A Latent Approach to Understanding Pain in Nursing Home Residents Who are Unable to Self-Report Pain.

Context Pain assessment in people with cognitive impairment is challenging. Objective The study sought to 1) identify pain subgroups based on staff-assessed pain, agitated and reactive behavior, functional status, and symptoms of depression; and 2) understand if cognitive impairment was associated with transitions between pain subgroups at nursing home admission, 3 months, and 6 months. Methods Using national Minimum Data Set 3.0 data (2011-2016), we included 26,816 newly admitted residents with staff-assessed pain at admission, 3 months, and 6 months. Pain subgroups were identified by latent class analysis at each time point. Transitions between pain subgroups were described using latent transition analysis. Results Five latent statuses of pain were identified at admission: "Behavioral and Severe Depression" (prevalence stable, severe or worsening cognitive impairment: 11%, mild/moderate or improved cognitive impairment: 10%), "Functional" (21%; 25%), "Physical" (22%; 23%), "Behavioral" (23%, 19%), and "Low" (23%; 24%). Regardless of change in cognitive status, most residents remained in the same pain latent class. Among residents with stable, severe or worsening cognitive impairment, 11% in the "Behavioral" class transitioned to the "Behavioral and Severe Depression" class by 3 months. Fewer residents transitioned between latent classes in the 3- to 6-month period (>80% remained in their 3-month class). Conclusion For nursing home residents unable to self-report pain, consideration of additional indicators including functioning, depressive symptoms, and agitation may be useful in identifying pain subgroups. Longitudinal changes in the pain subgroups over 6 months post-admission highlight that residents with severe cognitive impairment may be at risk for worsening pain.