Principles of Pain Assessment and Management in Nursing ......• Pain is also a perceptual experience that has an impact on all aspects of a person’s emotional, psychological, social

11/17/2014

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Principles of Pain Assessment

and Management in Older Nursing

Home Patients

Shaida Talebreza M.D.

[email protected]

Assistant Professor, Division of Geriatrics,

University of Utah School of Medicine

Palliative Care Specialist, Home Based Primary Care (HBPC)

George E. Wahlen Salt Lake City Veterans Affairs Medical Center

Medical Director, Inspiration Hospice

Pain Assessment Outline

• What is Pain

• Prevalence of Pain in Older Adults

• Geriatric Pain Special Considerations

• Types of Physical Pain

• Geriatric Pain Assessment: Physical Pain

History

– PQRST

– Cognitively Impaired Adults

What is Pain?

• An unpleasant sensory and emotional

experience associated with actual or

potential tissue damage

• Pain is also a perceptual experience that

has an impact on all aspects of a person’s

emotional, psychological, social and

physical functioning.

Hadjistavropoulos T, Herr K, Turk D, et al. An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons.

Clin J Pain. 2007;23:S1-S43

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What is Pain?

• Physical, psychological, social, and spiritual problems can affect a patient’s perception and tolerance of pain

• Multidisciplinary approach to assessment and treatment is very important and effective

Prevalence of Pain in Older

Adults

• Substantial pain is experienced by:

– 25%-50% of community dwelling adults

– 45%-80% of nursing home residents

GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.

Geriatric Pain is Undertreated

• Geriatric patients may: – Minimize their symptoms

– Not voluntarily report pain

– Be unable to report pain due to cognitive impairment

• Clinicians may: – Inadequately assess pain

– Treat pain with ineffective therapies

– Encounter adverse effects with otherwise effective therapies

GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.

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Types of Physical Pain Pain Type Nociceptive

Somatic

Nociceptive

Visceral

Neuropathic

Description Activation of

nociceptive sensory

receptors

Activation of

nociceptive sensory

receptors

Irritation of

components of the

CNS or PNS

Source •Tissue injury

•Bones

•Soft tissue

•Joints

•Muscles

•Viscera

•Cardiac

•Lung

•GI

•GU

Peripheral or central

nervous system

Examples •Arthritis

•Fracture

•Bone metastases

•Post-op pain

•Renal Colic

•Constipation

•Trigeminal

neuralgia

•PHN

•Diabetic

neuropathy

•Herniated disc

•Post-stroke

syndrome

Geriatric Pain Assessment:

Physical Pain History

• Provocative (aggravating) factors

• Palliative (relieving) factors

• Quality

• Region (location)

• Severity

• Timing

• Treatments tried





• Quality


• Severity

• Timing


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Provocative and Palliating

Factors

• What makes the pain better or

worse?

– Rest

– Movement

– Positioning

– Eating





• Quality


• Severity

• Timing


Quality

Aching Dull Sharp

Stabbing Colicky Burning

Gnawing Squeezing Pricking

Throbbing Deep Tingling

Cramping

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• Quality


• Severity

• Timing


Region (Location) of Pain

• Where do you hurt?

• Can use a pain map:





• Quality


• Severity

• Timing


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Pain Severity

Number Severity

0 None

1-3 Mild

(Background Pain)

4-6 Moderate

(Generally interferes with function and

sleep)

7-10 Severe

(Generally interferes with function, sleep

and concentration)

Quill TE, Holloway RG, Shah MS, et al. Primer of Palliative Care: 2010, 5th Edition. Illinois: American Academy of Hospice and Palliative Medicine; 2010.

Severity of Pain: Scales

Numeric Rating Scale Faces Pain Scale

•Good Validity •Fair Validity

•Fair Reliability •Fair Reliability

•Easy to use •Requires hearing or vision and cognition

•Requires vision, attention, and cognition

Halter JB, Ouslander JG, Tinetti ME, et al. Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. New York: McGraw Hill; 2009.

