NCHS Data Brief ■ No. 30 ■ March 2010

u.s. department of health and human services

Centers for Disease Control and Prevention

National Center for Health Statistics

Pain is common among nursing home residents, and effective pain 

management has an impact on improving quality of life (1,2). Previous 

research has shown race differences in pain reporting and management in 

various settings, with racial and ethnic minority groups less likely than white 

residents to report pain and receive adequate treatment (3–9). Other studies 

have documented cognitive impairment as a barrier in the detection and 

self-report of pain, with the underreporting likely resulting in undertreatment 

(10–15). However, the relationships among race, dementia, and pain reporting 

and management remain understudied. This report explores the combined 

impact of race and a diagnosis of dementia on reporting or showing signs of 

pain and pain management among nursing home residents.

Keywords: Appropriate pain management • pain underreporting • special 

pain management services • National Nursing Home Survey

Does pain vary by race? Does pain vary by a diagnosis of 

dementia?

Overall among nursing home residents, 23% reported or showed signs of pain 

in the 7 days prior to the interview.

Key findings

Data from the National 

Nursing Home Survey, 2004

•	 About one-quarter of 

all nursing home residents 

reported or showed signs of 

pain.

•	 Nonwhite residents and 

residents with dementia were 

less likely to report or show 

signs of pain compared with 

white residents and residents 

without dementia.

•	 Nonwhite residents with 

dementia were least likely, 

and white residents without 

dementia were most likely to 

report or show signs of pain. 

•	 Forty-four percent of 

nursing home residents with 

pain received neither standing 

orders for pain medication 

nor special services for pain 

management (i.e., appropriate 

pain management).

•	 Among residents with 

dementia and pain, nonwhite 

residents were more likely 

than white residents to lack 

appropriate pain management. 

Prevalence and Management of Pain, by Race and Dementia 

Among Nursing Home Residents: United States, 2004

Manisha Sengupta, Ph.D.; Anita Bercovitz, M.P.H., Ph.D.; and Lauren D. Harris-Kojetin, Ph.D.

0

10

20

30

40

White Nonwhite Without dementia With dementia

1

Significantly different from nonwhite residents (p<.05). 2

Significantly different from residents with dementia (p<.05).

NOTES: Dementia included the following International Classification of Diseases, Ninth Revision codes: 290.0, 294.1, 294.0, 

294.11, 294.8, 310, 331.0, 331, and 797. Data were adjusted for any current diagnosis of arthritis, cancer, pressure ulcers at 

stage II or higher, age, and sex. 

SOURCE: CDC/NCHS, National Nursing Home Survey, 2004.

Figure 1. Adjusted percentages of nursing home residents with pain, by race and dementia 

diagnosis: United States, 2004 Percent

1

24

17

2

29

17
NCHS Data Brief ■ No. 30 ■ March 2010

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Nonwhite residents were less likely to report or show signs of pain than white residents. Nursing 

home residents with dementia were also less likely to report or show signs of pain compared with 

residents who did not have dementia.

Among all residents, 17% of nonwhite residents compared with 24% of white residents reported 

or showed signs of pain.

Seventeen percent of those with dementia reported or showed signs of pain in the 7 days prior to 

the interview compared with 29% of those without dementia (Figure 1).

A similar association between dementia status and reporting of pain existed among both white 

and nonwhite residents, with a significantly greater proportion of residents without dementia

reporting or showing signs of pain compared with residents with dementia. Nonwhite residents 

with dementia (12%) were least likely to report or show signs of pain, and white residents without 

dementia (31%) were most likely to report or show signs of pain (Figure 2). 

0

10

20

30

40

50

White Nonwhite

1

Significantly different from white residents with dementia (p<.05). 2

Significantly different from nonwhite residents with dementia (p<.05).

NOTES: Dementia included the following International Classification of Diseases, Ninth Revision codes: 290.0, 294.1, 294.0, 

294.11, 294.8, 310, 331.0, 331, and 797. Data were adjusted for any current diagnosis of arthritis, cancer, pressure ulcers at 

stage II or higher, age, and sex.

