Pain

Pain is a common experience for older persons. The incidence of pain for residents of aged care facilities is variously reported as between 40% and 80%. Common causes of pain include neurological illnesses, musculoskeletal pain, contractures, wounds and vascular disease.

Poorly managed pain is associated with poor sleep, depression and impairment in activities of daily living. Unrelieved pain may also affect cognitive function. It may contribute to an increase in challenging behaviours and delirium.

Impediments to effective management of pain in RACFs may include:

  • difficulty assessing pain in cognitively impaired residents
  • misconceptions about the pain experiences of the aged
  • limited access to pain clinics and specialist pain management services
  • limited number of Registered Nurses (RN) to perform pain assessments and evaluate pain management strategies
  • professional isolation and difficulty accessing reliable up to date clinical information
  • for low care facilities, limited RN availability to administer as required and scheduled analgesics
  • obtaining medication supply in a timely manner for example, access to GP services and pharmacy support.
  • Useful Tip

Pain is a subjective experience and can only truly be appreciated by the person experiencing the pain. Asking if a person has pain is considered the most reliable indicator of pain.

Pain identification and assessment in older people

  • Requires staff with good observation and communication skills
  • Assessment should be undertaken while resident is moving or being assisted to move
  • Assessments are repeated regularly to evaluate effectiveness and safety of interventions
  • Includes a holistic assessment of resident, identifies illnesses and conditions that contribute to pain. It also identifies activities that exacerbate pain or activities that are avoided because they cause pain.
  • Residents with cognitive impairment or communication problems may be able to say if they have pain
  • Appropriate validated assessment tools should be used along with reports from informants (residents, family, caregivers) to assess their pain and response to treatment

Pain management in older people

  • There are few studies on pain treatment in the very old
  • There is large variation in individual response to medication in older people increasing the risk of toxicity and ineffective treatment. [1]
  • The very old are more likely to have alterations to liver and kidney function, affecting the clearance of medication
  • They may require lower doses of medication, and a cautious approach to increasing the dose to achieve pain relief. [2]
  • Effective pain management may require a combination of pharmacological and non-pharmacological approaches as well as emotional support and psychological interventions
  • Effective pain management recognises the resident’s cultural and personal beliefs about pain and incorporates them in the management plan

Medication

  • Information on medications used to manage pain in RAC in the RACGP Silver book (pps46-49)
  • The MIMS has information on all prescription medications
  • Chronic pain is best managed by regular administration of analgesia, with as required medication for breakthrough pain
  • Consider how the medication is to be administered:
    • does the resident have difficulty swallowing tablets?
    • what are the alternatives?
    • is there a price difference for the soluble form of a medication?
  • Anti-inflammatory medication can be administered topically, opioid medication via patches
  • A review by a pharmacist may identify concerns with medications.

Non-pharmacological approaches

  • Exercise has been shown to reduce chronic pain, but may not be appropriate for many residents at the end-of-life
    • Exercise programs should be prescribed by a physiotherapist, exercise physiologist or GP
  • Gentle massage, application of warmth, reiki, acupuncture, music and emotional support may benefit individual residents if acceptable to resident or their caregiver
  • There is some evidence that TENS therapy relieves the pain of diabetic neuropathy. [3]
  • Careful positioning of immobile residents ensuring good body alignment to minimise muscle pain and cramps.
 

Related Evidence

RAC PubMed Pain Search

  1. Mitchell SJ, Hilmer SN, McLachlan AJ. Clinical pharmacology of analgesics in old age and frailty. Rev Clin Gerontol. 2009;19(02):103-18.
  2. Schmader K, Baron R, Haanpää ML, Mayer J, O'Connor AB, Rice AS, et al. Treatment considerations for elderly and frail patients with neuropathic pain. Mayo Clin Proc. 2010 Mar;85(3 Suppl):S26-32.
  3. Dubinsky RM, Miyasaki J. Assessment: efficacy of transcutaneous electric nerve stimulation in the treatment of pain in neurologic disorders (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010 Jan 12;74(2):173-6. Epub 2009 Dec 30.

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Last updated 06 June 2017