Severity: Numeric Rating Scale

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Severity: FACES Pain Scale –

Revised (FPS-R)

Severity: Wong-Baker FACES

• Developed for pediatric patients

Cognitively Impaired Patients

• It has been shown that pain reports from

those with mild to moderate cognitive

impairment are no less valid than other

patients with normal cognitive function

• The NRS and FPS-R are feasible for use

in most patients with cognitive impairment

Halter JB, Ouslander JG, Tinetti ME, et al. Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. New York: McGraw Hill; 2009.

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• Use both self-report and observational

measures when possible

• Solicit the assistance of caregivers familiar

with the patient

• Determine if analgesic medications lead to

a reduction in pain behaviors




• The Interdisciplinary Expert Consensus

Statement on Assessment of Pain in Older

Persons could not reach definitive

recommendation of any particular scale for

patients with severe dementia


• Promising tools:

– PACSLAC

– Doloplus 2

• American Academy of Hospice and

Palliative Medicine

– PAINAD

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Physical Pain Assessment in

Cognitively Impaired Patients PACSLAC DOLOPLUS-2 PAINAD

60 item checklist

Present/Absent

10 items

0-3 Scale

Five Items

0-2 Scale

5 minutes to

administer

<5 minutes to

administer

<5 minutes to

administer

Strong Internal

Consistency

Strong Internal

Consistency

Lower Internal

Consistency

Strong Interrater

Reliability

Not Reported Strong Interrater

Reliability

Validity based on

retrospective RN

reports

Validated by

correlation with other

scales

Validated by

correlation with other

scales



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Pain Assessment in Advanced

Dementia (PAINAD) Scale

Items 0 1 2 Score

Breathing Normal •Occasional

labored breathing

•Short period

hyperventilation

•Noisy labored

breathing

•Long period

hyperventilation

•Cheyne-Stokes

Vocalization None •Occasional

moan or groan

•Low-level

speech with a

negative or

disapproving

quality

•Repeated troubled

calling out

•Loud moaning or

groaning

•Crying


Pain Assessment in Advanced

Dementia (PAINAD) Scale

Items 0 1 2 Score

Facial

Expression

Smiling or

inexpressive

•Sad

•Frightened

•Frown

•Facial grimacing

Body

Language

Relaxed •Tense

•Distressed

pacing

•Fidgeting

•Rigid

•Fists clenched

•Knees pulled up

•Pulling or pushing

away

•Striking out

Consolabillity No need •Distracted or

reassured by

voice or touch

•Unable to console,

distract or reassure


MDS Indicators of Pain

• J8. Indicators of pain or possible pain. • Select all that apply in last 5 days: • Check all that apply. • a. Non-verbal sounds (crying, whining, gasping, moaning,

or groaning) • b. Vocal complaints of pain (that hurts, ouch, stop) • c. Facial expressions (grimaces, winces, wrinkled forehead,

furrowed brow, clenched teeth or jaw) • d. Protective body movements or postures (bracing,

guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement)

• e. None of these signs observed or documented

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• Quality


• Severity

• Timing


Timing

• Onset (When does it start)

• Frequency (How often does it happen)

• Duration (How long does it last)





• Quality


• Severity

• Timing


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Treatments Tried

• Current and previous prescription drugs

• Review pain medication dosage and

frequency

• Over the counter medications

• Natural remedies

• Nondrug treatments

• Assess all for:

– Effectiveness and adverse events

Nociceptive Somatic Pain Examples •Arthritis

•Fracture

•Bone metastases

•Post-op pain

Pain source •Tissue injury

•Bones

•Soft tissue

•Joints

•Muscles

Quality •Aching

•Stabbing

•Gnawing

•Throbbing

Region Well-Localized

Timing Constant

Effective Drug Therapy •APAP (A)

•Opioid (B)

•PT and CBT (B)

Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. New York: American Geriatrics Society; 2010.

