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Management of Chronic Pain in Long-Term Care: A Systematic Review and Meta-Analysis

Open AccessPublished:May 17, 2022DOI:https://doi.org/10.1016/j.jamda.2022.04.008

      Abstract

      Objectives

      Pain, a complex subjective experience, is common in care home residents. Despite advances in pain management, optimal pain control remains a challenge. In this updated systematic review, we examined effectiveness of interventions for treating chronic pain in care home residents.

      Design

      A Cochrane-style systematic review and meta-analysis using PRISMA guidelines.

      Setting and Participants

      Randomized and nonrandomized controlled trials and intervention studies included care home residents aged ≥60 years receiving interventions to reduce chronic pain.

      Methods

      Six databases were searched to identify relevant studies. After duplicate removal, articles were screened by title and abstract. Full-text articles were reviewed and included if they implemented a pain management intervention and measured pain with a standardized quantitative pain scale. Meta-analyses calculated standardized mean differences (SMDs) using random-effect models. Risk of bias was assessed using the Cochrane Risk-of-Bias Tool 2.0.

      Results

      We included 42 trials in the meta-analysis and described 13 more studies narratively. Studies included 26 nondrug alternative treatments, 8 education interventions, 7 system modifications, 3 nonanalgesic drug treatments, 2 analgesic treatments, and 9 combined interventions. Pooled results at trial completion revealed that, except for nonanalgesic drugs and health system modification interventions, all interventions were at least moderately effective in reducing pain. Analgesic treatments (SMD −0.80; 95% CI −1.47 to −0.12; P = .02) showed the greatest treatment effect, followed by nondrug alternative treatments (SMD −0.70; 95% CI −0.95 to −0.45; P < .001), combined interventions (SMD −0.37; 95% CI −0.60 to −0.13; P = .002), and education interventions (SMD −0.31; 95% CI −0.48 to −0.15; P < .001).

      Conclusions and Implications

      Our findings suggest that analgesic drugs and nondrug alternative pain management strategies are the most effective in reducing pain among care home residents. Clinicians should also consider implementing nondrug alternative therapies in care homes, rather than relying solely on analgesic drug options.

      Keywords

      Pain, a complex subjective experience, is felt by more than 60% of long-term care (LTC) home residents.
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      Pain perception of older adults in nursing home and home care settings: Evidence from China.
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      Pain management in Dutch nursing homes leaves much to be desired.
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      Prevalence of pain in nursing home residents: The role of dementia stage and dementia subtypes.
      Many residents experience high degrees of pain, with approximately 40% reporting moderate pain, and one-third reporting severe pain.
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      Pain management in Dutch nursing homes leaves much to be desired.
      Because of issues in pain identification and assessment, the prevalence of pain among LTC home residents is underestimated and often inadequately treated.
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      • Chan K.C.
      Under-detection of pain in elderly nursing home residents with moderate to severe dementia.
      For example, LTC home staff often report difficulties determining if a resident with dementia is in pain and the intensity of their pain.
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      Pain reports and pain medication treatment in nursing home residents with and without dementia.
      Higher rates of pain are most often attributable to painful chronic conditions (eg, arthritis)
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      How, why and where it hurts—breaking down pain syndrome among nursing home patients with dementia: A cross-sectional analysis of the COSMOS Trial.
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      Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents.
      Care home residents may also have prolonged pain due to ineffective pain assessment and management.
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      • et al.
      Deficits in pain treatment in nursing homes in Germany: A cross-sectional study.
      Pain has numerous consequences for them: behavioral changes, poor emotional and mental well-being, impaired physical and cognitive functioning, increased social isolation, and decreased quality of life.
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      The silent epidemic of chronic pain in older adults.
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      Primacy of existential pain and suffering in residents in chronic pain in nursing homes: A phenomenological study.
      Many pain management interventions exist. Some manage pain from a pharmacological approach using analgesic (eg, paracetamol) or nonanalgesic (eg, cholecalciferol) drugs.
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      • Flo E.
      Identifying and managing pain in people with Alzheimer's disease and other types of dementia: A systematic review.
      Others use nonpharmacological approaches to reduce pain, including alternative therapies (eg, physical exercise),
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      Psychosocial interventions for pain management in older adults with dementia: A systematic review of randomized controlled trials.
      education interventions (eg, patient information sessions),
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      Improving the process of pain care in nursing homes: A literature synthesis.
      and system modifications (eg, pain treatment protocols).
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      Pain management interventions in the nursing home: A structured review of the literature.
      Selecting the right approach for care home residents remains challenging. The treatment of choice depends on type and severity of pain and resident-related factors, including personal preferences, comorbidities, and concurrent medications. Care home residents are usually frail, with multiple chronic conditions.
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      Patterns and predictors of transitions across residential care settings and nursing homes among community-dwelling older adults in the United States.
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      Prediction of institutionalization in the elderly. A systematic review.
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      • Brähler E.
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      Prediction of institutionalization in the elderly. A systematic review.
      Polypharmacy is common, with 6 to 10 medications prescribed per resident.
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      • Morley J.E.
      • Vellas B.
      An international survey of nursing homes.
      Thus, managing pain using additional medications may not always be the best option. This reinforces the need to implement nonpharmacological approaches into care home practice.
      To incorporate nonpharmacological approaches into practice or change existing pain management protocols, evidence synthesis is needed on effectiveness of different pain management interventions in care home residents. This review updates and widens the scope of our 2016 systematic review.
      • Knopp-Sihota J.A.
      • Patel P.
      • Estabrooks C.A.
      Interventions for the treatment of pain in nursing home residents: A systematic review and meta-analysis.
      Here we examine effectiveness of pain management interventions in care home residents with chronic pain (aged ≥60 years).

      Methods

      This review adhered to guidelines in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      PRISMA Group
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      (Supplementary Appendix 1) and the Cochrane Handbook for Systematic Reviews and Interventions.
      • Higgins J.
      • Thomas J.
      Cochrane handbook for systematic reviews of interventions. Version 6.2.
      Our protocol was registered in PROSPERO (CRD42021262680).

      Eligibility Criteria

      Design

      Randomized or nonrandomized controlled trials or intervention studies were eligible for inclusion. Studies without a comparison group, retrospective studies, and studies not implementing an intervention (eg, commentaries, letters to the editor) were excluded.