SOURCE: CDC/NCHS, National Nursing Home Survey, 2004. 

Figure 2. Adjusted percentages of nursing home residents with pain among white and nonwhite 

residents, by dementia diagnosis: United States, 2004

Residents without dementia Residents with dementia

Percent

1

31

18

2

21

12

Did residents with pain receive appropriate pain management?

Although the use of medications for pain management may vary by age, sex, and clinical 

condition, appropriate care for pain is either standing orders for pain medication or receipt of 

services from a special program for pain management, particularly among nursing home residents 

with moderate to severe pain (16). Figure 3 gives the overall distribution of pain management 

strategies used for nursing home residents with pain, without adjusting for age, sex, or clinical 

diagnosis. Among nursing home residents with pain, 44% neither had standing orders nor 

received special services for pain management, 46% either had standing orders or received 

special services, and another 10% had both standing orders and received special services for pain 

management (Figure 3). 
NCHS Data Brief ■ No. 30 ■ March 2010

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No standing

orders or

special services

44%

Lack

appropriate

pain

management

44%

Receive

appropriate 

pain

management

56%

Standing orders and

special services

Standing

orders or

special services

46%

NOTES: Special services refer to special programs for pain management. Appropriate pain management is receiving standing 

orders for pain medication or special services from a special program for pain management. 

SOURCE: CDC/NCHS, National Nursing Home Survey, 2004. 

Figure 3. Percentage of nursing home residents with pain, by pain management strategy, 2004

10%

Among residents with pain, does appropriate pain management vary by 

race or diagnosis of dementia?

There were no statistically significant differences in lack of appropriate pain management by

dementia diagnosis (44% of those with dementia and 45% of those without dementia) or race 

(45% of white residents and 48% of nonwhite residents) (not shown).

If one considers race and dementia diagnosis simultaneously, a similar percentage of white 

residents with or without dementia and nonwhite residents without dementia lacked appropriate 

pain management (43%, 46%, and 44%, respectively) (Figure 4). However, lack of appropriate 

0

10

20

30

40

50

60

White Nonwhite

NOTES: Dementia included the following International Classification of Diseases, Ninth Revision codes: 290.0, 294.1, 294.0, 

294.11, 294.8, 310, 331.0, 331, and 797. Data were adjusted for any current diagnosis of arthritis, cancer, pressure ulcers at 

stage II or higher, age, and sex. Appropriate pain management is receiving standing orders for pain medication or services from a 

special program for pain management.

SOURCE: CDC/NCHS, National Nursing Home Survey, 2004. 

Figure 4. Adjusted percentages of nursing home residents with pain who lack appropriate pain 

management among the white and nonwhite residents, by dementia diagnosis, 2004

Residents without dementia Residents with dementia

Percent

46

43 44

56
NCHS Data Brief ■ No. 30 ■ March 2010

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pain management differed between nonwhite residents with dementia and white residents with 

dementia; 56% of nonwhite residents with dementia lacked appropriate pain management 

compared with 43% of white residents with dementia (p<.05).

Summary

About one-quarter of nursing home residents reported or showed signs of pain. Prevalence of 

pain among residents varied by race and dementia diagnosis. Consistent with previous research, 

these nationally representative results suggest that nonwhite residents were less likely to report or 

show signs of pain than white residents, and residents with dementia were less likely to report or 

show signs of pain than residents without dementia. As a group, white residents without dementia 

appear at one end of the spectrum with the highest likelihood of reporting or showing signs of 

pain. At the other end of the spectrum are nonwhite residents with dementia, who are least likely 

to report or show signs of pain.

Over 40% of all nursing home residents with pain received neither standing orders for pain 

medication nor special services for pain management. Among residents with dementia and 

pain, there were differences in appropriate pain management between nonwhite and white 

residents, with nonwhite residents being more likely than white residents to lack appropriate pain 

management. Because questions about pain management were asked only if a resident reported 

or showed signs of pain, residents whose pain was controlled were not included in this analysis. 

