3483 NHR participated in the surveys from 2014 to 2018. Most of the residents were female (70.7%). The average age was 81.7 (+/-11.9).
Pain prevalence
Information on pain was available for 3437 NHR. The results of the study show that 31.8% of the NHR were affected by actual pain at the time of the survey. Table 1 shows the overall distribution of the pain prevalence classified by gender, age, cognitive impairment and the way in which the pain was reported.
Table 1
Pain prevalence classified by gender, age, CI and pain report
| | NHR with pain | | all NHR |
| | n | % in rows | | n | % |
| | 1093 | 31.8 | | 3437 | 100 |
gender χ²df=1 = 18.15 p < 0.05 | | | | | | |
female | 798 | 34.1 | | 2339 | 61.1 |
male | 260 | 26.6 | | 979 | 28.5 |
age χ²df=3 = 40.78 p < 0.05 | < 70a | 90 | 19.8 | | 454 | 13.2 |
< 80a | 182 | 29.4 | | 619 | 18.8 |
< 90a | 512 | 34.6 | | 1479 | 43.0 |
> 90a | 301 | 34.8 | | 864 | 25.1 |
CI χ²df=2 = 46.95 p < 0.05 | | | | | | |
no | 204 | 40.4 | | 505 | 14.7 |
mild | 382 | 34.0 | | 1122 | 32.6 |
severe | 303 | 24.9 | | 1219 | 35.5 |
pain report χ²df=1 = 9.02 p < 0.05 | | | | | |
self | 789 | 39.3 | | 2008 | 58.4 |
external | 224 | 32.8 | | 682 | 19.8 |
A comparative analysis of pain prevalence differentiated by gender, age group, degree of CI and type of pain report revealed significant differences. Pain prevalence was higher in women (34.1%) than in men (26.6%). Higher pain prevalence rates of 34.6% and 34.8% were observed in the higher age groups compared to the younger age groups (19.8% and 29.4%). Significantly lower pain prevalence rates were found for higher levels of CI. While 40.4% of NHR without CI reported pain, the proportion of NHR with severe CI was 24.9%. Pain reports was provided by 58.4% of the NHR themselves, while 19.8% of the NHR provided this information as a result of an external evaluation. At 39.3%, the proportion of persons affected by pain was significantly higher in the group of NHR who were able to give information than in the group of NHR who were unable to provide information (32.8%).
Table 2 shows the result of the logistic regression of pain prevalence, taking into account the variables gender, age, degree of CI and the way in which pain data are determined as influencing variables.
Table 2
Logistic regression of pain prevalence (n = 2231)
| | coefficient of regression B | significant p | Odd Ratio OR | OR 95%- confidence interval |
gender m = 1 / f = 2 | | 0.337 | 0.002 | 1.401 | 1.136–1.728 |
age | | 0.031 | 0.000 | 1.032 | 1.023–1.041 |
CI | no | (refer. categ.) | 0.000 | |
mild | -0.398 | 0.001 | 0.672 | 0.527–0.855 |
severe | -0.690 | 0.000 | 0.502 | 0.387–0.650 |
pain report pat.=1 / carer = 2 | | -0.107 | 0.360 | 0.899 | 0.715–1.129 |
Hosmer-Lemeshow-Test: χ²df=8=10.436; p = 0.236
With the exception of the variable "pain report", the predictors have a significant influence on the pain prevalence. The variable "CI" has the strongest influence on pain prevalence with an odds ratio of 0.67 and 0.50. This means compared to persons without CI, there exists the relative likelihood of having pain decreases by 32.8% for persons with "mild" CI and by 49.8% for persons with "severe" CI. Gender influenced the pain prevalence with an odds ratio of 1.4. Women reported pain 1.4 times more often than men. The Hosmer-Lemeshow test for goodness-of-fit shows that the model is suitable to adequately represent the data.