      Population

      Studies eligible for inclusion included participants aged ≥60 years, of either sex, with chronic pain, who reside permanently in any type of institutional home, including a nursing home or LTC or residential care home. To fit our criteria of being an institutional home, the residents needed to reside within the homes, and the homes needed to offer around-the-clock care.

      Intervention and outcomes

      Eligible studies evaluated effectiveness of pain intervention approaches: treatment-based (analgesic drugs, nonanalgesic drugs, alternative therapies) or education or system modification (quality improvement or feedback to improve the care delivery process). We also considered trials reporting combined interventions. Pain was measured as a primary or secondary outcome, using a quantitative standardized tool. Studies that only measured subjective opinions of pain, or examined other pain-related outcomes (eg, knowledge about pain, quality of life) were excluded.

      Other considerations

      Studies were included irrespective of country, date, and language of publication.

      Information Sources

      Search methods

      We adhered to the PRISMA for Searching (PRISMA-S) extension
      • Rethlefsen M.L.
      • Kirtley S.
      • Waffenschmidt S.
      • et al.
      PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews.
      and methodological guidance from the Cochrane Handbook for Systematic Reviews of Interventions.
      • Higgins J.
      • Thomas J.
      Cochrane handbook for systematic reviews of interventions. Version 6.2.
      Search concepts identified from our previous systematic review were expanded. We searched for trials from inception to April 2021 (Supplementary Appendix 2) in Medline (1946–present), Embase (1974–present), and PsycINFO (1806–present) via OVID; CINAHL (1936–present) via EBSCOhost; Scopus (1976–present) via Elsevier; and Cochrane Central Register of Controlled Trials (1993–present) via Cochrane Library.
      The search strategy had 3 components: (1) older people or geriatrics; (2) care homes, skilled nursing homes, or assisted living homes; and (3) pain intervention or pain management including pharmacological and nonpharmacological interventions. Concepts were searched using a combination of controlled terms (subject headings) wherever available, such as MeSH, and free-text terms (keywords). Results were limited to randomized controlled trials by the validated Cochrane-recommended filter for Medline.
      • Glanville J.M.
      • Lefebvre C.
      • Miles J.N.V.
      • Camosso-Stefinovic J.
      How to identify randomized controlled trials in MEDLINE: Ten years on.
      A publication date filter of 2016 to April 2021 limited results to records added since our original review. For studies not located by electronic searches, we scanned reference lists of included studies, relevant systematic reviews, and gray literature.

      Study Selection and Data Extraction

      Records were managed using the systematic review software Covidence (Veeritas Health Innovation, https://www.covidence.org). Two reviewers (JR, TM) independently screened titles and abstracts and accessed the full text of articles with a priori inclusion criteria (Supplementary Appendix 3). Disagreements were resolved by reviewers reexamining and discussing the article.
      JR extracted data with Cochrane's data extraction checklist
      • Li T.
      • Higgins J.P.T.
      • Deeks J.J.
      Chapter 5: Collecting data.
      and TM assessed data for accuracy. Corresponding authors were contacted for data missing from included articles.

      Risk of Bias in Included Studies

      Using the Cochrane Risk-of-Bias Tool 2.0 template for randomized trials,
      • Sterne J.A.C.
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      • Page M.J.
      • et al.
      RoB 2: a revised tool for assessing risk of bias in randomised trials.
      methodological quality was independently assessed by 2 reviewers (JR, MN). This template's 5 domains are as follows: randomization, deviations from intended interventions (eg, participant of study personnel blinding, analysis implemented), missing outcome data (attrition >20%), outcome measurement, and selection of reported results. Cluster trials were evaluated to assess recruitment. Crossover trials were evaluated for potential crossover effects. We classified overall risk of bias as low risk, some concerns, or high risk. A rating of high risk in a single domain classified a study as high overall risk of bias. Conflicts between reviewers were resolved through discussion.

      Measuring Intervention Effect

      Pain outcomes on continuous scales were expressed as standardized mean differences (SMDs), with a 95% CI. SMD (a summary statistic frequently used in meta-analyses
      • Deeks J.J.
      • Higgins J.P.T.
      • Altman D.G.
      Chapter 10: Analysing data and undertaking meta-analyses.
      ) was appropriate because all included studies examined resident pain but assessed pain with different scales. Studies needed standardization for comparison. SMD of 0.2 represented a small effect, 0.5 a moderate effect, and 0.8 a large effect.
      • Schünemann H.J.
      • Vist G.E.
      • Higgins J.P.T.
      • et al.
      Chapter 15: Interpreting results and drawing conclusions.
      For studies that reported partial pain outcomes (eg, means without SDs), we calculated outcomes as needed. Studies reporting insufficient pain data or nonrandomized were not included in the meta-analysis, but were described narratively. Heterogeneity between studies was examined using a χ2 test and the I2 statistic. We interpreted I2 according to the Cochrane Handbook
      • Deeks J.J.
      • Higgins J.P.T.
      • Altman D.G.
      Chapter 10: Analysing data and undertaking meta-analyses.
      : 0% to 40% likely not important, 30% to 60% moderate heterogeneity, 50% to 90% substantial heterogeneity, and 75% to 100% considerable heterogeneity.

      Data Synthesis

      Meta-analyses used Review Manager 5.4 (The Cochrane Collaboration, 2020). All analyses used a random-effect model, due to substantial differences in methodology, scales, and study goals within included studies, and levels of heterogeneity for most of our analyses,. For each analysis, we produced forest plot graphs with the area left of center (<0) indicating a favorable intervention outcome.
      We examined intervention effect by time of outcome measurement (2 weeks to 6 months) and intervention categories. All combination interventions were included in both the combination category and each category that composed them, to account for intervention components.