Therefore, residents without reported or noted pain because it was controlled, may have received 

pain management, and the estimates of receipt of pain management approaches presented in this 

report may be underestimated.

In light of national goals to reduce racial disparities in health care quality, these findings

contribute to the literature by exploring the complex associations among race, dementia, and pain 

management. 

Definitions 

Dementia: Nursing home providers were asked if the sampled resident had any diagnosis of 

dementia that included the following International Classification of Diseases, Ninth Revision

codes: 290.0, 294.1, 294.0, 294.11, 294.8, 310, 331.0, 331, and 797, in any of 16 current 

diagnoses.

Pain: Nursing home providers were asked if the sampled resident had reported or showed any 

signs of pain in the past 7 days prior to the interview. The question read, “Since admission/

In the past 7 days, that is, since {PAST 7 DAYS}, has sampled person/resident {SP} reported 

or shown evidence of pain? Please include grimacing or other non-verbal signs that suggest 

pain.” Throughout this report, “reported or showed signs of pain” and “with pain” are used 

interchangeably. 

PRN: A medication ordered by a medical practitioner to be administered on an “as needed” basis. 

Only nursing home residents who reported or showed signs of pain were asked if they received 

PRN pain medication.
NCHS Data Brief ■ No. 30 ■ March 2010

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Standing order: A protocol of medication administration allowing a registered nurse to administer 

medication without a prior prescription. Only nursing home residents who reported or showed 

signs of pain were asked if they received standing orders for pain medication. 

Special services for pain management: Nursing home providers were asked if the sampled 

resident was currently receiving services from a special program for pain management. Responses 

were categorized to indicate whether the resident was using special services, the resident was 

not using special services, or the nursing home did not have any specialty programs for pain 

management.

Data source and methods

The data used for this analysis come from the resident module of the 2004 National Nursing 

Home Survey (NNHS). NNHS is a periodic nationally representative cross-sectional survey of 

nursing homes in the United States. The survey provides a plethora of information on nursing 

home characteristics, the services they provide, the staffs they employ, and the residents they 

serve.

The 2004 survey used a stratified, multistage probability sample from a frame of nursing homes

based on strata defined by bed size and metropolitan statistical area status. The first stage

involved the selection of facilities followed by the selection of residents in the second stage. 

Using systematic sampling with probability proportional to bed size, 1,545 nursing homes 

were sampled. In the second stage, residents were randomly selected from a list provided at the 

time of the interview of residents as of midnight the day before the survey. A selection of up to 

12 residents per facility resulted in a total sample of 14,017 current residents. The survey was 

administered using a computer-assisted personal interview (CAPI) system. Data for the survey 

were obtained through personal interviews with facility administrators and designated staff who 

used administrative records to answer questions about the facilities, staff, services and programs, 

and medical records to answer questions about the residents.

Although residents with characteristics associated with pain may well vary across nursing 

homes, estimates of pain reporting and appropriate pain management by race and dementia 

status in Figures 1, 2, and 4 were adjusted for age, sex, and a set of conditions that are associated 

with pain. The adjusted percentages reported in Figures 1, 2, and 4 are the predicted marginal 

probabilities estimated for the average person in a given dementia status and racial group after 

adjusting for all other variables noted in the figure. Adjusted and unadjusted results were similar.

The marginal probabilities, their associated contrasts, and tests for statistical significance were

estimated using general estimating equations to construct logistic regression models in SAScallable SUDAAN. Figure 3 shows the overall distribution of pain management strategies used 

for nursing home residents in pain, irrespective of age, sex, or clinical diagnosis, and therefore 

does not control for these factors. Severity of pain, duration of pain, and the resident’s ability 

to ask for medication are not addressed in this report, and may affect the observed relationships 

among race, dementia, and pain reporting and management.

The analysis of differences in pain management strategies (standing order, special services) was 

limited to nursing home residents who reported or showed signs of pain. A resulting caveat is that 
NCHS Data Brief ■ No. 30 ■ March 2010

■  6  ■

there may be some underestimation of residents receiving standing orders or using services from 

special pain management programs, if these residents did not report or show any residual pain 

after receiving appropriate pain management.