Pain intensity and pain duration
Mild pain at rest (value 1–3) was found in 53.8%, acceptable pain at stress (value 1–5) had 88.5% of all NHR with actual pain. Moderate to excruciating pain at rest (value > 3) was experienced by 10.0% of the NHR, and 10.8% (value > 5) at stress. 5.7% of all NHR with pain had moderate to excruciating pain at rest (> 3) as well as at stress (> 5). Details on this will be found in Supplement, Fig. 1. On average, the intensity of pain at rest was 1.5 (+/-1.6), the average intensity of pain at stress 3.2 (+/-1.8). The inferential statistical tests show that the distribution of pain intensity at rest differed significantly according to the degree of CI and the type of pain report. A higher degree of CI corresponded to a lower pain intensity at rest ('H' test: χ²df=2 = 18.93; p < 0.05). Post-hoc tests (Dunn-Bonferroni tests) showed that the pain-at-rest-intensity of NHR with 'severe' CI differed significantly from NHR with 'mild' CI (z = 4.01, p < 0.05) and 'no' CI (z = 3.41, p < 0.05).
A lower pain intensity was found in NHR whose pain intensity was calculated by the nursing staff compared to NHR who reported information themselves (MWU test: U = -2.303, p < 0.05). Differentiated by gender and age groups, no significant differences in the distribution of pain intensity at rest and stress were found. The distributions of pain intensitys at stress, differentiated according to the degree of CI and the type of pain report, also showed no significant differences. Information on the duration of existing pain was available from 919 NHR. Details on this will be found in Supplement, Fig. 2, where 85.4% of NHR affected by actual pain were found to have been in pain for more than three months and 56.9% for more than six months.
Impairment of everyday life through pain
10.4% of all NHR with actual pain did not report any impairment of their daily life or were also externally assessed. A moderate to severe impairment of everyday life through pain (value > 3) was present in 25.6% of the NHR. On average, the impairment of everyday life related to pain was 2.6 (+/- 2.0). Details can be found in supplement, Fig. 3. The results of the inferential statistical test (MWU test) show significant differences only in the distribution of pain-related impairment of everyday life, differentiated by type of pain report. In the case of externally assessed NHR, significantly lower pain-related impairments of everyday life were documented in comparison to NHR who were able to provide information (MWU Test: U = -2.06, p < 0.05). Differentiated by gender, age groups and degree of CI, no significant differences in pain-related impairment of everyday life were found. The degree of pain-related impairment of everyday life correlated significantly with pain intensity at rest (rs = 0.56; p < 0.05; n = 996) and pain intensity at stress (rs = 0.78; p < 0.05; n = 996). According to the classification by Cohen [20], both of these correlations are strong effects. The higher the intensity of pain in rest or stress, the higher the degree of pain-related impairment of everyday life. The significance test according to Meng et. al. [21] showed that the two correlation coefficients differ significantly (z = 11.49; p < 0;05). This means, that the degree of pain-related impairment of everyday life correlates significantly higher with pain intensity at stress than at rest.
Pain management
In 22.8% of all NHR with actual pain, pain was recorded more than twice a day and 82.1% confirmed the use of painkiller. Table 3 shows the results for the use of painkiller and the frequency of pain recording more than twice a day, differentiated by gender, age, cognitive impairment and type of pain recording.
