Persistent pain is a widespread concern in residential aged care, often exacerbated by suboptimal analgesic use. Managing pain effectively in aged care settings is complex, facing numerous obstacles such as patient attitudes, altered drug responses in older bodies, and communication barriers due to conditions like dementia. Understanding these challenges is the first step in implementing a robust Pain Management Program Aged Care facilities desperately need to improve the quality of life for their residents.
Understanding Attitudes Towards Pain in the Elderly
Elderly individuals, particularly those with cognitive decline, may struggle to express their pain accurately. Even those with intact cognition may harbor beliefs that hinder effective pain reporting. Studies reveal that older patients, more so than nurses, often believe persistent pain is an inevitable part of aging with limited improvement potential. Fear of medication addiction, reluctance to acknowledge disease progression, or increased dependence also contribute to underreporting. Stoicism and a tendency to downplay sensations as “painful” are more prevalent in older adults, especially those over 60.
Healthcare providers must actively challenge these misconceptions. Encouraging, supporting, and even gently prompting patients to articulate their pain experience is crucial. If a patient denies pain, using alternative terms like “discomfort,” “throbbing,” or “soreness” might yield a more informative response. For patients unlikely to self-report, routine pain assessments, at least every few months or when warranted by changes in condition, are essential for proactive pain management program aged care facilities should incorporate.
Comprehensive Pain Assessment in Aged Care
A thorough pain assessment is foundational to designing a personalized pain management program aged care residents require. Accurate diagnosis of the pain’s cause is paramount, as treatment effectiveness varies with pain type, and the underlying cause may be treatable. Persistent pain assessment involves reviewing pain history, medical conditions, medications, mood, and quality of life. Disproportionate or systemic pain may indicate central nervous system sensitization. Neuropathic symptoms, multifocal pain reports, and comorbid somatic symptoms can also point to centralized pain.
A physical examination, both at rest and during movement (weight-bearing, walking, sitting, limb movements), is crucial. Diagnostic tests might be necessary, but it’s important to interpret radiographic findings cautiously, as age-related changes, especially in joints, are common and don’t always correlate with pain, as seen in osteoarthritis.
Pain Assessment Tools for Aged Care Settings
Various pain assessment tools are suitable for residential aged care, categorized as self-report, observational, and sensory testing tools.
Self-Report Tools: The Gold Standard
Despite attitudinal barriers, self-reporting remains the most reliable method of pain assessment. Scales using words, pictures, or numbers are effective when simple and easily understood. Examples include the Numerical Rating Scale (0-10 pain rating) and the Verbal Descriptor Scale (“no pain” to “extreme pain”). More complex multidimensional scales like the Brief Pain Inventory can track pain intensity and its impact on daily life, offering a deeper insight for a pain management program aged care facilities can utilize.
Observational Tools for Cognitive Impairment
Patients with cognitive impairment can often self-report pain reliably, but as dementia progresses, observational tools become increasingly valuable. These tools primarily detect pain presence in those unable to self-report adequately. They measure behaviors that may indicate pain, but can also be caused by other factors (like exertion), leading to false positives (25–30%). While no single tool is universally preferred, geriatric-specific tools like ABBEY, PAINAD, DOLOPLUS-2, NOPPAIN, and PACSLAC are all suitable options for a pain management program aged care facilities can adopt. These tools differ in pain indicators, ease of use, and administration time, but some have recently shown sensitivity to pain severity.
Key pain behaviors are consistent across observational scales: facial expressions (frowning, grimacing), body language (guarding, rigidity), and negative vocalizations (crying, groaning). These are validated in non-verbal pain assessment scales for dementia. Other indicators may include consolability, behavioral changes (aggression), physiological changes (pulse rate), physical changes (bruises), routine changes (eating, sleeping), and altered breathing. Wandering is now considered an unreliable pain indicator and may even suggest reduced pain.