Nociceptive Visceral Pain Examples •Renal Colic

•Constipation

Pain source •Viscera

•Cardiac

•Lung

•GI

•GU

Quality •Dull

•Colicky

•Deep

•Cramping

•Squeezing

Region •Poorly localized

•Diffuse

Timing •Intermittent

•Paroxysmal

Effective Drug Therapy •Treat Underlying Cause


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Neuropathic Pain Examples •Trigeminal neuralgia

•PHN

•Diabetic neuropathy

•Herniated disc

•Post-stroke syndrome

Pain Source Peripheral or central nervous system

Quality •Sharp

•Burning

•Pricking

•Tingling

•Squeezing

Region Varies

Timing Usually constant but can have paroxysms

Effective Drug Therapy •TCA (A)

•SNRI (A)

•Anticonvulsant (A)

•Opioid (B)

•Topical anesthetics (C)

•PT and CBT (C)


Summary

• Pain requires a thorough assessment to determine its source, severity, and impact on the well-being of the patient:

– Provocative (aggravating) factors

– Palliative (relieving) factors

– Quality

– Region (location)

– Severity

– Timing

– Treatments tried

Summary

• Use the same pain severity scale to assess response to treatment

– NRS or Faces for cognitive intact older adults

– PACSLAC, Doloplus or PainAD for non-communicative older adults

• Differentiate between nociceptive somatic or visceral pain and neuropathic pain as treatment differs

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PHYSICAL PAIN MANAGEMENT

Pain Management Outline

• World Health Organization (WHO) Pain Ladder

• Acetaminophen

• NSAIDS

• Tramadol

• Opioids

• Adjuvant Medications

WHO 3-Step Ladder

1-3 mild

4-6 moderate

7-10 severe

Morphine

Oxycodone

Hydromorphone

Methadone

Fentanyl

± Adjuvants

A/Codeine

A/Hydrocodone

A/Oxycodone

Tramadol

± Adjuvants

ASA

Acetaminophen

NSAID’s

± Adjuvants WHO Geneva, 1996.

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Treating Mild To Moderate Pain

Acetaminophen:

Recommended as first-line therapy for

mild persistent pain in older adults

Particularly effective for musculoskeletal

pain from osteoarthritis

For chronic pain it is most effective if

scheduled regularly rather than as-needed

Starting dose: 325-500 mg q4-6 hrs

Slide 43


• Acetaminophen

• No more than 4g/24h; or 2g/24h if on coumadin due to increase in INR

• Lower the dose by 50-75%, or avoid, in patients at risk of liver dysfunction, especially with history of heavy alcohol intake

• Know all meds the patient is taking, as acetaminophen is a common ingredient in prescription and OTC drugs


• NSAIDs

Use judiciously if at all only after acetaminophen has been tried and only in highly select individuals due to significant adverse effects

Use COX-2 inhibitor with extreme caution, if at all, in older persons

Topical NSAIDs appear to be safe and effective in the short term, but no long-term studies

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• NSAIDs

Many significant adverse effects in older adults:

Renal dysfunction

GI bleeding

Platelet dysfunction

Fluid retention

Worsening HTN

Precipitate Heart Failure

Precipitate Delirium


• Tramadol

– Great potential for precipitating seizures even at therapeutic dosages

• Although this risk is likely only 1%, it is increased among people with multiple comorbidities

– Tramadol has a ceiling effect at 300 mg/day for its analgesic effect

– In general, cost, side effects and the ceiling effect make it less attractive option for pain management in the palliative care setting

Treating Moderate To Severe

Pain o Opioids:

o Equianalgesic Dose Relative Strength

o Onset, Peak Effect, Duration

o Opioids in Renal and Hepatic Insufficiency

o Initiating Immediate Release/Short Acting (IR/SA) Opioids

o Initiating Extended Release/Long Acting (ER/LA) Opioids

o Side Effects

o Medications to Avoid in Older Adults

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Equianalgesic Dose of Opioid

Analgesic

Oral/Rectal Dose

(MG)

Medication IV/SC Dose (MG)

200 mg Codeine 130 mg

30 mg Hydrocodone Not available

30 mg Morphine 10 mg

20 mg Oxycodone Not available

7.5 mg Hydromorphone

(Dilaudid)

1.5 mg

12.5 mcg patch = for

patients >60 mg

morphine in 24 hours

Fentanyl 0.1 mg

S

T

R

O

N

G

E

R

Equianalgesic Dose of Opioid

Analgesic

Oral/Rectal Dose (MG) Medication IV/IM Dose (MG)

24 hr oral morphine

Morphine:Methadone

Ratio

<30 mg 2:1

31-99 mg 4:1

100-299 mg 8:1

300-499 mg 12:1

500-999 mg 15:1

1000-1200 mg 20:1

>1200 mg Consult

Methadone ½ oral dose

2 mg po

methadone=

1 mg IM/IV

methadone

Treatments Tried

• Review pain medication dosage and frequency:

– Does the pain medication relieve some pain in 15-60 minutes (or 3-4 hours)?