Table 3
Intake of painkillers and frequency of daily pain assessment differentiated by gender, age, CI and type of pain report
| | Taking painkillers | | Frequency of daily pain recording |
| | yes | no | | ≤ 2 times | > 2 times |
| | n | % | n | % | | n | % | n | % |
total | | 837 | 82.1 | 182 | 17.9 | | 784 | 77.2 | 232 | 22.8 |
gender | female | 622 | 83.6 | 57 | 23.3 | | 577 | 78.2 | 161 | 21.8 |
male | 188 | 76.7 | 122 | 16.4 | | 189 | 77.5 | 55 | 22.5 |
| | χ²df=1 = 5.86; p < 0.05 | | χ²df=1 = 0.06; p > 0.05 |
age | < 70a | 71 | 81.6 | 16 | 18.4 | | 66 | 79.5 | 17 | 20.5 |
< 79a | 138 | 84.1 | 26 | 15.9 | | 120 | 71.9 | 47 | 28.1 |
< 89a | 388 | 81.2 | 90 | 18.8 | | 369 | 78.3 | 102 | 21.7 |
> 89a | 234 | 82.7 | 49 | 17.3 | | 223 | 77.7 | 64 | 22.3 |
| | χ²df=3 = 0.83; p > 0.05 | | χ²df=3 = 3.35; p > 0.05 |
CI | no | 167 | 87.0 | 25 | 13.0 | | 140 | 73.3 | 51 | 26.7 |
mild | 295 | 81.5 | 67 | 18.5 | | 283 | 78.4 | 78 | 21.6 |
severe | 225 | 78.7 | 61 | 21.3 | | 234 | 82.1 | 51 | 17.9 |
| | χ²df=2 = 6.36; p < 0.05 | | χ²df=2 = 6.25; p < 0.05 |
pain reporting | self | 626 | 83.6 | 123 | 16.4 | | 562 | 76.4 | 174 | 23.6 |
external | 165 | 77.8 | 47 | 22.2 | | 169 | 82.0 | 37 | 18.0 |
| | χ²df=1 = 3.84; p < 0.05 | | χ²df=1 = 2.99; p > 0.05 |
The use of painkiller was significantly more frequent in women (83.6%) than in men (76.7%). The proportion of NHR taking pain medication was significantly higher among NHR without CI compared to NHR with CI. At 83.6%, the proportion of NHR who took painkiller was significantly higher among those who were able to report about their pain than those who were unable to do so. There were no significant differences between the age groups. The proportion of NHR who had pain assessment more than twice a day was significantly higher in residents without CI (26.7%) compared to NHR with mild or severe CI. Differences in NHR with pain assessment more than twice a day indicated by gender, age group and type of pain report are not significant. Table 4 shows the logistic regression of the dependent variable ‚taking a painkiller‘ and Table 5 the logistic regression of the dependent variable ‚frequency of daily pain recording‘, taking into account the variables gender, age, CI and the summscore of painintensity at rest and stress as influencing variables
Table 4
Logistic regression of the dependent variable ‚taking a painkiller‘ (n = 780; yes = 1/ no = 0)
| | regression-coefficient B | significance p | Odd Ratio OR | OR 95%- confidence intervall |
gnder m = 1 / f = 2 | | 0.493 | 0.025 | 1.637 | 1.064–2.518 |
age | | -0.006 | 0.518 | 0.994 | 0.978–1.013 |
painintensity (summscore rest + stress) | | 0.289 | 0.000 | 1.335 | 1.221–1.459 |
CI | No | (refer. cat.) | 0.076 | |
mild | 0.487 | 0.066 | 0.614 | 0.978–1.013 |
severe | 0.605 | 0.026 | 0.546 | 0.320–0.930 |
Hosmer – Lemeshow - Test: χ²df=8 = 9.928; p = 0.270
Table 5
Logistic regression of the dependent variable ‚frequency of daily pain recording‘ (n = 772; > 2 daily = 1/ ≤ 2 daily = 0)
| | regression coefficient B | signifikance p | Odd Ratio OR | OR 95%- confidence intervall |
gender m = 1 / f = 2 | | -0.174 | 0.423 | 0.840 | 0.549–1.286 |
age | | -0.007 | 0.459 | 0.993 | 0.973–1.012 |
painintensity (summscore rest + stress) | | 0.108 | 0.000 | 1.114 | 1.055–1.176 |
CI | No | (refer. cat.) | 0.037 | |
mild | -0.289 | 0.191 | 0.749 | 0.486–1.155 |
severe | -0.629 | 0.010 | 0.533 | 0.329–0.862 |
Hosmer-Lemeshow-Test: χ²df=8=10.793; p = 0.214
The results of the logistic regression models show that the intensity of pain and the degree of CI significantly influence the intake of a painkiller as well as the frequency of daily pain recording. Increasing the pain intensity score by one unit increased the relative probability of taking a painkiller by 33.5% and of recording pain more than three times a day by 11.4%. At constant pain intensities compared to NHR without CI, for NHR with "severe" CI the relative probability of taking a painkiller decreased by 45.4% and pain recording more than three times a day by 46.7%. There were significant differences between women and men with regard to the use of pain medication. The relative probability of taking a painkiller was 63.7% higher for women than for men. The Hosmer-Lemeshow-Test as a test for the goodness of fit, show that both models are suitable for adequately representing the data.