Disparities in Pain Among Nursing Home Residents: Race, Cognitive Impairment, and Nursing Home Racial Composition

TL;DR

This study finds racial disparities in pain documentation among nursing home residents, with differences linked to cognitive impairment and facility racial composition.

Contribution

The study reveals how race, cognitive impairment, and nursing home racial composition influence pain documentation disparities.

Findings

Pain documentation rates varied by race, with American Indian residents having the highest rates and Native Hawaiian or other Pacific Islander residents the lowest.

Pain was more frequently reported in predominantly White nursing homes compared to racially diverse facilities.

Cognitive impairment was associated with decreased pain documentation, especially for self-reported pain.

Abstract

Pain is common among nursing home (NH) residents and can significantly impact quality of end-of-life experiences, yet inequities in pain assessment and treatment persist and are less studied among racial groups with smaller population sizes. This study examined associations between resident race, cognitive impairment, and NH racial composition with any pain documented in the last five days. We conducted a longitudinal multi-level logistic regression using MDS 3.0, LTCFocus, and MBSF data. We focused on residents who died in 2018 or 2019, regardless of place of death (n = 617,922). Analyses were stratified by staff- and self-reported pain, controlling for resident age, function, comorbidity, gender, and NH percent Medicaid, bed number, staffing, ownership, and rurality. In the initial adjusted models, both staff- and self-reported pain increased over the year before death. Staff- and self-reported pain decreased as cognitive impairment increased, and this was more dramatic in the self-reported model. In both models, pain varied by race, with American Indian or Alaskan Native residents having the highest rates, followed by Hispanic and White residents at similar rates; Black residents had slightly lower rates, followed by Asian residents, and Native Hawaiian or other Pacific Islander residents at the lowest. Pain was more frequently reported in predominately White NHs than in more racially diverse NHs, especially in the staff-reported model. Disparities may reflect underassessment of pain and inappropriate pain assessment methods, particularly at the NH-level in facilities that included more racially minoritized residents. Further research is needed to clarify these disparities and ensure equitable pain management.