Pain management in older adults

Pain management in older adults

MEDICINE IN OLDER ADULTS Pain management in older adults They are also more likely to have diminished functional status and physiological reserve, a...

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MEDICINE IN OLDER ADULTS

Pain management in older adults

They are also more likely to have diminished functional status and physiological reserve, as well as age-related pharmacodynamic and pharmacokinetic changes.4 Cognitive impairment can prevent or complicate adequate pain assessment. In all care settings, healthcare professionals need to be aware of pain assessment tools that can be used with older adults e both for those who can communicate their pain and those who are unable to do so as a result of cognitive impairment.

Patricia Schofield

Abstract

Pain assessment

As our populations age healthcare professionals in most areas of practice will increasingly deal with older people and the health problems they present. One such problem is pain, but at the moment, the assessment and management of pain in this age group are poorly practised, particularly in those with dementia. The limited evidence base for many treatments and the concurrence of co-morbidities that complicate the use of many pharmacological treatments provide additional challenges. This paper will discuss the current recommendations regarding the assessment and management of pain, and suggest areas where research needs to be carried out.

The process of assessment of pain in older adults can be complicated not only by the presence of cognitive impairment, but also visual or hearing problems and other communication difficulties e for example, dysphasia caused by the common co-morbidity of cerebrovascular disease. The American Pain Society has stated that pain is the ‘Fifth Vital SignÔ’,5 emphasizing the importance of routine and systematic assessment and monitoring similar to that undertaken for respiration, pulse and blood pressure, and not an assessment to be avoided because it may be challenging. Pain intensity scales can be used for older adults with mild or moderate levels of cognitive impairment. If possible, the patient’s own descriptive words should be used, and if the person denies the presence of pain when asked directly it may be useful to follow up with questions around ‘aching’ or ‘soreness’.6 It has been demonstrated that many older adults do not like to complain about pain, perhaps because of increased levels of stoicism, and that this can be worse amongst the care home population7 who may not wish to be perceived as a ‘problem’ to carers or staff. In 2007 a UK national pain assessment guideline was published (http://www.britishpainsociety.org/pub_professional.htm#

Keywords ageing; assessment; management; pain

Evidence suggests that pain is a common problem for older people, with chronic persistent pain affecting at least 50% of community-dwelling older adults1 and this number increases to 80% amongst those living in care homes. As the percentage of our ageing population increases over time (Figure 1) greater demands will be placed on healthcare professionals to cope with the problems associated will old age, in particular pain management. It is frequently assumed that chronic pain is simply a part of getting older and something with which the individual must learn to live. However, research into chronic pain management for older adults is developing and there is increasing awareness that self-management of chronic pain is a viable strategy for this population.2 Pain management of older adults is generally poor. Admission to hospital for patients over the age of 65 years is three times higher than for younger people and there is evidence that professionals tend to underestimate pain needs, under-prescribe and under-medicate.3 This may in part relate to fears and misconceptions amongst prescribers regarding pre-existing comorbidities and the effects of prescribed medicines. Such fears and anxieties are not totally unfounded as older adults do tend to have co-morbidities and concurrent medications prescribed.

Proportion of world’s population over 65 years old will rise from 7.4% to 16.4% by 2050

1996

2006

2025

2050 Patricia Schofield RGN PhD PGDipEd DipN is Professor of Nursing, University of Greenwich, UK. She has completed a number of post-doctoral projects around pain management in older people including talking to them about their pain experiences and including funding from MRC, EU and ESRC. Currently she is working with the British Geriatrics Society and the British Pain Society setting up guidelines for pain assessment in older adults and leading a large multi-centre funded study on pain in older adults. She is also involved in a number of other studies. She has written over 50 books and publications in this area of research. Conflicts of interest: none declared.

