Pain in older people

To improve the quality of life of older people and prevent functional decline, pain should be identified, assessed and managed.

All healthcare professionals should be alert to the possibility of pain in older people. We should be prepared to treat the cause of pain and the pain itself.

Pain and ageing

Almost 46 per cent of hospital patients aged 80 years or older report experiencing pain and almost 13 per cent of those are not satisfied with the pain control provided¹.

Older people can be under-treated for pain because of misconceptions about ageing and pain.

Some older people are less likely to report pain as they think it is a natural part of ageing, they don’t want to be a nuisance to staff, or they worry that pain signals disease progression which could mean more medications with undesirable side effects, diagnostic tests and loss of independence².

Common causes of pain in older people

Common causes of pain in older people include:

• arthritis (osteoarthritis and rheumatoid arthritis)
• fibromyalgia (a condition characterised by widespread pain and other symptoms)
• cancer
• circulatory problems
• bowel disease
• urinary tract infections
• pressure injuries
• old injuries
• infections.

Impacts of pain on older people

Pain can have a negative impact on an older person’s quality of life, contributing to:

• impaired mobility or immobility and associated muscle wastage
• depression and anxiety
• social isolation
• financial distress
• sleep disturbances
• reduced participation in everyday activities
• confusion and delirium
• fatigue
• delayed healing and recovery
• pulmonary complications
• increased mortality.

Persistent pain in older people can also have a negative impact on their:

• gait
• physical condition and muscle strength
• risk of falls
• cognitive function and mood
• nutrition
• ability to participate in rehabilitation activities.

Identifying pain

Screening questions

Ask the patient if they are experiencing any pain using questions like the following.

• Do you have pain/are you aching or hurting anywhere right now?
• Where do you have pain/are you aching or hurting?
• How long have you been in pain/aching/hurting?
• Does pain/aching ever keep you from sleeping at night?
• Does your pain/aching ever keep you from participating in activities/doing things you enjoy?
• Do you have pain/are you aching or hurting every day?

If the older person has no pain on admission, record ‘0’ as the pain score and advise them to let staff know if pain develops.

If the older person does report pain during the initial screening interview, then further assessment of pain intensity, location, quality and symptoms is needed to guide diagnosis and treatment.

Assessing for pain

There are two main methods for identifying pain in older people: self-report and observational.

Self-report

Self-report is the most reliable source of information on pain. Use it with all older people, including those with a cognitive or communication impairment.^3,4 Self-report of pain may be obtained by:

• asking an older person questions about their pain – consider using terms such as ‘hurting’, ‘aching’ and ‘soreness’ and document these terms if the older person uses them³
• using a pain intensity scale
• using a multidimensional self-report tool.

All self-reports should be taken seriously, including those from older people with a cognitive impairment.⁶ Self-reported pain from people with a severe cognitive impairment or non-communicative patients should be cross-validated with an observational pain assessment and, where appropriate, discussed with the patient’s family or carer. However, take care when using family or carer reports of pain in an older person, as pain intensity may be over- or under-estimated.⁴

Self-report pain assessment tools

Multidimensional tools are used for an initial comprehensive pain assessment. They evaluate the sensory component of pain (what the person is feeling), the emotional response to pain (impact on the person’s function and relationships, and the meaning of the pain) and quality of life (activities, mood, sleep). The following tools may be used.

• Short-form McGill questionnaire
• Brief pain inventory – short form
• Brief pain inventory – long form
• Pain disability index.

Unidimensional pain assessment tools are used for ongoing evaluation of pain intensity and response to treatment. They evaluate only the sensory component of pain. Examples include:

• Numeric Rating Scale (NRS)
• Verbal Descriptor Scale (VDS)
• Pain thermometer
• Visual Analogue Scale (VAS)
• A pictorial pain scale (FACES pain scale).

Some patients prefer to use numbers to describe their pain, while others prefer words. If you are not successful in using one type of self-report tool with an older person, try a different tool.

Observational

In older people who have severe cognitive impairments or communication difficulties, their behaviour may be the only external indicator of pain.⁴

Pain behaviours are individual, so identifying pain requires clinical judgement and familiarity with the older person. Involving family and carers can help with identifying and confirming observational pain.⁴

The following observation scales are recommended for older people with severe cognitive or communication difficulties.⁷

• Pain assessment checklist for seniors with limited ability to communicate (PACSLAC)
• Pain Assessment in Advanced Dementia (PAINAD)
• Abbey Pain Scale

Pain should be assessed at rest and during activity, such as movement or transfer.