      Results

      Of 2277 records retrieved, we removed 607 duplicates (Supplementary Figure 1). Of the 1670 records screened for title and abstract, we removed 1517. We examined the remaining 153 full-text articles and excluded 115. From our original systematic review,
      • Knopp-Sihota J.A.
      • Patel P.
      • Estabrooks C.A.
      Interventions for the treatment of pain in nursing home residents: A systematic review and meta-analysis.
      we screened 24 studies and excluded 7. Thus, 55 articles met inclusion criteria. Thirteen were not included in our meta-analysis due to design or incomplete or missing pain data.
      • Cino K.
      Aromatherapy hand massage for older adults with chronic pain living in long-term care.
      • Ernst S.
      • Welke J.
      • Heintze C.
      • et al.
      Effects of mindfulness-based stress reduction on quality of life in nursing home residents: A feasibility study.
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      • Hull K.
      • et al.
      A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).
      • Husebø B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      • Jones K.R.
      • Fink R.
      • Vojir C.
      • et al.
      Translation research in long-term care: Improving pain management in nursing homes.
      • Kutschar P.
      • Berger S.
      • Brandauer A.
      • et al.
      Nursing education intervention effects on pain intensity of nursing home residents with different levels of cognitive impairment: A cluster-randomized controlled trial.
      • Ng M.M.L.
      • Leung M.C.P.
      • Poon D.M.Y.
      The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation.
      • Piedras-Jorge C.
      • Meléndez-Moral J.C.
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      Benefits of physical activity in nursing home residents.
      • Pieper M.J.C.
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      Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial.
      • Stern A.
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      • et al.
      Pressure ulcer multidisciplinary teams via telemedicine: A pragmatic cluster randomized stepped wedge trial in long term care.
      • van Dam P.H.
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      • Caljouw M.A.A.
      Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial.
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      • Okram D.
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      • Chavan R.
      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.
      Our meta-analysis thus included 42 studies.
      • Okram D.
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      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.
      • Akbarnezhad N.
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      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
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      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      • Ansari G.
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      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      • Behrouz S.
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      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.
      • Cook A.J.
      Cognitive-behavioral pain management for elderly nursing home residents.
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      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
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      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
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      The effects of guided imagery on affect, cognition, and pain inolder adults in residential care: A randomized controlled study from Thailand.
      • Ersek M.
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      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
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      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
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      Pain assessment as intervention: A study of older adults with severe dementia.
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      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
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      The clinical efficacy of reflexology in nursing home residents with dementia.
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      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      • Kaasalainen S.
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      • et al.
      The evaluation of an interdisciplinary pain protocol in long term care.
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      • Kuhnert R.
      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      • Kapoor Y.
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      Effect of therapeutic massage on pain in patients with dementia.
      • Kovach C.R.
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      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      • Lee K.I.
      • Eun Y.
      Effect of laugher therapy on pain, depression and sleep with elderly patients in long term care facility.
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      • Maltais M.
      • Rolland Y.
      • Vellas B.
      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      • Mamhidir A.G.
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      • Wimo A.
      • Sköldunger A.
      • Engström M.
      Systematic pain assessment in nursing homes: A cluster-randomized trial using mixed-methods approach.
      • Pehlivan S.
      • Karadakovan A.
      Effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis.
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
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      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      • Rostad H.M.
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      • Grov E.K.
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      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      • Tse M.
      • Ho S.
      Management of chronic pain for older persons: A multisensory stimulation approach.
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • Chan E.K.K.
      • Chan A.H.Y.
      • Chung H.S.W.
      Humor therapy: relieving chronic pain and enhancing happiness for older adults.
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      The effect of using PARO for people living with dementia and chronic pain: A pilot randomized controlled trial.

