Nursing home patients

April 2015

FocusNursing home patients

Pain management in residential aged care facilities

Volume 44, No.4, April 2015 Pages 198-203

Steven Savvas

Stephen Gibson

Background

Persistent pain is prevalent in aged care facilities and there are a number of barriers that make effective pain management more difficult to achieve in this setting.

Objective

The aim of this article is to provide an evidence-based approach to assessment and management of pain experienced by resi-dents of aged care facilities.

Discussion

Barriers to effective pain management in residential aged care facilities include patient beliefs and attitudes towards pain, communication deficits and cognitive impairment, frailty and its effect on pharmacotherapy, and limited evidence of compre-hensive pain management strategies for people with dementia. Education programs, developments in observational behaviour scales and stepwise pain management protocols have enabled good progress to be made in addressing these obstacles and improving patient outcomes.

Persistent, bothersome pain is a very common health issue in residential aged care facilities and a review of the literature also suggests suboptimal use of analgesics in this setting.1 This is unsurprising as risk factors for inadequate pain management include older age2 and the presence of cognitive impairment.3 Pain management in aged care facilities is challenging and a number of barriers have been identified, including patient beliefs and attitudes, altered age-associated drug response profiles that may affect pharmacotherapy, and diseases and disorders that impair communication or insight, such as dementia. Early studies showed a lack of analgesic use in practice, particularly for those with dementia,3 though more recent work suggests this trend may have now reversed.4,5 Great strides are being made in regards to education and fostering awareness of pain management in residential aged care facilities, the development of pain identification and assessment scales for people with dementia, and proof-of-concept evidence for pain management approaches. Implementation of Australian Pain Society guidelines for best practice management of pain in aged care facilities6 can improve pain relief and analgesic prescription practice,7 as well as increase nursing staff confidence and overall pain management standards in the Australian residential aged care setting.8

For mild aches and pains, pain management that addresses symptomatic relief may be sufficient. If pain is more persistent, symptomatic relief may only be needed when pain is particularly problematic, such as prior to activities of daily living. When pain is persistent, interferes with function and is non-responsive to conventional treatment, a more careful assessment with an integrated biopsychosocial approach may be required, including input from a specialist pain service in some cases.

Attitudes to pain

Elderly patients may not articulate their pain experience for a number of reasons, and this may be affected by their level of cognitive impairment. In those with sufficient cognitive function, the main barriers to accurate self-reporting of pain are their age-related pain beliefs and attitudes. A study in residential aged care facilities suggests that, compared with nurses, patients more strongly endorse the belief that persistent pain is a normal part of ageing and there is little potential for improvement.9 Other attitudes include fear of addiction to pain medications and reluctance to seek help for fear of an acknowledgement of disease progression or further functional dependence.9 Attitudes of stoicism and reluctance are also age-dependent and older adults are increasingly more cautious about labelling sensations as ‘painful’, and are reticent in reporting pain; this is especially the case for patients over the age of 60 years.10 Physicians and nursing staff need to dispel these beliefs and attitudes, and encourage, support and even coax patients into expressing their pain experience. If patients do not acknowledge their pain, rephrasing using similar words such as ‘discomfort’, ‘throbbing’, ‘aching’ and ‘soreness’ may elicit a different response. When a patient is unlikely to self-report pain, assessment should be conducted when warranted, and routinely at least every few months.11

Assessment of pain in residential aged care facilities

A comprehensive pain assessment is important to design a tailored pain management program for a patient in an aged care facility.12–14 Correct diagnosis of the cause of pain is needed as different types of pain are more responsive to certain treatments and the underlying cause of pain may be remediable. Assessment of persistent pain includes evaluating current and past pain history, concurrent medical conditions, current medications, mood and quality of life. If the pain seems disproportionate or systemic, then consider whether it is being amplified by central nervous system sensitisation.15 Neuropathic symptoms, patients’ reports of multifocal pain and/or comorbid somatic symptoms may be indicators of centralised pain. A physical examination should be conducted with the patient at rest and during mobilisation, which should include weight-bearing, walking, sitting and getting up, as well as a full range of articulated limb movements. Diagnostic investigations may be indicated but care is needed as radiographic changes, particularly in joints, are common with increasing age, but correlate poorly with the experience of pain in conditions such as osteoarthritis.16

Pain assessment tools

A number of pain assessment tools are appropriate for use in residential aged care facilities and can be divided into self-report tools, observational behavioural tools and sensory testing tools.