Sensory Testing Tools for Neuropathic Pain
Sensory testing tools aid in identifying neuropathic pain, assessing peripheral nerve function non-invasively. While comprehensive testing is time-consuming, simple brush and pinprick tests are practical in aged care. Brush tests detect allodynia (pain from non-painful stimuli), and pinprick tests assess hyperalgesia (increased sensitivity to painful stimuli), both indicative of neuropathic pain. Consider these tests if neuropathic pain is suspected due to conditions like diabetes or stroke, or patient reports of tingling, numbness, or burning pain. However, their effectiveness in advanced dementia is uncertain. Integrating sensory testing considerations into a pain management program aged care facilities provide can enhance diagnostic accuracy.
Multidisciplinary Pain Management Approaches
Effective pain management program aged care requires a multidisciplinary approach, combining pharmacological and non-pharmacological therapies. Musculoskeletal pain is common in aged care, and treatment may involve medication, physical therapy (exercise, orthotics), and occupational therapy (joint protection, assistive devices).
Non-Pharmacological Strategies
Non-pharmacological options like exercise, acupuncture, massage, and cognitive-behavioral therapies play a significant role in pain management program aged care. Exercise is effective for osteoarthritis pain and function. Acupuncture and massage are recommended adjuncts for osteoarthritis, potentially reducing pain and disability, although acupuncture’s efficacy for chronic pain may be more modest than previously thought. Manual therapy and TENS may benefit certain persistent pain types, but evidence is less robust, and manual therapy requires specialized skills.
The biopsychosocial pain model addresses psychological and behavioral pain components, valuable for centralized or neuropathic pain. Musculoskeletal pain often co-occurs with sleep disturbance, fatigue, and depression. Cognitive behavior therapy shows moderate benefits for pain and slight function improvements in older adults. Non-pharmacological approaches are crucial and can be combined with medication as a comprehensive “analgesic platform.” However, evidence for their effectiveness in dementia is limited, highlighting the need for further research to strengthen the pain management program aged care facilities offer to residents with cognitive decline.
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 behavior 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 Strategies
Pharmacological pain management program aged care facilities utilize must be carefully considered due to age-related physiological changes that impact drug response. Elderly patients show varied medication responses due to changes in body composition and organ function. Pharmacokinetic and pharmacodynamic alterations are expected in older adults.
Paracetamol is typically the first-line drug for persistent pain, especially musculoskeletal pain. Oral NSAIDs are more effective for inflammatory pain but are generally avoided due to side effects. If used, NSAIDs should be short-term. Regular, around-the-clock dosing is preferable to PRN medication, especially for dementia residents who may not request medication as needed.
Opioids may be considered if pain persists despite first-line therapies (e.g., for cancer pain or severe non-cancer pain). Start with low doses and titrate upwards. Be aware of increased fall risk, especially initially with short-acting opioids. Prophylactic constipation treatment is crucial, or consider newer opioid formulations like oxycodone/naloxone.
Combining drugs with synergistic effects (e.g., paracetamol and codeine) can refine pharmacotherapy. For neuropathic pain, adjuvants like tricyclic antidepressants (amitriptyline), serotonin-noradrenaline reuptake inhibitors (duloxetine), or anticonvulsants (gabapentin) may be used. Their pain-relieving effects appear independent of antidepressant properties. Neuropathic pain management is challenging, aiming for pain reduction to tolerable levels and improved function rather than complete relief. Monitor medication side effects and drug interactions carefully, especially in frail older patients. A stepwise pain treatment protocol has proven effective in reducing pain and behavioral symptoms in dementia patients.
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: Enhancing Pain Management in Aged Care
Effective pain management program aged care requires overcoming barriers like attitudes, communication challenges, variable drug responses in frail elderly individuals, and limited evidence for dementia pain treatment. However, advancements like observational tools and stepwise protocols offer solutions. By addressing these obstacles, aged care facilities can significantly improve pain management and enhance the well-being of their residents.