      Characteristics of Included Studies

      Participants

      The 55 included studies had 9955 participants (Table 1 and Supplementary Table 1)
      • Dräger D.
      • Budnick A.
      • Kuhnert R.
      • Kalinowski S.
      • Könner F.
      • Kreutz R.
      Pain management intervention targeting nursing staff and general practitioners: Pain intensity, consequences and clinical relevance for nursing home residents.
      . Meta-analyses included 42 studies with 5401 participants. Studies were conducted in 19 countries, most from Hong Kong,
      • Ng M.M.L.
      • Leung M.C.P.
      • Poon D.M.Y.
      The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation.
      ,
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      ,
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      • Tse M.
      • Ho S.
      Management of chronic pain for older persons: A multisensory stimulation approach.
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • Chan E.K.K.
      • Chan A.H.Y.
      • Chung H.S.W.
      Humor therapy: relieving chronic pain and enhancing happiness for older adults.
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      the United States,
      • Cino K.
      Aromatherapy hand massage for older adults with chronic pain living in long-term care.
      ,
      • Jones K.R.
      • Fink R.
      • Vojir C.
      • et al.
      Translation research in long-term care: Improving pain management in nursing homes.
      ,
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      ,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      ,
      • Hodgson N.A.
      • Andersen S.
      The clinical efficacy of reflexology in nursing home residents with dementia.
      ,
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      ,
      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      ,
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      and Spain.
      • Piedras-Jorge C.
      • Meléndez-Moral J.C.
      • Tomás-Miguel J.M.
      Benefits of physical activity in nursing home residents.
      ,
      • Alonso-Fernández M.
      • López-López A.
      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      ,
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      ,
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      Table 1Design and Methodology of Included Studies
      Author, YearInterventions
      Study DesignSampleAnalgesicNonanalgesicNondrug/Alternative TherapyEducationSystem ModificationOutcomes
      Akbarnezhad et al., 2019RCTN = 49XaVAS, WOMAC
      Alonso-Fernandez et al., 2016RCTN = 64XbBPI
      Ansari et al., 2020RCTN = 61XWOMAC
      Behrouz et al., 2017Cluster RCTN = 55XcBPI, MPQ
      Björkman et al., 2008RCTN = 203XRAI-MDS, PAINAD
      Chapman & Toseland, 2007CrN = 118XFLACC, PAINAD
      Chang & Park, 2018Controlled BAN = 49XaBPI
      Chen & Lin, 2016Cluster RCTN = 195XXVDS, PAINAD
      Cino, 2014RCTN = 118XdIPT, GMPT
      Cook, 1998Controlled BAN = 21XeXMPQ NRS
      Corsinovi et al., 2009RCTN = 154XNRS
      Costa et al., 2018RCT, CrN = 113XfVDS (MPQ), IPT
      Elsegood & Wongpakaran, 2012BAN = 31XgNRS
      Ersek et al., 2016Cluster RCTN = 485XIPT, RAI-MDS, Certified Nursing Assistant assessment
      Ernst et al., 2008NR, FeN = 16XhVAS
      Espejo Antunez et al., 2012RCTN = 31XiVAS, WOMAC, Short Form Health Survey
      Fuchs-Lacelle et al., 2008RCTN = 173XMQS
      Graham et al., 2020Cluster RCTN = 146XIPT
      Hobbelen et al., 2012RCTN = 101XjPACSLAC
      Hodgson & Andersen, 2008RCT, CrN = 21XkChecklist Of Nonverbal Pain Indicators
      Husebø et al, 2011Cluster RCTN = 352XXMOBID-2
      Husebø et al., 2019Cluster RCTN = 545XMOBID-2
      Jones et al., 2004Controlled trialNH = 12XRAI-MDS
      Kapoor & Orr, 2017RCTN = 10XdPAINAD
      Kaasalainen et al., 2012Controlled BAN = 200XXPACSLAC, PACI, PPI
      Kalinowski et al., 2015 & Drager et al., 2017Cluster RCTN = 195XBPI, Global self-assessment question
      Kovach et al., 2006RCTN = 114XXXlXDS-DAT
      Kovacs et al., 2007Cluster RCTN = 661XVAS, RMQ
      Kutschar et al., 2020Cluster RCTN = 509XNRS/BPI, PAINAD
      Lee & Eun, 2011NEC, BAN = 40XcVAS
      Liu & Lai, 2017Cluster RCTN = 128XPAINAD, Frequency of administration of nonpharmacological pain treatment
      Maltais et al., 2019Cluster RCTN = 91XiAlgoplus Scale
      Mamhidir et al, 2017Cluster RCTN = 213XNRS, Dolplus-2 Scale, Nursing documentation related to pain
      Ng et al., 2003RCTN = 24XmNRS
      Okram et al., 2020QE, NR, BAN = 40XGPS
      Pehlivan & Karadakovan, 2019Controlled BAN = 90XdWOMAC
      Piedras-Jorge et al., 2010QEN = 51XiVAS
      Pieper et al., 2016Cluster RCTN = 288XPACSLAC, RAI-MDS
      Pu et al., 2020Parallel Pilot RCTN = 43XnPAINAD, Registered nurse estimated pain level
      Rodriguez-Mansilla et al., 2015Pilot RCTN = 120XaDolplus-2 Scale, Campbell Scale
      Rostad et al., 2018Cluster RCTN = 112XDolplus-2 Scale
      Simmons et al., 2002RCTN = 51XiGPM-M
      Stern et al., 2014Cluster SW, RCTN = 161XVAS
      Stein et al., 2001RCTN = 147XVAS
      Tse & Au, 2010QE, BAN = 62XaNPIS
      Tse & Ho, 2010Cluster QE, BAN = 141XoNRS
      Tse et al., 2010QE, BAN = 70XcVRS
      Tse et al., 2012Cluster RCTN = 535Xi,oXVRS
      Tse & Ho, 2013QE, BAN = 90Xi,pXGeriatric Pain Assessment, Frequency of administration of nonpharmacological pain treatment
      Tse et al., 2014Cluster RCTN = 396XiNRS
      Tse et al., 2016Cluster RCTN = 115XqNRS, PIS, Pain self-efficacy
      Tse et al., 2018Cluster QE, BAN = 141XqNRS
      Tse et al., 2020Cluster RCTN = 68XiXBPI, Pain self-efficacy
      Van Dam et al., 2020RCT, CrN = 95XMOBID-2, DS-DAT
      Yip et al., 2004NR, QEN = 42XiXVAS
      Study design: BA, before and after; Cr, crossover; Fe, feasibility study; NEC, nonequivalent control group; NR, nonrandomized; QE, quasi-experimental; RCT, randomized controlled trial; SW, stepped wedge.
      Intervention: aacupressure; bAcceptance and Commitment Therapy and Selective Optimization with Compensation therapy; chumor/laughter therapy; dmassage; ecognitive-behavioral; fmusic therapy; gguided imagery; hmindfulness-based stress reduction (breathing, meditation, and yoga); iexercise; jpassive movement therapy; kreflexology; ltailored to individual (psychosocial and environmental treatments); melectroacupuncture; nsocial robot pet; omultisensory and arts and crafts; pgardening; qplay activities.
      Outcome: BPI, Brief Pain Inventory; DS-DAT, Discomfort Scale-Dementia of Alzheimer Type; FLACC, Faces Legs Activity Cry Consolability Behavioral Pain Scale; IPT, Iowa Pain Thermometer; MOBID-2, Mobilization Observation Behavior Intensity Dementia Pain Scale; MPQ, McGill Pain Questionnaire; MQS, Medication Quantification Scale; NPIS, Numeric Pain Intensity Scale; NRS, Numeric Rating Scale; PACI, Pain Assessment in the Communicatively Impaired Elderly; PACSLAC, Pain Assessment Checklist for Seniors with Limited Ability to Communicate; PAINAD, Pain Assessment in Advanced Dementia Scale; PIS, Pain Intensity Score; PPI, Present Pain Intensity scale; RAI-MDS, Resident Assessment Instrument, Minimum Data Set; RMQ, Roland-Morris questionnaire; VAS, Visual Analogue Scale; VDS, Verbal Descriptor Scale; VRS, Verbal Rating Scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

      Design

      Most studies were randomized controlled trials or had some form of randomization.
      • Cino K.
      Aromatherapy hand massage for older adults with chronic pain living in long-term care.
      ,
      • Graham L.
      • Ellwood A.
      • Hull K.
      • et al.
      A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).
      ,
      • Husebø B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      ,
      • Kutschar P.
      • Berger S.
      • Brandauer A.
      • et al.
      Nursing education intervention effects on pain intensity of nursing home residents with different levels of cognitive impairment: A cluster-randomized controlled trial.
      ,
      • Ng M.M.L.
      • Leung M.C.P.
      • Poon D.M.Y.
      The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation.
      ,
      • Pieper M.J.C.
      • Francke A.L.
      • van der Steen J.T.
      • et al.
      Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial.
      • Stern A.
      • Mitsakakis N.
      • Paulden M.
      • et al.
      Pressure ulcer multidisciplinary teams via telemedicine: A pragmatic cluster randomized stepped wedge trial in long term care.
      • van Dam P.H.
      • Achterberg W.P.
      • Husebo B.S.
      • Caljouw M.A.A.
      Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial.
      ,
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      • Alonso-Fernández M.
      • López-López A.
      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      ,
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.
      ,
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      • Fuchs-Lacelle S.
      • Hadjistavropoulos T.
      • Lix L.
      Pain assessment as intervention: A study of older adults with severe dementia.
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
      • Hodgson N.A.
      • Andersen S.
      The clinical efficacy of reflexology in nursing home residents with dementia.
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Kalinowski S.
      • Budnick A.
      • Kuhnert R.
      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      • Kapoor Y.
      • Orr R.
      Effect of therapeutic massage on pain in patients with dementia.
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      • Maltais M.
      • Rolland Y.
      • Vellas B.
      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      • Mamhidir A.G.
      • Sjölund B.M.
      • Fläckman B.
      • Wimo A.
      • Sköldunger A.
      • Engström M.
      Systematic pain assessment in nursing homes: A cluster-randomized trial using mixed-methods approach.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      • Rostad H.M.
      • Utne I.
      • Grov E.K.
      • Småstuen M.C.
      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      ,
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      ,
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      The effect of using PARO for people living with dementia and chronic pain: A pilot randomized controlled trial.
      Three studies were not randomized.
      • Ernst S.
      • Welke J.
      • Heintze C.
      • et al.
      Effects of mindfulness-based stress reduction on quality of life in nursing home residents: A feasibility study.
      ,
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      ,
      • Okram D.
      • Sethi D.
      • Chavan R.
      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.