About the authors

Manisha Sengupta, Anita Bercovitz, and Lauren D. Harris-Kojetin are with the Centers for 

Disease Control and Prevention’s National Center for Health Statistics, Division of Health Care 

Statistics, Long-Term Care Statistics Branch. 

References

1. Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain 

Symptom Manage; 10(8):591–8. 1995.

2. Katz N. The impact of pain management on quality of life. J Pain Symptom Manage; 

24(1):S38–S47. 2002.

3. Council of Ethical and Judicial Affairs. Black-White disparities in health care. JAMA; 

263:2344–6. 1990.

4. Green CR, Anderson KO, Baker TA, Campbell LC, et al. The Unequal Burden of Pain: 

Confronting Racial and Ethnic Disparities in Pain. Pain Med; 4(3):277–94. 2003.

5. Green CR, Baker TA, Sato Y, Washington TL, Smith, EM. Race and chronic pain: A 

comparative study of young black and white Americans. J Pain; 4(4):176–83. 2003.

6. Bonham VL. Race, Ethnicity, and Pain Treatment: Striving to Understand the Causes and 

Solutions to the Disparities in Pain Treatment. J Law Med Ethics; 29:52–68. 2001.

7. Cleeland CS, Gonin R, Baez L, Loehrer P, Oandya KJ. Pain and treatment of pain in minority 

patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study. 

Ann Intern Med; 127(9):813–8. 1997. 

8. Johnson-Umezulike JM. A comparison of pain perception of elderly African Americans and 

Caucasians. Nursingconnections; 12:5–12. 1999. 

9. Bernabei R, Gambassu G, Lapane K, landi F, et al. Management of Pain in Elderly Patients 

With Cancer. JAMA; 279(23):1877–82. 1998.

10. Horgas AL, Elliott AF. Pain assessment and management in persons with dementia. Nurs Clin 

North Am; 39:593–606. 2004.

11. Reynolds KS, Hanson LC, DeVellis RF, Henderson M, Steinhauser KE. Disparities in pain 

management between cognitively intact and cognitively impaired nursing home residents. J Pain 

Symptom Manage; 35(4):388–96. 2008.

12. Martin R, Williams J, Hadjistavropoulos T, Hadjistavropoulos HD, MacLean M. A qualitative 

investigation of seniors’ and caregivers’ views on pain assessment and management. Can J Nurs 

Res; 37(2):142–64. 2005.
NCHS Data Brief ■ No. 30 ■ March 2010

■  7  ■

13. Fisher SE, Burgio LD, Thorn BE, Hardin JM. Obtaining self-report data from cognitively 

impaired elders: methodological issues and clinical implications for nursing home pain 

assessment. Gerontologist; 46:81–8. 2006.

14. Stolee P, Hillier LM, Esbaugh J, Bol N, McKellar L, Gauthier N. Instruments for the 

assessment of pain in older persons with cognitive impairment. J Am Geriatr Soc 53(2):319–26. 

2005.

15. Horgas AL, Tsai PF. Analgesic drug prescription and use in cognitively impaired nursing 

home residents. Nurs Res; 47(4):235–42. 1998.

16. Agency for Healthcare Research and Quality (AHRQ). 2007 National Healthcare Quality 

Report. Rockville, MD: U.S. Department of Health and Human Services, Agency for Healthcare 

Research and Quality, AHRQ Pub No. 08–0040. 2008.
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Suggested citation

Sengupta M, Bercovitz A, Harris-Kojetin 

LD. Prevalence and management of pain, 

by race and dementia among nursing home 

residents: United States, 2004. NCHS data 

brief, no 30. Hyattsville, MD: National 

Center for Health Statistics. 2010.

Copyright information

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the public domain and may be reproduced 

or copied without permission; citation as to 

source, however, is appreciated.

National Center for Health 

Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Associate 

Director for Science

Division of Health Care Statistics

Jane E. Sisk, Ph.D., Director