Self-report tools

Despite potential attitudinal barriers to patients accurately reporting their pain, self-reporting is still the gold standard. Self-reporting scales incorporate words, pictures or numbers. The most effective scales are simply worded and easily understood, and include the Numerical Rating Scale (with pain rated from 0 to 10) and the Verbal Descriptor Scale (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,17 are more complex but can monitor pain intensity and pain-related interference in the patient’s life.

Observational tools

Patients with cognitive impairment can often self-report pain in a reliable and valid manner,18 although as dementia worsens, proxy scales may have increasing usage. Generally, these tools detect the presence or absence of pain in those with dementia when self-reporting is insufficient. The tools typically measure behaviours that may be manifestations of pain, but cannot differentiate from similar behaviours that are unrelated to pain (such as exertion), resulting in high false-positive rates of 25–30%.19 There is no consensus on which tool is best so any of those developed for geriatric settings are suitable. Examples include the ABBEY,20 PAINAD,21 DOLOPLUS-2,22 NOPPAIN23 and PACSLAC.24 These tools differ in the items that describe pain, ease of use and time to administer. Recently, some of these scales have also been found to be sensitive measures of pain severity.19

Although there are several observational scales, key behaviours indicative of pain are common to all. The top three behaviours are facial expressions (such as frowning, sadness, grimacing), body language (including guarding, rigidity, fidgeting, pacing, altered gait) and negative vocalisations (crying, pain noises, verbal aggression, moaning, groaning). These three elements are validated in all non-verbal behaviour pain assessment scales for dementia. Other additional behavioural indicators reflect the nuances of the various scales and may include items such as consolability, behavioural changes (eg aggression), physiological changes (such as quickened pulse), physical changes (eg bruises, lacerations), sudden changes in daily routines (eg eating habits, sleeping patterns) and altered breathing. Wandering has recently been shown to be an unreliable indicator of pain and is predictive of lessened pain.25

Sensory testing tools

Identification of neuropathic pain often requires the use of sensory testing tools. These tests are non-invasive procedures that can evaluate peripheral nerve function. Comprehensive testing is lengthy. For the physician visiting an aged care facility, simple brush and pinprick tests are more practical. Brush tests are appropriate in identifying allodynia, a condition associated with neuropathic pain where normally non-painful stimuli are perceived as painful. Pinprick tests are suitable in diagnosing hyperalgesia that is associated with neuropathic pain. Hyperalgesia relates to increased sensitivity to a painful stimulus. Common causes (such as diabetes, cancer, or stroke) or patients’ reports of tingling, numbness, shooting or burning pain are flags for neuropathic pain, in which case these tests may be illuminative. However, the utility of such testing in patients with advanced dementia is unclear.

Pain management approaches

A multidisciplinary treatment approach incorporates pharmacological and non-pharmacological therapies.6 Musculoskeletal pain is the predominant pain-related condition in residential aged care facilities, and pharmacological, non-pharmacological (physical therapy such as exercise, foot orthotics or patellar taping for knee osteoarthritis) and occupational therapies (joint protection education, assistive devices) may all be appropriate.