      Interventions

      Most intervention groups (26) used nondrug alternative interventions,
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      Psychosocial interventions for pain management in older adults with dementia: A systematic review of randomized controlled trials.
      ,
      • Cino K.
      Aromatherapy hand massage for older adults with chronic pain living in long-term care.
      ,
      • Ernst S.
      • Welke J.
      • Heintze C.
      • et al.
      Effects of mindfulness-based stress reduction on quality of life in nursing home residents: A feasibility study.
      ,
      • Ng M.M.L.
      • Leung M.C.P.
      • Poon D.M.Y.
      The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation.
      ,
      • Piedras-Jorge C.
      • Meléndez-Moral J.C.
      • Tomás-Miguel J.M.
      Benefits of physical activity in nursing home residents.
      ,
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      ,
      • Alonso-Fernández M.
      • López-López A.
      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      ,
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      ,
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Elsegood K.J.
      • Wongpakaran N.
      The effects of guided imagery on affect, cognition, and pain inolder adults in residential care: A randomized controlled study from Thailand.
      ,
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      ,
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
      ,
      • Hodgson N.A.
      • Andersen S.
      The clinical efficacy of reflexology in nursing home residents with dementia.
      ,
      • Kapoor Y.
      • Orr R.
      Effect of therapeutic massage on pain in patients with dementia.
      ,
      • Lee K.I.
      • Eun Y.
      Effect of laugher therapy on pain, depression and sleep with elderly patients in long term care facility.
      ,
      • Maltais M.
      • Rolland Y.
      • Vellas B.
      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      ,
      • Pehlivan S.
      • Karadakovan A.
      Effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      ,
      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      ,
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      • Tse M.
      • Ho S.
      Management of chronic pain for older persons: A multisensory stimulation approach.
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • Chan E.K.K.
      • Chan A.H.Y.
      • Chung H.S.W.
      Humor therapy: relieving chronic pain and enhancing happiness for older adults.
      ,
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      with exercise the most common,
      • Piedras-Jorge C.
      • Meléndez-Moral J.C.
      • Tomás-Miguel J.M.
      Benefits of physical activity in nursing home residents.
      ,
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      ,
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      ,
      • Maltais M.
      • Rolland Y.
      • Vellas B.
      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      ,
      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      ,
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      ,
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      ,
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      ,
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      followed by acupressure.
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      ,
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      ,
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      Eight studies used education interventions,
      • Graham L.
      • Ellwood A.
      • Hull K.
      • et al.
      A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).
      • Husebø B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      • Jones K.R.
      • Fink R.
      • Vojir C.
      • et al.
      Translation research in long-term care: Improving pain management in nursing homes.
      • Kutschar P.
      • Berger S.
      • Brandauer A.
      • et al.
      Nursing education intervention effects on pain intensity of nursing home residents with different levels of cognitive impairment: A cluster-randomized controlled trial.
      ,
      • Kalinowski S.
      • Budnick A.
      • Kuhnert R.
      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      ,
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      ,
      • Mamhidir A.G.
      • Sjölund B.M.
      • Fläckman B.
      • Wimo A.
      • Sköldunger A.
      • Engström M.
      Systematic pain assessment in nursing homes: A cluster-randomized trial using mixed-methods approach.
      ,
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      of which 7 were staff education interventions,
      • Graham L.
      • Ellwood A.
      • Hull K.
      • et al.
      A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).
      • Husebø B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      • Jones K.R.
      • Fink R.
      • Vojir C.
      • et al.
      Translation research in long-term care: Improving pain management in nursing homes.
      • Kutschar P.
      • Berger S.
      • Brandauer A.
      • et al.
      Nursing education intervention effects on pain intensity of nursing home residents with different levels of cognitive impairment: A cluster-randomized controlled trial.
      ,
      • Kalinowski S.
      • Budnick A.
      • Kuhnert R.
      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      ,
      • Mamhidir A.G.
      • Sjölund B.M.
      • Fläckman B.
      • Wimo A.
      • Sköldunger A.
      • Engström M.
      Systematic pain assessment in nursing homes: A cluster-randomized trial using mixed-methods approach.
      ,
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      and 1 resident education intervention.
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      Seven used system modifications,
      • Pieper M.J.C.
      • Francke A.L.
      • van der Steen J.T.
      • et al.
      Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial.
      ,
      • Stern A.
      • Mitsakakis N.
      • Paulden M.
      • et al.
      Pressure ulcer multidisciplinary teams via telemedicine: A pragmatic cluster randomized stepped wedge trial in long term care.
      ,
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      ,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      ,
      • Fuchs-Lacelle S.
      • Hadjistavropoulos T.
      • Lix L.
      Pain assessment as intervention: A study of older adults with severe dementia.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      ,
      • Rostad H.M.
      • Utne I.
      • Grov E.K.
      • Småstuen M.C.
      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      including 2 that implemented new specialized care teams,
      • Stern A.
      • Mitsakakis N.
      • Paulden M.
      • et al.
      Pressure ulcer multidisciplinary teams via telemedicine: A pragmatic cluster randomized stepped wedge trial in long term care.
      ,
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      and 5 that introduced new methods of assessing or treating pain.
      • Pieper M.J.C.
      • Francke A.L.
      • van der Steen J.T.
      • et al.
      Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial.
      ,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      ,
      • Fuchs-Lacelle S.
      • Hadjistavropoulos T.
      • Lix L.
      Pain assessment as intervention: A study of older adults with severe dementia.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      ,
      • Rostad H.M.
      • Utne I.
      • Grov E.K.
      • Småstuen M.C.
      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      For pharmacological interventions, 3 studies used a nonanalgesic drug intervention,
      • Okram D.
      • Sethi D.
      • Chavan R.
      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.
      ,
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      ,
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      and 2 studies an analgesic intervention.
      • van Dam P.H.
      • Achterberg W.P.
      • Husebo B.S.
      • Caljouw M.A.A.
      Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial.
      ,
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      Nine studies used combined interventions: 5 combining nondrug alternative and education,
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      ,
      • Cook A.J.
      Cognitive-behavioral pain management for elderly nursing home residents.
      ,
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      ,
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      ,
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      2 combining system modifications and education,
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.
      ,
      • Kaasalainen S.
      • Brazil K.
      • Akhtar-Danesh N.
      • et al.
      The evaluation of an interdisciplinary pain protocol in long term care.
      1 combining analgesic and system modification,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      and 1 combining analgesic drugs, nonanalgesic drugs, nondrug alternative therapies, and system modification.
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.