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Proportion of population >65 years old (%) World More developed countries Less developed countries Source: U.S. Census Bureau, International Programs Center, International Data Base

Figure 1

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Abbey Pain Scale For measurement of pain in people with dementia who cannot verbalize

How to use scale: While observing the resident, score questions 1 to 6 Name of resident: Name and designation of person completing the scale: Date: Time: Latest pain relief given was at

hrs

Q1. Vocalization e.g. whimpering, groaning, crying Absent 0 Mild 1 Moderate 2 Severe 3

Q1

Q2. Facial expression e.g. looking tense, frowning grimacing, looking frightened Absent 0 Mild 1 Moderate 2 Severe 3

Q2

Q3. Change in body language e.g. fidgeting, rocking, guarding part of the body, withdrawn Absent 0 Mild 1 Moderate 2 Severe 3

Q3

Q4. Behavioural change e.g. increased confusion, refusing to eat, alteration in usual patterns Absent 0 Mild 1 Moderate 2 Severe 3

Q4

Q5. Physiological change e.g. temperature, pulse or blood pressure outside normal limits, perspiring, flushing or pallor Absent 0 Mild 1 Moderate 2 Severe 3

Q5

Q6. Physical changes e.g. skin tears, pressure areas, arthritis, contractures, previous injuries Absent 0 Mild 1 Moderate 2 Severe 3

Add score for 1–6 and record here Now tick the box that matches the Total pain score

Q6

Total pain score

0–2 No pain

Finally, tick the box that matches the type of pain

3–7 Mild

8–13 Moderate

14+ Severe

Chronic

Acute

Acute on Chronic

Dementia Care Australia Pty Ltd Website: www.dementiacareaustralia.com Abbey, J; De Bellis, A; Piller, N; Esterman, A; Giles L; Parker, D and Lowcay, B. Funded by the JH and JD Gunn Medical Research Foundation 1998–2002. (This document may be reproduced with this acknowledgment retained)

Figure 2

assessmentpop) 8 for specific use in older people. Many pain intensity scales are used in practice. The best evidence to date recommends numerical rating scales9 (0e10) and verbal rating scales10 (none, mild, moderate, severe) (Figure 2 and Box 1). Both scales can be used in the presence of mild-to-moderate cognitive impairment, but consideration must be given to the visual presentation to ensure that the scales are in large enough print to be seen. The least effective scale for use with the older population is the visual analogue scale.11 Assessment of the presence and intensity of pain is the only factor that should be assessed. Pain is a multidimensional experience and assessment

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Pain assessment scales Verbal rating scale None Mild Moderate Severe Numerical rating scale 0___1___2___3___4___5___6___7___8___9____ 10 Worst pain imaginable No pain

Box 1

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MEDICINE IN OLDER ADULTS

should also consider onset, time course, radiation, aggravating/ relieving factors, information regarding current and previous management, which should include medication and complementary therapies, impact of the symptom on physical function or quality of life, and the patient’s beliefs, understanding and expectations. The patient is the main source of information in the assessment process but it is also important that carers, or family

members are involved, particularly if the patient is unable to communicate.

Behavioural pain assessment Observation is a vital tool in the assessment of the existence or intensity of pain particularly in patients who have

Analgesics for use with older adults (the WHO “three step analgesic ladder” is a good way to titrate people into appropriate drug regimes and this can fit well with pain assessment scales, therefore; none, mild, moderate, severe) Drug

Adverse effects

Dose

Paracetamol should be considered as first-line treatment for the management of both acute and persistent pain in older people, particularly of musculoskeletal origin, due to demonstrated efficacy and good safety profile

There are few relative cautions and absolute contraindications to prescribing paracetamol

It is important that the maximum daily dose (4 g/24 h) is not exceeded

Non-selective NSAIDs and selective COX-2 inhibitors should be used in older people only after other safer treatments have not provided sufficient pain relief

For older people, an NSAID or selective COX-2 inhibitor should be co-prescribed with a proton pump inhibitor, choosing the one with the lowest acquisition cost All older people taking NSAIDs or COX-2 inhibitors should be routinely monitored for GI, renal and cardiovascular adverse effects, and drugedrug and drugedisease interactions

The lowest dose should be used for the shortest duration

Opioids have demonstrated efficacy in the short term for both cancer and non-cancer pains, but long-term data are lacking All patients with moderate and severe pain should be considered for opioid therapy, particularly if pain is causing functional impairment or reducing quality of life Patients with continuous pain should be treated with modified-release oral or transdermal opioid formulations aimed at providing relatively constant plasma concentrations