Managing and treating pain

The treatment and management of pain should be based on the findings of a pain assessment.

Treatment approaches vary according to the type of pain, but all involve a combination of pharmacological and non-pharmacological approaches.

Coordinated, multidisciplinary treatment strategies are sometimes required, particularly if pain persists and does not respond to conventional treatment.

The National Pain Strategy (2010)¹¹ , which is currently under review, recommends a multidisciplinary pain management plan that includes a combination of medical approaches, physiotherapy, environmental and psychological interventions based on Cognitive Behavioural Therapy (CBT).

Identify the pain

Classify the pain to inform treatment planning.Most chronic pain may be classified as:

• nociceptive - pain that arises from actual or threathened damage to non-neronal tissue and is due to the activation of nociceptors. This could include post-operative and inflammatory arthropathy (such as arthritis or gout) and may be described as dull, aching or throbbing.
• neuropathic - to describe pain caused by a lesion or disease of the somatosensory nervous pain, it is often described as burning and may be associated with tingling, pins and needles, numbness or itching.

Some types of pain can be both nociceptive and neuropathic (cancer pain)

• Treat pain without a pain score when the older person is not able to focus or use a pain rating scale or is visibly in pain¹².
• Always consider the possibility of pain in all contacts with older people.
• Ask older patients about pain routinely and be aware of behaviours that might indicate underlying pain.
• Regularly record assessment results to facilitate ongoing care.

Manage the pain

Follow your hospital policies and procedures and pathways for pain management.

Consider pharmacological and non-pharmacological approaches:

A pharmacological approach requires an understanding of the mode of action, common side effects and common drug interactions. Medication dose, administration, monitoring and adjustment must be carefully considered, taking into account age-related changes in drug sensitivity, efficacy, metabolism and side effects. Analgesic treatments should be tailored to individual needs.

• Consider pre-emptive analgesia prior to any medical procedure (IV cannulation, dressing change), or rehabilitation procedure (physiotherapy exercises) likely to cause significant pain.
• Consider patient-controlled analgesia post-operatively.
• Chronic pain is best managed with around-the-clock analgesia. Medications should be given, even if the person doesn’t have pain at the time the medication is due.
• Monitor regularly for any side effects following pain treatment (such as nausea, vomiting, sedation, constipation or dizziness)
• Address opiophobia:
  • Many older people with pain respond well to opioid therapy, particularly if nociceptive pain. Opioids should not be denied because of fears of addiction.
  • It is reasonable for a person with severe pain to seek and/or be offered analgesia.
  • Addiction, also known as psychological dependency, is manifested by opioid-seeking behaviours for reasons other than pain relief. Psychological dependency should be differentiated from physical dependency.
  • Physical dependency occurs after a person has been on certain medications for some time, including opioid analgesics, and is manifested as withdrawal symptoms if the drug is suddenly stopped. Chronic opioid therapy should therefore not be abruptly stopped.
  • Opiophobia by health care staff may contribute to persistent unrelieved pain.
• Simple analgesia, such as regular paracetamol, is well tolerated and can provide a background level of analgesia. If the person's pain is not well controlled the addition of opioids provided regularly and/or as required can be an effective strategy to manage a person's pain.
• Some medications that are not typically used for pain may also be helpful for its management. Examples of these include tricyclic or SNRI antidepressants and gabapentinoids. These may improve the quality of opioid analgesia and limit the development of opioid tolerance.

Non-pharmacological approaches include psychological approaches (cognitive behavioural therapy, relaxation, education), physical therapies (physiotherapy, occupational therapy, superficial heat and cold, TENS, gentle exercise, hydrotherapy), and complementary and alternative therapies (acupuncture, massage, other supplements).

• Encourage the older person to move regularly around the ward if they are capable and it is appropriate.

Refer the patient for an inpatient management assessment or to an outpatient multidisciplinary pain clinic on discharge if their pain persists after pharmacological and non-pharmacological therapies.