      Outcomes

      Timing of outcome measurements varied. All studies included outcomes at baseline, 5 studies at 2 weeks,
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      4 studies at 3 weeks,
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      ,
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Elsegood K.J.
      • Wongpakaran N.
      The effects of guided imagery on affect, cognition, and pain inolder adults in residential care: A randomized controlled study from Thailand.
      12 studies at 1 month,
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      ,
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Kapoor Y.
      • Orr R.
      Effect of therapeutic massage on pain in patients with dementia.
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      • Lee K.I.
      • Eun Y.
      Effect of laugher therapy on pain, depression and sleep with elderly patients in long term care facility.
      ,
      • Pehlivan S.
      • Karadakovan A.
      Effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      ,
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      5 studies at 6 weeks,
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      ,
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      ,
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      The effect of using PARO for people living with dementia and chronic pain: A pilot randomized controlled trial.
      14 studies at 2 months,
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      ,
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      ,
      • Hodgson N.A.
      • Andersen S.
      The clinical efficacy of reflexology in nursing home residents with dementia.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      ,
      • Pehlivan S.
      • Karadakovan A.
      Effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      ,
      • Tse M.
      • Ho S.
      Management of chronic pain for older persons: A multisensory stimulation approach.
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • Chan E.K.K.
      • Chan A.H.Y.
      • Chung H.S.W.
      Humor therapy: relieving chronic pain and enhancing happiness for older adults.
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      8 studies at 3 months,
      • Cook A.J.
      Cognitive-behavioral pain management for elderly nursing home residents.
      ,
      • Fuchs-Lacelle S.
      • Hadjistavropoulos T.
      • Lix L.
      Pain assessment as intervention: A study of older adults with severe dementia.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      ,
      • Rostad H.M.
      • Utne I.
      • Grov E.K.
      • Småstuen M.C.
      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      ,
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      ,
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      ,
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      3 studies at 4 months,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      ,
      • Rodríguez-Mansilla J.
      • González López-Arza M.V.
      • Varela-Donoso E.
      • Montanero-Fernández J.
      • González Sánchez B.
      • Garrido-Ardila E.M.
      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
      and 6 studies at 6 months.
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      ,
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      ,
      • Kalinowski S.
      • Budnick A.
      • Kuhnert R.
      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      ,
      • Kovacs F.
      • Abraira V.
      • Santos S.
      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      ,
      • Maltais M.
      • Rolland Y.
      • Vellas B.
      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      ,
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      Three studies measured pain postintervention but did not specify intervention duration.
      • Okram D.
      • Sethi D.
      • Chavan R.
      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.
      ,
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      ,
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.
      One study measured outcomes only at 3 months postintervention.
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.