Opioid adverse effects (including nausea and vomiting) should be anticipated and suitable prophylaxis considered Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people taking opioid therapy Regular patient review is required to assess the therapeutic benefit and to monitor adverse effects

As there is marked variability in individual response to opioids, treatment must be individualized and carefully monitored for efficacy and tolerability

Anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain

Adverse effects and the need for blood monitoring limit the use of older anti-epileptic drugs in older people Dose adjustment of gabapentin and pregabalin is required in renal impairment Regular patient review is required to assess therapeutic benefit and to monitor adverse effects

Tricyclic antidepressants have demonstrated efficacy in several types of neuropathic pain

Adverse effects and contraindications limit the use of tricyclic antidepressants in older people Duloxetine has been shown to be effective for the treatment of neuropathic pain and some studies suggest efficacy for non-neuropathic pain such as osteoarthritis and low back pain Other antidepressants (e.g. SSRIs) have very limited evidence of analgesic efficacy and should not be used as analgesics

The lowest dose should be initiated and the dose increased slowly as tolerated Regular patient review is required to assess therapeutic benefit and to monitor adverse effects

Adapted from Knaggs R pharmacological approaches to management in Schofield P et al (2012) BPS/BGS guidelines for the management of pain in older adults. COX-2, cyclooxygenase-2; GI, gastrointestinal; NSAID, non-steroidal anti-inflammatory drug; SSRI, selective serotonin reuptake inhibitor.

Table 1

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REFERENCES 1 Helme RD, Gibson SJ. The epidemiology of pain in elderly people. Clin Geriatr Med 2001; 17: 417e31. 2 Schofield P, Clarke A, Jones D, Martin D, McNamee P, Smith B. Chronic pain in later life: a review of current issues and challenges. Ageing Health 2011; 7: 551e6. 3 Catananti C, Gambassi G. Pain assessment in the elderly. Surg Oncol 2010 Sep; 19: 140e8. Epub 2009 Dec 16. 4 Aubrun F, Marmion F. The elderly patient and postoperative pain treatment. Best Pract Res Clin Anaesthesiol 2007 Mar; 21: 109e27. 5 JCAHO. Pain assessment and management standards 2002 (accessed 2 July 2012), http://www.ipcaz.org/pages/new.html. 6 Bergh I, Sjostrom B, Oden A, Steen B. Assessing pain and pain relief in geriatric patients with non-pathological fractures with different rating scales. Aging Clin Exp Res 2001; 13: 355e61. 7 Schofield PA. Pain management in care homes. J Community Nurs 2006; 20: 30e4. 8 British Pain Society/British Geriatrics Society. The assessment of pain in older adults e national guidelines 2007, http://www. britishpainsociety.org/pub_professional.htm#assessmentpop (accessed 2 July 2012). 9 Closs J, Barr B, Briggs M, Cash K, Seers K. The clinical utility of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. J Clin Nurs Verbal Commun 2003, Submitted for publication. 10 Herr K, Mobiliy P. Pain assessment in the elderly: clinical considerations. J Gerontol Nurs 1991; 17: 12e9. 11 Hadjistavropoulos T, Martin RR, Sharpe D, Lints AC, McCreary DR, Asmundson GJ. A longitudinal investigation of fear of falling, fear of pain, and activity avoidance in community-dwelling older adults. J Aging Health 2007 Dec; 19: 965e84. 12 Blomqvist K. Older people in persistent pain: nursing and paramedical staff perceptions and pain management. J Adv Nurs 2003; 41: 575e84. 13 Herr K, Bjoro K, Decker S. Tools for assessment of pain in non-verbal older adults with dementia: a state of the science review. J Pain Symptom Manag 2006; 31: 170e92. 14 Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992; 15: 369e77. 15 Abbey J, Piller N, De Bellis A, et al. The Abbey pain scale: a one minute indicator for people with end stage dementia. Int J Palliat Nurs 2004; 10: 6e13. 16 Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Association 2003; 4: 9e15. 17 Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain Manag Nurs 2004; 5: 37e49. 18 Malloy DC, Hadjistavropoulos T. The problem of pain management among persons with dementia, personhood, and the ontology of relationships. Nurs Philos 2004 Jul; 5: 147e59. 19 Snow AL, Weber JB, O’Malley KJ, et al. NOPAIN: a nursing assistantadministered pain assessment instrument for use in dementia. Geriatr Cogn Disord 2004; 17: 240e6. 20 Lefebre-Chapiro S. The Doloplus 2 scale e evaluating pain in the elderly. Eur J Palliat Care 2001; 8: 191e4. 21 Pautex S, Hermann FR, Michon A, Giannakopoulos P, Gold G. Psychometric properties of the Doloplus-2 observational pain

