17.4)1 32 (32.3)2 41 (41.4)1 39 (39.4)1

P-values represent comparison of analgesic prescription before the time of hospitalization, during hospitalization, and at discharge among patients with

and without a history of chronic pain.

P <1.001, 2.05 3Antidepressant, anticonvulsant, antiarrhythmic.

6 DENG ET AL. 2018 JAGS

with cognitive impairment.48,49 There is no validated
conversion of CNPI to NPRS scores, but our sensitivity
analysis indicated that overall results were essentially
unchanged when CNPI scores were excluded. Dosing
information was not collected for other analgesics except
opioids. Because of heterogeneity of admission diagnoses
and lack of clarity regarding the rationale for pain man-
agement decisions in inpatient and outpatient settings, we
could not determine with certainty the indications for
analgesic prescription based on chart review. As with any
retrospective study, it is difficult to determine temporal
relationships between variables. Nevertheless, this study
offers important new insights into pain characteristics
and pain management in hospitalized older adults with
moderate to severe pain.

CONCLUSIONS

Moderate to severe pain was present in 20% older adults
admitted to the general medicine service. Opioid therapy
was commonly used for pain management. Participants
with chronic pain were often less responsive than those
without to multiple pharmacological agents. Future
research is needed to clarify factors that contribute to the
pain experience of hospitalized older adults and to identify
optimal pain management strategies in this population.

ACKNOWLEDGMENTS

This study was supported by Tideswell at the University of
California at San Fransisco, which seeks to advance the care
of older adults living in the community with multiple chronic
conditions and functional limitations, and the Medical Stu-
dent Training in Aging Research Program, sponsored by the
National Institute on Aging and American Federation for
Aging Research.

The research reported in this paper was presented as a
poster at the Journal of the American Geriatrics Society 2016
Annual Scientific Meeting May 19, 2016, Long Beach,
California.

Conflict of Interest: None.
Author Contributions: Concept and design: Deng,

Ritchie. Data acquisition and analysis: Deng, Patel, Mara-
villa, Schear, Garrigues, Ritchie. Data interpretation, draft-
ing of manuscript, critical revision, final approval of
submitted manuscript: All authors.

Sponsor’s Role: The sponsors had no role in develop-
ment of the study, data acquisition, data interpretation, writ-
ing, or editing of manuscript.

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8 DENG ET AL. 2018 JAGS

The Questions below should be answered according to the article.

1) Write a brief summary of the article.

2) If a research article what were the results.

3) nursing implications.

4) how would this information impact your practice.

You don’t need additional reference other than the article, but if you have additional resource that would be great.