An effective pain management regime can be a major determinant of the quality of life residents in residential aged care homes can expect to enjoy.
Pain and aging seemingly go hand in hand. As we get older, those aches and pains, which were once humorously dismissed, become very real day-to-day issues to be managed. Persistent pain can seriously undermine a resident’s quality of life. From a facility management point of view, providing effective yet targeted pain management practices can prove complex and frustrating to implement.
Many of the challenges faced by care providers relate to the difficulty posed in communicating with and gaining feedback from patients suffering from dementia and other cognitive impairments. Similarly, elderly patients are frequently prescribed a range of medications and the interaction between medications is often poorly understood. Moreover, elderly patients often perceive pain as a natural part of aging and believe little can be done to mitigate it.
Advances In Pain Management
Improvements in the provision of pain management practices in residential aged care is being achieved in three areas:
- Improved education about pain and its treatments
- Greater awareness of pain management options amongst caregivers
- Development and implementation of pain identification and assessment scales for residents with dementia
These advances are generating proof-of-concept evidence for improved pain management approaches. Implementing the Australian Pain Society guidelines for best practices in pain management improves pain mitigation while giving nurses greater confidence in their pain management practices.
Treating the symptoms of mild aches and pains appears to be adequate in many situations. Persistent pain, which interferes with a resident’s life and is often non-responsive to conventional treatments, demands a more structured biopsychosocial approach with specialist advice from a pain specialist.
Elderly Attitudes To Pain
One irony of pain management amongst the elderly is hindered by a seeming generational belief that pain is a natural condition of aging and not to be fussed over. Many candidates for pain management are concerned about:
- Possible addiction
- Revealing the extent of their degenerative disease
- Becoming dependent on medication
- Habitual under-reporting of pain
Physicians and nursing staff need to actively change these beliefs, by encouraging greater self-reporting and finding descriptions of pain residents are more comfortable in discussing be it substituting words such as; aching, soreness, throbbing or discomfort for pain.
In instances of suspected under-reporting, pain assessments should be conducted every few months to ensure adequate care id being given.
Pain Assessment In Residential Aged Care
Greater attention to diagnosing pain is an essential step in implementing more effective pain management. Some pain types are more responsive to treatment than others, while with some types of pain treatment needs to be directed to the underlying causes rather than simply remediating symptoms.
Persistent pain should be assessed in the context of:
- Pain history
- Current pain profile
- Medical conditions and medications
- Overall patient quality of life
If the pain appears to be systemic in nature, the patients’ central nervous system could be the culprit. If a patient report multiple pain sources, neuropathic or comorbid somatic symptoms, the patient’s pain may be centralized. In these instances, a physical examination of the patient’s resting and mobilized responses including weight-bearing, walking, sitting and getting up, together with a full range of limb movement simulations should be conducted.
Pain Assessment Tool Kit
There are three forms of pain assessment tools currently recommended:
- Observational Behavioural
- Sensory Testing
Despite the limitations of aged patient reporting discussed previously, self-reporting remains the gold standard. A combination of numbers picture or words can be used to establish a scale of 0 to 10 rating pain as either ‘no pain, ‘slight pain’, ‘mild pain’, ‘moderate pain’, ‘severe pain’, ‘extreme pain’ or ‘the most intense pain imaginable’. Multi-dimensional scales, such as the Brief Pain Inventory are more complex to implement and use but provide a better snapshot of pain’s impact on a patient’s quality of life.
Most patients can manage self-reporting even those with a degree of cognitive impairment. Amongst dementia patients, observational methods such as the ABBEY, PAINAD, DOLOPLUS-2, NOPPAIN and PACSLAC models can measure behaviours that evidence the presence of pain, albeit with a false positive rate of around 25 to 30 percent. These tools may differ in the terms that they use to describe pain together with their levels of ease of use and administrative complexity. Some have been found to be good indicators of pain severity.
The key behavioural indictors used by these models are facial expressions (frowning, grimacing), body language (rigidity, altered gait) and verbal expressions (moaning, groaning). Other behavioural indicators, which complement these observational models include; changes in daily routines (eating habits, sleeping patterns), physical changes (bruises) and altered breathing.
Sensory testing are non-invasive procedures that evaluate peripheral nerve function. Many physicians find simple brush and pinprick tests more practical in the field. Brush tests identify allodynia, a condition linked to neuropathic pain where normally non-painful stimuli are perceived as painful. Pinprick tests are useful in diagnosing hyperalgesia often associated with neuropathic pain. Patient reports of tingling, numbness, shooting or burning pain are indicators of neuropathic pain
Pain Management Options
Contemporary multidisciplinary approaches combine pharmacological, physical and occupational based therapies such as TENS machine use.
Exercise, physical rehabilitation, acupuncture and massage all contribute to pain management amongst aged care residents, reducing pain and improving physical function in patients with osteoarthritis. Acupuncture appears less effective in treating chronic pain than has been previously reported. Manual therapy and transcutaneous electrical nerve stimulation (TENS) may also relieve certain types of persistent pain. Musculoskeletal pain is associated with high levels of sleep disturbance, fatigue and depression. Biopsychosocial pain management targets the psychological and behavioural components of pain linked to neuropathic pain. While these treatment methods can be effective, there is limited evidence they are useful in patients with dementia.
This is a complex area of practice. The efficiency of medication is reduced due to declining physiological reserves and increased frailty amongst patients. Age-related issues such as a loss of body mass and changes in composition leading to loss of muscle and increased body fat alter the patients’ responses to medication.
Paracetamol is the preferred therapy for persistent musculoskeletal pain although its effectiveness is being questioned. Anti-inflammatory medications are effective for treating rheumatoid arthritis but may have gastrointestinal and cardiac side effects so should only be used for limited periods. If chronic pain persists, opioid therapy is an alternative for selected patients. Opioid use risks usually manifest in the first two weeks.
Administering a combination of medication with synergistic effects such as paracetamol and codeine or a mix of tricyclic antidepressants such as amitriptyline, nortriptyline, the serotonin-noradrenaline reuptake inhibitors duloxetine for fibromyalgia or anticonvulsants like gabapentin for diabetic neuropathy and post-herpetic neuralgia, carbamazepine for trigeminal neuralgia, gabapentin, carbamazepine or pregabalin for post-stroke central pain may be viable alternatives.
Neuropathic pain is difficult to manage and while complete pain relief often proves elusive, it may be possible to reduce pain to tolerable levels, improving the patient’s quality of life. As always the danger of side effects in frail patients demands close monitoring, while drug-to-drug interactions such as paracetamol with anticonvulsants may limit pharmacotherapy options dosages.
A step-by-step approach to pain management has proven to be effective in reducing pain amongst dementia patients and in reducing dementia’s accompanying behavioural and psychological symptoms. Experience has seen a reduction in constant attention seeking, complaining and repetitive questions together with physical manifestations such as hitting, kicking, grabbing and pacing, restlessness, repetitive behaviours after analgesic treatment.
Effective pain management in residential aged-care facilities must include both psychological and physiological indicators. Attitudes to pain, communication problem and responsiveness to medication are all factors, which challenge pain management amongst elderly and frail patients, particularly those suffering from dementia. A structured model of pain management can be effective in addressing patient pain, improving the quality of life they experience.