Non-pharmacological

Physical rehabilitation and exercise, acupuncture and massage, or cognitive and behavioural therapies may have some utility in pain management for aged care (Table 1). Exercise-based activities have been shown to be effective in reducing pain and improving physical function in patients with osteoarthritis.26 Acupuncture27 and massage28 are also recommended as adjunctive therapies and evidence shows that both approaches may reduce pain and functional disability from osteoarthritis, although a recent meta-analysis suggests that the efficacy of acupuncture is more modest for some chronic pain than was previously reported.29 Manual therapy and transcutaneous electrical nerve stimulation (TENS) may also be of benefit for certain types of persistent pain, although the evidence base is not well established,30 and manual therapy requires significant levels of care and skill. The biopsychosocial model of pain management advocates targeting the psychological and behavioural components of pain and has value in treating symptoms that accompany centralised or neuropathic pain. High levels of musculoskeletal pain are associated with high levels of sleep disturbance, fatigue and depression.31 There is some evidence that cognitive behaviour therapy in the elderly has a moderate effect on self-reported pain and small improvements in physical function.32 Overall, non-pharmacological approaches have a substantive role in pain management and can even be conceptualised in conjunction with pharmacotherapy as an ‘analgesic platform’.33 However, there is still only very limited evidence for the efficacy of non-pharmacological approaches in people with dementia34 and further research is needed.

Table 1. Pain management strategies: non-pharmacological approaches

Approach

Considerations

Physical therapy

Exercise

Recommended pain management strategy

Inconsistent evidence whether one type of exercise is better than another

Patient preference is the primary consideration

Focus on strengthening, flexibility, endurance, and balance

Individual capacity limits options

Foot orthotics, patellar taping

Foot orthotics may change gait pattern/muscle activation and reduce joint loading

Manual therapy

Requires significant levels of skill and care

TENS

Consider for persistent pain when patient can provide accurate feedback

Physical modalities (eg heat)

Beneficial for acute pain as effects are transient

Monitor for safety if used for patients with dementia

Occupational therapies

Assistive devices (eg walking frames)

Some evidence of reducing functional decline and pain intensity

Can increase pain if used incorrectly

Psychological approaches

Cognitive behaviour therapy

Demonstrated benefit for patients in aged care

Recommended if delivered by a professional

Complementary and alternative medicine

Acupuncture

Consider for older people as adjunctive therapy

May improve function and pain relief

Duration of long-term effects are uncertain

Massage, Tai Chi, yoga

Consider for older people as adjunctive therapy

Massage may have some benefit for non-specific lower back pain

Nutritional supplements

Some evidence that chondroitin and glucosamine improve pain and function in osteoarthritis

TENS, transcutaneous electrical nerve stimulation

Pharmacological

Pharmacological management of pain in residential aged care facilities can be complex as increasing age is accompanied by physiological changes that reduce physiological reserve and may increase frailty. There is heterogeneity in the response to medications among elderly patients, due in part to age-associated changes in body mass composition (fat mass increase, muscle mass and body water decrease) and organ function (central nervous system, hepatic clearance and renal system decline). In general, pharmacokinetic and pharmacodynamic changes and, therefore altered drug responses, are to be expected in elderly patients (Table 2).35

Paracetamol is considered as the most appropriate first-line therapy for persistent pain, particularly musculoskeletal pain. Oral non-steroidal anti-inflammatory drugs (NSAIDs) are typically more effective for chronic inflammatory pain (eg pain related to rheumatoid arthritis), although they are not generally recommended because of gastrointestinal and/or cardiac side effects. If prescribed, NSAIDs should be used for limited periods.36 Around-the-clock, regular dosing should be considered as nurse-initiated and PRN medications are generally not used as often as required for residents with dementia.

If pain persists with first-line therapies, opioid therapy could be considered (for certain types of pain such as cancer pain and in selected patients with severe non-cancer pain). The approach to using opioid analgesics is to start with low doses and titrate up until treatment goals are met. The increased risk of falls when initiating opioid therapy, particularly in the first 2 weeks when using short-acting opioids, should be kept in mind.37 Prophylactic treatment of constipation is especially important for older patients, or one of the newer opioid preparations could be considered (eg combination oxycodone/naloxone).