      Quality Assessment: Risk of Bias in Included Studies

      Most included studies had significant risk of bias (Supplementary Figure 2),
      • McGuinness L.A.
      • Higgins J.P.T.
      Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments.
      with 42 assessed as high risk,
      • Cino K.
      Aromatherapy hand massage for older adults with chronic pain living in long-term care.
      • Ernst S.
      • Welke J.
      • Heintze C.
      • et al.
      Effects of mindfulness-based stress reduction on quality of life in nursing home residents: A feasibility study.
      • Graham L.
      • Ellwood A.
      • Hull K.
      • et al.
      A posture and mobility training package for care home staff: results of a cluster randomised controlled feasibility trial (the PATCH trial).
      ,
      • Jones K.R.
      • Fink R.
      • Vojir C.
      • et al.
      Translation research in long-term care: Improving pain management in nursing homes.
      • Kutschar P.
      • Berger S.
      • Brandauer A.
      • et al.
      Nursing education intervention effects on pain intensity of nursing home residents with different levels of cognitive impairment: A cluster-randomized controlled trial.
      • Ng M.M.L.
      • Leung M.C.P.
      • Poon D.M.Y.
      The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: A randomized controlled trial with follow-up evaluation.
      • Piedras-Jorge C.
      • Meléndez-Moral J.C.
      • Tomás-Miguel J.M.
      Benefits of physical activity in nursing home residents.
      • Pieper M.J.C.
      • Francke A.L.
      • van der Steen J.T.
      • et al.
      Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia: A cluster randomized controlled trial.
      • Stern A.
      • Mitsakakis N.
      • Paulden M.
      • et al.
      Pressure ulcer multidisciplinary teams via telemedicine: A pragmatic cluster randomized stepped wedge trial in long term care.
      ,
      • Yip Y.
      • Sit J.
      • Wong D.
      A quasi-experimental study on improving arthritis self-management for residents of an aged people's home in Hong Kong.
      ,
      • Okram D.
      • Sethi D.
      • Chavan R.
      • Ramesh S.
      The effectiveness of hot fomentation with Epsom salt versus common salt on knee joint pain among elderly in the selected old age home of Pune city.
      ,
      • Alonso-Fernández M.
      • López-López A.
      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      ,
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      • Chapman D.G.
      • Toseland R.W.
      Effectiveness of advanced illness care teams for nursing home residents with dementia.
      ,
      • Cook A.J.
      Cognitive-behavioral pain management for elderly nursing home residents.
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      • Elsegood K.J.
      • Wongpakaran N.
      The effects of guided imagery on affect, cognition, and pain inolder adults in residential care: A randomized controlled study from Thailand.
      • Ersek M.
      • Neradilek M.B.
      • Herr K.
      • Jablonski A.
      • Polissar N.
      • Du Pen A.
      Pain management algorithms for implementing best practices in nursing homes: Results of a randomized controlled trial.
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      • Fuchs-Lacelle S.
      • Hadjistavropoulos T.
      • Lix L.
      Pain assessment as intervention: A study of older adults with severe dementia.
      ,
      • Hodgson N.A.
      • Andersen S.
      The clinical efficacy of reflexology in nursing home residents with dementia.
      ,
      • Kaasalainen S.
      • Brazil K.
      • Akhtar-Danesh N.
      • et al.
      The evaluation of an interdisciplinary pain protocol in long term care.
      ,
      • Kapoor Y.
      • Orr R.
      Effect of therapeutic massage on pain in patients with dementia.
      ,
      • Liu J.Y.W.
      • Lai C.K.Y.
      Implementation of observational pain management protocol for residents with dementia: A cluster-RCT.
      • Maltais M.
      • Rolland Y.
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      • et al.
      Effect of exercise on behavioral symptoms and pain in patients with dementia living in nursing homes.
      • Mamhidir A.G.
      • Sjölund B.M.
      • Fläckman B.
      • Wimo A.
      • Sköldunger A.
      • Engström M.
      Systematic pain assessment in nursing homes: A cluster-randomized trial using mixed-methods approach.
      • Pehlivan S.
      • Karadakovan A.
      Effects of aromatherapy massage on pain, functional state, and quality of life in an elderly individual with knee osteoarthritis.
      ,
      • Rostad H.M.
      • Utne I.
      • Grov E.K.
      • Småstuen M.C.
      • Puts M.
      • Halvorsrud L.
      The impact of a pain assessment intervention on pain score and analgesic use in older nursing home residents with severe dementia: A cluster randomised controlled trial.
      ,
      • Stein C.M.
      • Griffin M.R.
      • Taylor J.A.
      • Pichert J.W.
      • Brandt K.D.
      • Ray W.A.
      Educational program for nursing home physicians and staff to reduce use of non-steroidal anti-inflammatory drugs among nursing home residents: A randomized controlled trial.
      • Tse M.
      • Li Y.
      • Tang S.K.
      • et al.
      An exploration of the effectiveness of a peer-led pain management program (PAP) for nursing home residents with chronic pain and an evaluation of their experiences: A pilot randomized controlled trial.
      • Tse M.
      • Au J.
      The effects of acupressure in older adults with chronic knee pain: depression, pain, activities of daily living and mobility.
      • Tse M.
      • Ho S.
      Management of chronic pain for older persons: A multisensory stimulation approach.
      • Tse M.M.Y.
      • Lo A.P.K.
      • Cheng T.L.Y.
      • Chan E.K.K.
      • Chan A.H.Y.
      • Chung H.S.W.
      Humor therapy: relieving chronic pain and enhancing happiness for older adults.
      • Tse M.M.Y.
      • Vong S.K.S.
      • Ho S.S.K.
      The effectiveness of an integrated pain management program for older persons and staff in nursing homes.
      • Tse M.M.Y.
      • Tang S.K.
      • Wan V.T.C.
      • Vong S.K.S.
      The effectiveness of physical exercise training in pain, mobility, and psychological well-being of older persons living in nursing homes.
      • Tse M.M.Y.
      • Ng S.S.M.
      • Lee P.H.
      • et al.
      Play activities program to relieve chronic pain and enhance functional mobility and psychological well-being for frail older adults: A pilot cluster randomized controlled trial.
      • Tse M.M.Y.
      • Lau J.L.
      • Kwan R.
      • et al.
      Effects of play activities program for nursing home residents with dementia on pain and psychological well-being: Cluster randomized controlled trial.
      • Tse M.M.Y.
      • Ho S.S.K.
      Pain management for older persons living in nursing homes: A pilot study.
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      The effect of using PARO for people living with dementia and chronic pain: A pilot randomized controlled trial.
      11 with some concerns,
      • Husebø B.S.
      • Ballard C.
      • Aarsland D.
      • et al.
      The effect of a multicomponent intervention on quality of life in residents of nursing homes: A randomized controlled trial (COSMOS).
      ,
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      ,
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      ,
      • Chen Y.H.
      • Lin L.C.
      Ability of the pain recognition and treatment (PRT) protocol to reduce expressions of pain among institutionalized residents with dementia: A cluster randomized controlled trial.
      ,
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
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      • et al.
      A comparison of two short education programs for improving low back pain-related disability in the elderly: A cluster randomized controlled trial.
      • Lee K.I.
      • Eun Y.
      Effect of laugher therapy on pain, depression and sleep with elderly patients in long term care facility.
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      The effects of ear acupressure, massage therapy and no therapy on symptoms of dementia: A randomized controlled trial.
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      • Simmons S.F.
      • Ferrell B.A.
      • Schnelle J.F.
      Effects of a controlled exercise trial on pain in nursing home residents.
      and 2 with low risk.
      • van Dam P.H.
      • Achterberg W.P.
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      • Caljouw M.A.A.
      Does paracetamol improve quality of life, discomfort, pain and neuropsychiatric symptoms in persons with advanced dementia living in long-term care facilities? A randomised double-blind placebo-controlled crossover (Q-PID) trial.
      ,
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      • et al.
      Nonpharmacologic pain management interventions in German nursing homes: A cluster randomized trial.
      The domain most commonly judged to be high risk was the risk of bias due to deviations from the intended interventions, whereas the domain regarding bias due to missing outcome data had the least risk among included studies.

      Intervention Effects: Meta-Analysis

      Meta-analyses included data from 42 studies, with 5401 participants at baseline and 5083 at study completion. Studies were grouped by timing of outcome assessment and intervention type (analgesic drugs, nonanalgesic drugs, nondrug alternative therapies, system modifications, education, combined interventions). Analyses at different time points were only examined if 3 or more studies reported outcomes at that specific time point.

