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Pain management in older people: the changes you can make to improve quality of life

Addressing patient needs starts with thorough pain assessment – here’s what you need to know
An older lady sitting on a hospital bed. Picture: iStock

Guidance is due to be updated, but addressing patients needs starts with a thorough pain assessment. Here's what you need to know

As the older population of the UK increases, we are seeing an increase in older adults experiencing poorly controlled chronic pain.

There are a number of difficulties when dealing with pain in this group, including fear of using drugs, belief that pain is part of ageing, belief that healthcare professionals are the experts, not wanting to complain and restrictions associated with reporting pain due to the time-limited consultations.

The factors that hinder pain assessment

Pain assessment is the fundamental first step in the process and national guidelines were published in 2018 to aid this. But often management is hindered by:

  • Lack of evidence supporting approaches applied in this group.
  • Comorbidities that
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Guidance is due to be updated, but addressing patients’ needs starts with a thorough pain assessment. Here's what you need to know

 iStock
 Picture: iStock

As the older population of the UK increases, we are seeing an increase in older adults experiencing poorly controlled chronic pain.

There are a number of difficulties when dealing with pain in this group, including fear of using drugs, belief that pain is part of ageing, belief that healthcare professionals are ‘the experts’, not wanting to complain and restrictions associated with reporting pain due to the time-limited consultations.

The factors that hinder pain assessment

Pain assessment is the fundamental first step in the process and national guidelines were published in 2018 to aid this. But often management is hindered by:

  • Lack of evidence supporting approaches applied in this group.
  • Comorbidities that prevent use of many pharmacological approaches.
  • Misconceptions among health care professionals and older adults themselves.

British Geriatrics Society and British Pain Society guidelines for the management of pain, published in 2013, are soon to be updated, with a new edition to be published this year. So I'd like to summarise the latest evidence that underpins the management of pain in older people.

Step 1: Assessment of pain

Before we can begin to manage pain in any cohort, we need to carry out a thorough pain assessment. Older adults are no exception. However, we need to acknowledge that the assessment process may take a bit longer and that they may be reluctant to report their pain, expect pain as part of ‘being older’, or expect healthcare professionals to ‘know’ when they are in pain.

Furthermore, communication difficulties can inhibit pain reporting in this group. According to the 2018 guidelines, generally assessment of pain intensity can be achieved using verbal rating scales or numerical rating scales, even when there is evidence of mild to moderate dementia.

When the individual’s level of dementia is more severe, we need to resort to behavioural pain assessment scales. For example, Doloplus-2 or Abbey scales have been shown to be reliable, valid and user-friendly.

It is important we consider the impact on the older person of the pain they are experiencing. For example, simple tasks such as household activities or social interaction can be significantly affected, particularly when pain is chronic.

When to consider pharmacological interventions

  • Pharmacological management of pain in older people remains challenging because of comorbidities and potential side effects. So, considerations such as attention to route of administration, timing and side effects are essential
  • Where possible, use of nonpharmacological methods is preferred, such as TENS or acupuncture
  • Paracetamol remains the safest option, although recommendations now suggest efficacy is reduced in chronic pain, and long-term use does increase the risk of side effects
  • Awareness of the increased risks of NSAIDs (non-steroidal anti-inflammatory drugs) remains essential and we have no safe NSAID for use with this population
  • Opioids are effective for acute or cancer pain in older people, as with the general adult population. But there is no evidence to support their use for chronic pain with any age cohort
  • Gabapentin, pregabalin, amitriptyline and duloxetine are recommended as first-line treatments for neuropathic pain, but choice must be individualised, depending on comorbidities and other medicines being taken

 

Step 2: Pain management

A recent systematic review was carried out for the pain guidelines update, in vital areas including:

  • Attitudes.
  • Pharmacology.
  • Invasive treatment.
  • Psychology.
  • Physical activity.
  • Carers’ perspectives.
  • Palliative care.

It is important to note the 2020 guidelines should be read alongside the 2013 guidelines because some aspects of pain management remain unchanged.

Some 40% of older adults living in the community have poorly controlled chronic pain and for those living in nursing homes this may rise to 80%. This remains an issue that needs to be addressed, particularly because chronic pain is associated with increased falls and frailty.

What about alternatives to pharmacological interventions?

Psychological interventions such as CBT (cognitive behavioural therapy), pain management programmes, mindfulness and humour have been investigated with some positive results. Studies of these tend to be small scale.

However, we are seeing increasing numbers of studies that recommend the use of physical activity in the management of pain, such as walking, strengthening and even yoga.

 

Understanding and overcoming barriers to pain management

Common pain sites include shoulders, neck, back, hips, knees and feet. Obesity and female sex are more likely to be associated with chronic pain, and osteoporosis and osteoarthritis are common underlying conditions.

The persistence of barriers to effective pain management in older people – in spite of a number of guidelines introduced globally – continues to demonstrate the need for better education among healthcare professionals and older adults. 

There is still much research needed to determine the most appropriate management of pain in the older population. Pharmacological interventions are not without risk. The key, wherever possible, is to promote activity, exercise, strengthening, flexibility, endurance and balance, which help reduce pain and prevent falls.


Professor Patrica SchofieldPatricia Schofield is a nurse by background. She works for Sheffield Hallam University as UoA3 (units of assessment) lead, having recently stepped down as a deputy dean for research. She is honorary professor of pain and ageing at Abertay University and led the development of national guidelines for the assessment and management of pain in older adults

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