Refining pharmacotherapy for pain management may also include administration of multiple agents with synergistic effects (eg paracetamol in combination with codeine). For neuropathic pain, adjuvants such as certain tricyclic antidepressants (eg amitriptyline, nortriptyline), serotonin-noradrenaline reuptake inhibitors (eg duloxetine for fibromyalgia) or anticonvulsants (eg gabapentin for diabetic neuropathy and post-herpetic neuralgia, carbamazepine for trigeminal neuralgia, gabapentin, carbamazepine or pregabalin for post-stroke central pain) may be appropriate instead.13 The use of these medications in improving pain seems to be independent of any antidepressant properties these drugs have.38 Neuropathic pain is difficult to manage and although complete pain relief is usually unachievable, it may be sufficient to reduce pain to tolerable levels and improve pain-related disability. Medication side effects (especially with anticonvulsants) in frail older patients need careful monitoring, and drug–drug interactions (such as paracetamol with certain anticonvulsants) may limit pharmacotherapy options or require downward dose adjustment (Table 2).39

A stepwise protocol for treating pain40 has been shown to be effective in reducing pain scores in patients with dementia, as well as reducing behavioural and psychological symptoms of dementia. In particular, verbally agitated behaviour (eg complaining, constant attention seeking, repetitive questions and negativisms) was reduced after analgesic intervention, as were physically aggressive (eg hitting, kicking, grabbing) and non-aggressive behaviours (eg pacing, restlessness, repetitive mannerisms).

Table 2. Pain management strategies: pharmacological approaches

Approach

Considerations

Simple analgesics and anti-inflammatory agents

Paracetamol

Recommended first-line therapy

Well tolerated and side effects are rare

Do not exceed recommended maximum daily dose

NSAIDs

High risk of serious side effects in elderly

Use for shortest time possible. Increased risk of gastrointestinal side effects when combined with low dose aspirin

Topical NSAIDs effective for localised non-neuropathic pain and generally well-tolerated

Opioids

Weak opioids (eg codeine)

For moderate pain

Consider combination with paracetamol

Anticipate constipation

Strong opioids (eg morphine)

Indicated for severe pain not responding to non-opioid treatment

Side effects such as sedation, nausea and vomiting may worsen at opioid initiation/dose escalation

Anticipate constipation

Increased falls risk

Opioids for pain management rarely leads to addiction

Tramadol

Limited analgesic effect, but lower sedative and respiratory effects

Lower risk of constipation

Contraindicated in patients with a history of seizures or prescribed other serotonergic drugs

Adjuvants

Tricyclic antidepressants
(eg amitriptyline, nortriptyline)

Good efficacy for neuropathic pain but anticholinergic side effects limit use in older patients

Effective for diabetic neuropathy but prescribe with caution as high incidence of side effects

Nortriptyline may produce less anticholinergic side effects

Serotonin-noradrenaline reuptake inhibitors (eg duloxetine)

Duloxetine has demonstrated efficacy in some neuropathic pain conditions

Recommended for use in older patients with neuropathic pain

Generally well tolerated but side effects include hyponatremia, dizziness, abdominal pain, and nausea

Anticonvulsants (eg pregablin, gabapentin, carbamazepine)

Side effects include sedation, dizziness, peripheral edema

Elimination of gabapentin/pregablin dependent on renal function

Dose reduction for patients with renal impairment

NSAIDs, non-steroidal anti-inflammatory drugs

Nb: Physiological changes in older people have a direct and variable impact on the pharmacokinetics and pharmacodynamics of drugs used in treating pain. Therefore pain management medication needs careful titration to response. Consider a combination of pharmacological and non-pharmacological approaches for comprehensive pain management.

Conclusion

Good pain management in residential aged care settings must address a number of barriers such as attitudes to pain, communication deficiencies, heterogeneity of responses to pharmacotherapy in elderly frail patients and limited evidence for effective treatment approaches for patients with dementia. However, developments including behavioural observational tools and stepwise pain protocols may help address some of these obstacles.

Competing interests: Stephen Gibson has been paid by CSL Limited and Pfizer Australia for consultancy relating to activities outside this article. He has also received payment for the development of educational presentations from various professional associations and has had his travel expenses covered when a plenary speaker.
Provenance and peer review: Commissioned, externally peer reviewed.

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Correspondence afp@racgp.org.au

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