• If not you may need to increase the dosage of medication (if possible) or change the class of medication

– Does the pain medication relieve pain in 15-60 (or 3-4 hours) minutes but wear off before the next dose is given?

• If so you many need to increase the frequency of medication (if possible)

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Opioids

Medication Onset of

Analgesia in

Hours

Peak Effect

in Hours

Duration of

Analgesia in

Hours

Half-Life in

Hours*

Morphine

SC, IV

0.25-0.5 hour

0.5-1 hour

3-6 hours

2-3 hours

Morphine

PO

0.5-1 hour

1.5-2 hours

4-7 hours

2-3 hours

Sustained-

Release

Morphine

0.5-1 hour 3-6 hours 8-24 hours 2-3 hours as

drug is

released/

absorbed

•*Half-Life becomes longer with impaired renal function


Doyle D, Hanks G, Cherny N, et al. Oxford Textbook of Palliative Medicine: 2005, 3rd Edition. New York: Oxford Press; 2005

Opioids

Medication Onset of

Analgesia

in Hours

Peak Effect

in Hours

Duration of

Analgesia

in Hours

Half-Life in

Hours

Hydrocodone 0.5 -1 hour 0.5 -1 hour

4-6 hours 2-4 hours

Oxycodone 0.5 -1 hour 1 hour 3-6 hours 2-3 hours

Sustained-

Release

Oxycodone

0.5 -1 hour 3-4 hours 8-12 hours 2-3 hours as

drug is

released/

absorbed



Opioids

Medication Onset of

Analgesia

in Hours

Peak Effect

in Hours

Duration of

Analgesia

in Hours

Half-Life in

Hours

Dilaudid

SC/IV

0.25-0.5

hour

0.5-1.5

hours

3-4 hours 2-3 hours

Dilaudid PO 0.5 -1 hour 1-2 hours 3-4 hours 2-3 hours

Methadone 0.5 -1 hour 0.5-1.5

hours

4-8 hours 12 >150

hours

Fentanyl

Patch

-------------

(of first

dose)

18-24 hrs

48-72 hours 13-22 hours



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Renal Insufficiency

Appear Optimal Use with Caution Avoid

Fentanyl Hydromorphone (Dilaudid)

Morphine

Methadone Oxycodone

Hepatic Insufficiency

Appear Optimal Use with Caution Avoid

Fentanyl Morphine

Hydromorphone (Dilaudid)

Oxycodone

Methadone

Moderate to Severe Pain in Opioid

Non-Tolerant Patients

• In general, start at lowest dose of Immediate Release/ Short Acting (IR/SA) opioid and titrate slowly

• If the patient is in pain crisis, do not withhold medications – may need higher starting dose

• Strongly consider scheduled medication rather than only prn dosing

– Scheduled dosing is vital for patients with cognitive impairment who cannot request prn doses

• Do not start with ER/LA opioids in opioid non-tolerant patients!

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Starting IR/SA Dosages in Opioid

Non-Tolerant Older Adults

Moderate pain: Starting Dose When to titrate dose

Hydrocodone +

APAP

2.5-5 mg po q4-6 hrs

After 3-4 doses

Oxycodone +

APAP

2.5-5 mg po q4-6 hrs

After 3-4 doses

Moderate to

severe pain:

Morphine 2.5-10 mg po q4 hrs

After 1-2 doses

Hydromorphone 1-2 mg po q3-4 hrs

After 3-4 doses

Opioid-Tolerant Patient

• Patients considered opioid tolerant are those who are taking at least

- 60 mg oral morphine/day

- 25 mcg transdermal fentanyl/hour

- 30 mg oral oxycodone/day

- 8 mg oral hydromorphone/day

- 25 mg oral oxymorphone/day

- An equianalgesic dose of another opioid

For 1 week or longer

Appropriate Patient Selection ER/LA

− Opioid tolerant, generally not naive

− Avoid in acute pain

− Avoid when short duration anticipated

− Avoid post-op pain management

− Not for use in mild pain

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Extended Release/Long Acting

(ER/LA) Opioids: • ER/LA medication released over 8, 12, 24, 72

hours (depending on the product)

• Pills must be ingested whole, not crushed or chewed

• Patch must not be cut

• Importance of adherence to dosing regimen

• Do not start with ER/LA opioids in opioid non-tolerant patients!