Re-assess pain regularly

• Interventions introduced to manage pain should be regularly re-assessed.
• Re-assess pain levels every one to two hours until the pain episode is under control (for example, post-procedural pain).
• Increase the frequency of pain assessments if:
  • pain is poorly controlled, that is, if the patient is experiencing moderate pain, scores 5/10 on a measurement scale or the pain stimulus or intervention alters. Consider the potential for undiagnosed serious pathology, including ischaemia.
  • an analgesic infusion is in progress, which indicates a higher intensity of pain and appropriate safety monitoring occurs.
• Reassess pain after analgesic treatment to determine if:
  • the treatment was effective
  • further treatment is necessary
  • any side effects have occurred as a consequence of the treatment (for example, nausea, vomiting, constipation and sedation).
• Wear badges and use stickers on care plans as visual reminders to regularly assess and report pain.

Assess and document the pain assessment outcome and pain management treatment provided^12,13.

Pain and discharge planning

We can help patients make a smooth transition from hospital to their home or residential aged care facility by planning their discharge and providing information about what to do when they leave hospital.

Develop a discharge plan

Pain should be assessed as part of hospital discharge.

Allow enough time to develop a pain management discharge plan with the older person and their family or carer.

Ensure the person’s GP and other healthcare professionals are informed of the care plan and ask them to be involved in developing the plan.

The plan should include:

• the person’s functional goals following discharge
• a list of prescribed medication, including the dose, frequency and expected duration medication is to be taken. If an opioid has been started during the admission, outline the prescribing plan and include the potential weaning strategy as the pain resolves
• prevention and management strategies for potential medication side effects
• restrictions and precautions associated with prescribed medication, such as limitations on driving and work
• potential drug interactions between pre-hospital prescribed medication, over-the-counter medication and medications prescribed on discharge
• details of the person who should be contacted (by the patient or their family or carer) if pain relief on discharge is inadequate
• details of follow-up appointments or referrals for outpatient or community-based rehabilitation.

Share the plan

Give the older person and their family and carers a copy of the pain management discharge plan.

With the older person’s consent, and where appropriate, give a copy of the pain management discharge plan to their:

• GP
• residential aged care facility
• rehabilitation service
• community services.

Educate patients and carers

Older people and their family and carers should be educated about implementing the pain management discharge plan and the importance of maintaining adequate pain control on discharge.

Discuss ongoing pain control with the older person and their carers prior to discharge.

Medication information

Provide information about medication doses, how often the medications need to be taken and for how long, and how to deal with any side effects. Discuss the plan regarding a medication review and weaning strategy if improvement is expected. Encourage older people to request pain relief at the onset of pain.

Self-managing pain

Provide information on self-management interventions to reduce pain, including:

• energy conservation
• pacing activity
• work simplification techniques
• relaxation strategies and anxiety reduction.

Social engagement

Pain can increase the risk of social isolation. Help the older person to find ways of becoming or remaining as engaged as possible and include these strategies as part of their discharge plan.

Informing others

Remind older people to tell healthcare professionals about any pain they feel, where it is, the intensity and characteristics of the pain, activities that make pain better or worse, and how pain impacts on their daily routine (appetite, sleep, mood, mobility).

Managing chronic pain

Sometimes chronic pain cannot be relieved; however, the negative impact can be reduced. Give older people advice on how to deal with chronic pain. Share the following strategies.

• Find out as much as possible about the condition so you understand what is happening and don’t worry unnecessarily about the pain.
• Keep active and exercise gently, even though this may cause some discomfort. Discuss what options would be best with your doctor.
• Take steps to prevent or reduce depression and loneliness by any means that work for you, including talking to friends or health professionals.
• Think positively; identify and challenge negative thoughts you have in response to pain.
• Don’t let pain interfere with your life more than necessary – if you miss activities you used to do before the pain, try reintroducing them gradually and remember to pace yourself. Take pain medication before an activity that you know will aggravate your pain. You may need to cut back on activities if pain flares up, but you will be able to increase slowly again as you did before. Remember: pacing, planning and pre-emptive pain medication.
• Recognise that pain increases your risk of becoming socially isolated. Make an effort to stay engaged and involved with others and your community.
• Focus on finding enjoyable and fulfilling activities that don’t aggravate your pain.
• Seek advice on different types of coping strategies.
• Seek a referral to a pain clinic or chronic pain specialist or team if pain is ongoing.