      Pooled effect of interventions at different time points

      We pooled data from the 42 studies based on outcome timing and found significant heterogeneity at baseline (I2 = 60%; P < .001), but no statistically significant group differences (P = .13) (Supplementary Figure 3). We found a small treatment effect as early as week 2 (SMD −0.20; 95% CI –0.35 to −0.06; P = .007), a significant moderate to large treatment effect at week 4 (SMD −0.73; 95% CI −1.11 to −0.35; P < .001), a significant large treatment effect at week 6 (SMD −1.30; 95% CI −2.25 to −0.34; P = .008), and a significant moderate to large treatment effect at month 2 (SMD −0.79; 95% CI −1.06 to −0.52; P < .001). Week 3 was insignificant (P = .16), as were 3 months (P = .07), 4 months (P = .13), and 6 months (P = .67). At study completion, treatment effect was significant moderate (SMD −0.48; 95% CI −0.68 to −0.31; P < .001).

      Analgesic interventions

      Three studies (526 participants) used an analgesic intervention
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      ,
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ,
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      : 2 with combined interventions (analgesics plus system modifications
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ; analgesic drugs, nonanalgesic drugs, nondrug alternative therapies, and system modifications
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      ) (Figure 1). Of these, 1 study used acetaminophen and either oxycodone or codeine
      • Corsinovi L.
      • Martinelli E.
      • Fonte G.
      • et al.
      Efficacy of oxycodone/acetaminophen and codeine/acetaminophen vs. conventional therapy in elderly women with persistent, moderate to severe osteoarthritis-related pain.
      ; 1 involved a stepwise approach with paracetamol, oral morphine, a buprenorphine transdermal patch, and pregabaline
      • Husebø B.S.
      • Ballard C.
      • Sandvik R.
      • Nilsen O.B.
      • Aarsland D.
      Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: Cluster randomised clinical trial.
      ; and 1 used an unspecified analgesic medication.
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      At baseline, the sample was homogeneous (I2 = 0%; P = .92), with no significant differences between treatment and control groups (P = .52). Pain scores had statistically significant improvements at all time points and by study completion, with a large treatment effect favoring the treatment group (SMD −0.80; 95% CI −1.47 to −0.12; P = .02).
      Figure thumbnail gr1
      Fig. 1Forest plot of studies reporting analgesic drug interventions for pain treatment. Horizontal lines: 95% CIs of each study; green squares: SMDs of each study (size represents the weight given to the study in meta-analysis): diamond, summary estimate; solid vertical line, null value. SMDs less than zero indicate a treatment benefit. Study: aOxycodone/acetaminophen, bStepwise analgesic protocol (paracetamol, morphine, buprenorphine transdermal patch, pregabalin), c5-step serial trial intervention. IV, inverse variance.

      Nonanalgesic drug treatment interventions

      Three studies (345 participants) used a nonanalgesic drug intervention: 2 exclusively nonanalgesic drug interventions (melilotus officinalis oil, vitamin D)
      • Ansari G.
      • Delbari A.
      • Karimi M.
      • Akbari Kamrani A.A.
      • Mohammadi S.
      • Sahaf R.
      Effect of melilotus officinalis oil on knee joint pain and stiffness in the elderly with primary knee osteoarthritis.
      ,
      • Björkman M.
      • Sorva A.
      • Tilvis R.
      Vitamin D supplementation has no major effect on pain or pain behavior in bedridden geriatric patients with advanced dementia.
      and 1 combining analgesic drug, nonanalgesic drug, nondrug alternative therapies, and system modification (Supplementary Figure 4).
      • Kovach C.R.
      • Logan B.R.
      • Noonan P.E.
      • et al.
      Effects of the serial trial intervention on discomfort and behavior of nursing home residents with dementia.
      At baseline, this sample was homogeneous (I2 = 0%; P = .36) and had no significant differences between groups (P = .36). By study completion, groups did not differ significantly, although a small to moderate treatment effect favored the treatment group (SMD −0.32; 95% CI −0.92 to 0.28; P = .30).

      Nondrug interventions/alternative therapies

      Twenty-seven studies (2516 participants) used a nondrug alternative therapy intervention (Figure 2).
      • Pu L.
      • Moyle W.
      • Jones C.
      • Todorovic M.
      Psychosocial interventions for pain management in older adults with dementia: A systematic review of randomized controlled trials.
      ,
      • Akbarnezhad N.
      • Shahboulaghi F.M.
      • Khankeh H.
      • Sokhangouie Y.
      • Biglarian A.
      • Modanloo S.
      The effect of acupressure therapy on pain, stiffness and physical functioning of knees among older adults diagnosed with osteoarthritis: A pilot randomized control trial.
      ,
      • Alonso-Fernández M.
      • López-López A.
      • Losada A.
      • González J.L.
      • Wetherell J.L.
      Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain.
      ,
      • Behrouz S.
      • Mazlom S.
      • Kooshiar H.
      • Aghebati N.
      • Asgharipour N.
      • Behnam H.
      Investigating the effect of humor therapy on chronic pain in the elderly living in nursing homes in Mashhad, Iran.
      ,
      • Chang E.
      • Park H.
      Effects of auricular acupressure therapy on musculoskeletal pain, depression and sleep of the elderly in long-term care facilities.
      ,
      • Cook A.J.
      Cognitive-behavioral pain management for elderly nursing home residents.
      ,
      • Costa F.
      • Ockelford A.
      • Hargreaves D.J.
      The effect of regular listening to preferred music on pain, depression and anxiety in older care home residents.
      ,
      • Elsegood K.J.
      • Wongpakaran N.
      The effects of guided imagery on affect, cognition, and pain inolder adults in residential care: A randomized controlled study from Thailand.
      ,
      • Espejo Antúnez L.
      • Cardero Durán M.Á.
      • Caro Puértolas B.
      • Téllez de Peralta G.
      Effects of exercise on the function and quality of life in the institutionalised elderly diagnosed with gonarthrosis.
      ,
      • Hobbelen J.H.S.M.
      • Tan F.E.S.
      • Verhey F.R.J.
      • Koopmans R.T.C.M.
      • de Bie R.A.
      Passive movement therapy in severe paratonia: A multicenter randomized clinical trial.