• Patients are first started on IR/SA opioids to determine how much opioid is needed

Extended Release/Long Acting

(ER/LA) Opioids: • After opioid need is determined using IR/SA

opiods (over an appropriate time period):

• Continuous pain is then treated with 24-hour opioids in long-acting or sustained-release formulations

To cover breakthrough pain, combine with IR/SA (fast-onset medications that have short half-lives)

Breakthrough pain typically requires 5%–15% of the daily dose, offered q2 to q4h orally or or q30-60 minutes SC or IV

Extended Release / Long-Acting

(ER/LA) Opioids

Long Half Life Extended Release

Methadone: Morphine:

Dolophine Morphine ER

Methadose MS Contin

Fentanyl Kadian

Avinza

Oxycodone:

OxyContin

Hydromorphone:

Exalgo

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ER/LA Starting Dosages

Geriatric Patients

Lowest Starting Dose When to titrate dose

Morphine ER/LA 10-15 mg po q8-24 hrs After 3-5 days

Oxycodone

ER/LA

10 mg po q12 hrs

After 3-5 days

Methadone 1.25-2.5 mg po qd-bid After 1 week in low doses

After 1-2 weeks in higher

doses

Hydromorphone

ER/LA

8 mg qd

Opioid Tolerant Only

After 3-4 days

Fentanyl Patch 12.5 mcg/q72 hrs

Opioid Tolerant Only

After 2-3 patch changes

Medications to Avoid in Older

Adults

• Nalbuphine

– Restlessness and tremulousness

• Butorphanol

– Restlessness and tremulousness

• Meperidine (Demerol)

– Agitation, confusion, delirium, disorientation

Opioid Side Effects

Common Uncommon Constipation Bad dreams / hallucinations

Dry mouth Dysphoria / delirium

Nausea / vomiting Pruritus / urticaria

Sedation Urinary retention

Sweats Myoclonus / seizures

Respiratory depression

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Side Effects: Constipation

• Constipation

– Opioids decrease bowel motility

– Constipation develops in almost all patients on chronic opioids

– Constipation should be anticipated and (almost) always treated prophylactically

• With a bowel stimulant (senna, biscodyl)

• If needed addition of osmotic agent (miralax, sorbitol, lactulose)

– Easier to prevent than to treat

– No tolerance to this side effect

Side Effects: Nausea

• Nausea usually resolves after several days as the patient develops tolerance to this side effect

• If Nausea persists make sure the patient isn’t constipated, look for drug interactions

• Consider reducing the dose of the opioid medication or switching to another medication

• May also consider addition of antiemetic: – Haloperidol 0.5-1 mg po before opioid and q6 hrs

for several days

Side Effects: Sedation

• Mild sedation is common when first starting an opioid or when making significant dose increases

• Tolerance to sedation typically develops after several days to weeks of consistent use

• Sedation is dose dependent and should decrease at lower dosages or once medication is stopped

• Consider a limited course of low dose methylphenidate

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Side Effects: Urticaria

Pruritus

• Mast cell destabilization and histamine

release by morphine, hydromorphone

• Treat with routine long-acting, non-

sedating antihistamines

– Fexofenadine 60 mg PO bid

– Loratadin 5-10 mg qd

• Try a different opioid

Side Effects: Urinary Retention

• Opioids can cause urine retention

• This may require a urinary catheter

Side Effects: Myoclonus

• Some patients develop uncontrolled muscle twitching

• This can usually managed by decreasing the dose, changing the opioid or adding benzodiazepines

• If myoclonus and hyperalgesia occur in the setting of renal impairment it can be opioid induced neurotoxicity – switch to an opioid recommended for renal impairment

