Pain Trajectories of Nursing Home Residents

Connie S. Cole PhD, DNP, APRN; Janet S. Carpenter PhD, RN; Justin Blackburn PhD; Chen X. Chen PhD; Bobby L. Jones PhD; Susan E. Hickman PhD


J Am Geriatr Soc. 2023;71(4):1188-1197. 

In This Article

Abstract and Introduction


Background: Understanding changes in nursing home (NH) resident pain over time would provide a more informed perspective, allowing opportunities to alter the course of illness, plan care, and set priorities. Therefore, the purpose of this analysis was to identify and characterize clinically meaningful, dynamic pain trajectories in NH residents.

Methods: Retrospective longitudinal analysis of NH resident pain scores with a length of stay >100 days (N = 4864). Group-based trajectory modeling was applied to Minimum Data Set 3.0 assessments to identify pain trajectories. Trajectories were then characterized using unadjusted and adjusted cross-sectional associations between residents' demographic and clinical characteristics and their pain trajectory.

Results: We identified four distinct trajectories: (1) consistent pain absence (48.9%), (2) decreasing-increasing pain presence (21.8%), (3) increasing-decreasing pain presence (15.3%), and (4) persistent pain presence (14.0%). Demographics of younger age and living in a rural area were associated with the persistent pain presence trajectory. Clinical variables of obesity and intact cognition were associated with being in the persistent pain presence trajectory. A smaller proportion of residents with moderately or severely impaired cognition were in any of the trajectory groups with pain.

Conclusions: We identified and characterized four pain trajectories among NH residents, including persistent pain presence which was associated with demographic characteristics (younger, female, rural) and clinical factors (obese, fracture, contracture). Moreover, residents with a diagnosis of Alzheimer's disease or dementia were less likely to be in any of the three trajectories with pain, likely representing the difficulty in evaluating pain in these residents. It is important that NH staff understand, recognize, and respond to the factors associated with the identified pain trajectories to improve mitigation of potentially persistent pain (e.g., hip fracture, contracture) or improve proxy pain assessment skills for residents at risk for under reporting of pain (e.g., Alzheimer's Disease).


Pain in nursing home (NH) residents is common and negatively impacts outcomes. Up to 85.0% of older adults living in a NH experience pain and up to 58.5% have persistent pain. Pain in NH residents is associated with poor quality of life and higher likelihood of depression, decreased happiness, decreased life satisfaction, greater ADL dependency, and more sleep problems.[1]

Approaches to improving recognition of pain in NH residents have aimed to identify factors associated with pain in NH residents,[2–4] develop improved pain assessment tools[5–9] and improve staff pain assessment knowledge.[10–12] Although many researchers are working to ameliorate pain in NH residents, most have done so using a cross-sectional approach. The use of a cross-sectional design fails to consider how the course or trajectory of pain changes over time. Understanding the trajectory of pain experience may provide opportunities to alter the course of illness, prevent adverse outcomes, and provide supportive therapies to improve quality of life.

Trajectories of pain in NH residents have not been well-described or characterized as existing studies are limited. Using growth mixture modeling, Brennan et al identified 9-month pain trajectory groups and the influence of mental health disorders on group membership, in a sample of 2539 department of Veterans Affairs (VA) Community Living Center residents.[13] Residents of VA nursing facilities tend to be younger, almost all male, and have more complex medical and behavioral conditions than residents in the general population of NH residents. This includes increased prevalence of serious mental illness (e.g., schizophrenia), posttraumatic stress disorder, and substance use disorder,[14] and is noted by the study's authors as a limiting factor of this research. In an additional study, using five measurement points within a 14-day period, Landmark et al, identified and characterized four distinct pain trajectories in a sample of 201 Norwegian NH residents.[15] However, the trajectory beyond 14 days is unknown. Finally, in a third study, Thompson et al identified pain trajectories during the 6 months before death in a sample of 962 NH residents in Western Canada.[16] Pain trajectories were generally described but not characterized.[16] It is unknown whether resident sociodemographic and clinical characteristics were associated with these different trajectory patterns. In addition, the identified trajectories were not generalizable to residents not in the final 6 months of life.

Moreover, the impact of pain trajectories on mortality has not been described for a general sample of NH residents. Using two longitudinal population cohorts of adults ages 50 and older in private households, Smith et al, identified that individuals who were "often troubled with pain" or reported pain interference with normal work activities were at increased risk of mortality.[17] It is unclear if this association is applicable to older adults living in NHs.

Understanding how NH resident pain changes over time and the factors associated with belonging to an adverse pain trajectory (i.e., one that remains persistently present) will provide a more informed perspective, allowing opportunities to alter the course of illness, plan care and set priorities, prevent adverse outcomes, and provide supportive therapies to improve quality of life. Therefore, the purpose of this analysis was to characterize clinically meaningful, dynamic pain trajectories in NH residents. The main goals were to (1) define pain trajectories based on the presence of pain using group-based trajectory modeling, (2) identify demographic and clinical correlates, and (3) examine associations between trajectories and mortality.