communication problems, such as cognitive impairments or visual and hearing problems. Common indicators cited include facial expressions and body movement (guarding)12,13 and physical indicators such as pallor, tachycardia and hypertension. The last two decades have seen the development of a number of pain scales designed to measure behaviours associated with pain. At least seven currently exist14e20 and are consistent in listing the following observable or recordable phenomena associated with pain:  physiological observations (e.g. changes in respiration or pulse)  facial expressions (e.g. grimacing)  body movements (e.g. uncharacteristic restlessness)  verbalizations (not clearly indicating the presence of pain)  changes in interpersonal interactions (e.g. uncharacteristic aggression towards carers)  changes in activity or routines (e.g. wishing to stay longer in bed)  changes in mental status (e.g. depression, confusion). Currently, the tools have been evaluated only in single clinical settings, and it is difficult to recommend one particular tool as being more reliable and valid. Since the publication of the UK Assessment Guidance in 2007,8 further research, using the Doloplus scale,21 PAINAD22 and NOPAIN23 scales, has been undertaken and there is a move to develop an internationally recognized scale. Furthermore, a ‘sister scale’ to Doloplus, the Algoplus24 has been developed for measuring acute pain in adults with cognitive impairment. This scale only takes 1 minute to complete, thereby lending itself to busy acute care settings.

Management of pain UK national pain management guidelines for older people will be published in 2012.25 Key messages will include the use of drugs such as paracetamol as the first line of treatment for acute or persistent pain, but will emphasize that alternatives, even including opioids, can be used if necessary on a ‘start low, go slow’ basis. Non-steroidal anti-inflammatory drugs have a place, but only for short-term use (Table 1). Finally, there are alternative approaches such as psychological therapies and selfmanagement strategies, and adjuvant treatments such as transcutaneous electrical nerve stimulation or acupuncture, which have a relatively small body of evidence supporting their use. There is limited evidence regarding invasive modalities. Guidelines, although challenging to implement, can reduce variation in practice and can also inform the development of randomized controlled trials, inform medical and allied health professional education, and influence policy, as has been seen with the NHS Cancer Plan.26 A personal literature search on ‘pain in older adults’ several years ago revealed that whereas some 4000 papers were published annually relating to pain, less than 1% focused upon pain in the older population. In a review of eight geriatric textbooks, only 18 out of 5000 pages focused on pain. Further research is needed into the use of all management approaches applied to the older population if pain management is to improve, as much current practice is based on the extrapolation of studies undertaken in younger cohorts. A

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patients pain assessment instrument, self report and behavioural observations. Pain Manag Nurs 2007; 8: 77e85. 24 Rat P, Jouve E, Bonin-Gulliaume S, Doloplus C. The Algoplus scale for the assessment of induced pain behaviour. Soins 2010 Oct; 749: 50e1. 25 Schofield PA. The management of pain in older adults e guidelines for practice. British Geriatrics Society/British Pain Society, 2012. 26 Levin A. Practice guidelines do improve patient outcomes: association or causation? Blood Purif 2008; 26: 67e72.

assessment scale and comparison to self-assessment in hospitalised elderly. Clin J Pain 2007; 23: 774e9. 22 Schuler MS, Becker S, Kaspar S, Nikolaus T, Kruse A, Basler HD. Psychometric properties of the German “Pain Assessment in Advanced Dementia Scale (PAINAD-G)” in nursing home residents. J Am Med Dir Association 2007; 8: 388e95. 23 Horgas A, Nichols AL, Scapson CA, Vietes K. Assessing pain in persons with dementia: relationships among the non-communicative

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