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Side Effects: Respiratory

Depression

• Respiratory depression is rare when opioid

doses are carefully titrated

• Patients who retain CO2 are at more risk

but this should not be a barrier to opioid

use

• It is almost always preceded by sedation

• Cutting back on dosages if sedation

develops usually avoids respiratory

depression

Adjuvant Analgesics

• Medications that, when added to primary

analgesics, further improve pain control

• May also be primary analgesics or in

combination with opioids to treat

neuropathic pain

• There is no clear consensus on what

adjuvant category to utilize first

Tricyclic Antidepressants (TCA)

• Best studied antidepressant class that show efficacy for neuropathic pain

• Avoid Amitriptyline in older adults

• Use Desipramine or Nortriptyline

– Initial dose 10 mg po qhs

– Effective dose 25-100 mg qhs

– Titrate dose after 3-5 days

– Typically takes 1-2 weeks to titrate up to an effective dose to determine if the therapy is working

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Serotonin-Norephinephrine

Reuptake Inhibitor (SNRI)

• Show some evidence of efficacy for

neuropathic pain but they have not been

well studied

• Duloxetine (Cymbalta)

– FDA approved for Diabetic Peripheral

Neuropathy

– Initial dose 20 mg/d

– Effective dose 60 mg/d

– Titrate dose after 7 days

– Contraindicated if CrCl <30

Anticonvulsants

• Gabapentin (Neurontin)

– Approved for Post herpetic neuralgia

– (Off Label) Postoperative pain, Chronic pain

• Pregabalin (Lyrica)

– Post herpetic neuralgia

– Diabetic peripheral neuropathy

– Fibromyalgia

Anticonvulsants

• Gabapentin

– Initial dose 100 mg po qhs

– May need up to 300-900 mg q8h for effect

– Titrate dose after 1-2 days

– CrCl <15: dose @ 100-300 mg/d

– CrCl >15-29: dose @ 200-700 mg/d

– CrCl >30-59: dose @ 200-700 q12h

– Most troubling side effect is lethargy

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Anticonvulsants

• Pregabalin (Lyrica):

– Initial dose 50 mg qhs

– Effective dose 300 mg/d

– Titrate dose after 7 days

– Often turned to when gabapentin is not

effective or has intolerable side effects

Summary • A stepped approach to pain treatment is advised,

starting with local and non-pharmacologic approaches

• Consider Tylenol instead of NSAIDS

• Systemic analgesics should not be withheld if needed

initially

• Do not start with ER/LA opioids in opioid non-

tolerant patients!

• Patients being treated with opioids usually develop

tolerance to the respiratory depression, fatigue, and

sedation, but not to the constipating effect

Slide 80

References

• Doyle D, Hanks G, Cherny N, et al. Oxford Textbook of Palliative Medicine: 2005, 3rd Edition. New York: Oxford Press; 2005.

• Emanuel LL, Hauser JM, Bailey FA, Ferris FD, von Gunten CF, Von Roenn J. EPEC for Veterans: Education in Palliative and End-of-life Care for Veterans. Chicago, IL, and Washington, DC, 2010

• GRS Teaching Slides Web site http://www.frycomm.com/ags/teachingslides.

• Hadjistavropoulos T, Herr K, Turk D, et al. An Interdisciplinary Expert Consensus Statement on Assessment of Pain in Older Persons. Clin J Pain. 2007;23:S1-S43

• Halter JB, Ouslander JG, Tinetti ME, et al. Hazzard’s Geriatric Medicine and Gerontology, 6th Edition. New York: McGraw Hill; 2009.

• Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, 7th ed. New York: American Geriatrics Society; 2010.

• Quill TE, Holloway RG, Shah MS, et al. Primer of Palliative Care: 2010, 5th Edition. Illinois: American Academy of Hospice and Palliative Medicine; 2010.

• Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at your Fingertips: 2010, 12th Edition. New York: The American Geriatrics Society; 2010.

Principles of Pain Assessment and Management in Nursing ......• Pain is also a perceptual experience that has an impact on all aspects of a person’s emotional, psychological, social

Documents

Principles of Pain Assessment and Management in Nursing ......• Pain is also a perceptual experience that has an impact on all aspects of a person’s emotional, psychological, social