Pain: Assessment and Management
This Clinical Information Sheet has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) to assess and manage residents in pain. It addresses issues that may occur in RACF, particularly pain assessment, treatment of common types of acute and chronic pain, and the use of common medications.
This CIS covers:
About Pain; Assessment; Management; Non-pharmacological Strategies; Medication; and Sources of Information.
Reference cards:
Breakthrough Pain Management
Pain Assessment and Management
Resident’s verbal brief pain inventory
Abbey Pain Scale for people with dementia or who cannot verbalise
Pain care plan
Sedation scale
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Pain
Acute pain has a prevalence of approximately 5% across all age groups, whereas the prevalence of chronic pain increases with age. The prevalence of chronic pain in nursing home residents is as high as 60-83% [1] and although nursing home residents may be diagnosed with medical conditions giving rise to pain, treatment of pain is often inadequate.
It is well established that less analgesia is prescribed and administered for people who have dementia [2-5]. In Australian nursing homes 90% of residents have some form of cognitive impairment, with reduced reasoning and language skills, resulting in impaired communication and difficulty reporting pain [6]. If behaviours are not recognised as emanating from pain, a significant number of people with dementia remain untreated [4, 5].
Pain disrupts sleep, impairs mobility and results in a reduction of social activities [7, 8]. Pain can exacerbate confusion and cause unexpected behaviours which complicate medical and nursing management of residents with dementia [9].
Characteristics of pain
The International Association for the Study of Pain [10] defines pain as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’ In the clinical setting pain is understood as being a personal experience that occurs when and where the person says it does.
Pain has a complex aetiology involving not just physical disorders, but also pathological, physiological, psychological, cognitive and environmental factors [11].
It can be described in a number of ways, which assist in the understanding of the pain experience, and help to determine the appropriate treatment of the pain.
Duration
Acute pain is of recent onset, usually of short duration, and the cause is often identifiable, e.g. disease, trauma. Chronic pain persists for more than 3 months or persists after healing is expected to be complete. It is often further classified into cancer or non-cancer pain. Acute exacerbations of chronic pain may occur. A new acute pain may occur concurrently with chronic pain, and should be investigated and treated.
Pathology
Diagnosis of the cause of the pain impacts on treatment of the pathology and choice of analgesia.
- Nociceptive pain is due to activation of normal pain fibres. It may be somatic, e.g. involving superficial structures such as skin and muscle, or visceral, e.g. involving deeper organs such as liver, pancreas [11]. - Neuropathic pain is due to nerve injury, disease or surgical section occurring anywhere in the pain pathway from peripheral, e.g. post-herpetic neuralgia, diabetic neuropathy, phantom limb, to central, e.g. spinal cord injury, post stroke, including the autonomic nervous system [11].
The most common type of pain seen in nursing home residents is nocioceptive pain, often resulting from pathologies related to ageing such as arthritis, osteoporosis and vascular disease.
Emerging patterns
Identification of emerging patterns helps to establish a treatment regime:
Baseline pain is experienced for more than 12 hours per day. Breakthrough (intermittent) pain is increased pain for transient periods, or between doses in patients receiving regular analgesia [11]. Incident pain occurs on, or is exacerbated by, movement [11].
Experiential phenomena
Descriptive terms enhance understanding of the pain experience as well as the aetiology of the condition.
Allodynia: A painful response to non painful stimuli. Hyperesthesia: Increased sensitivity to stimuli. Hyperalgesia: Excessive sensitivity to stimuli. Dysesthesia :Unusual sensations that are painful eg. pins & needles, tingling, burning, lancinating, shooting.
Beliefs about pain
There are many myths associated with pain assessment and management in older people, and often they are linked to ageist attitudes. Some myths and their counter facts are set out in Table 1, adapted from McCaffery & Pasero, in Guidelines for a Palliative Approach in Residential Aged Care [12]
Table 1: Myths and facts about pain
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Myth
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Fact
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1. |
The nurse or the doctor is the best judge of whether a resident is in pain. |
The resident knows best about her/his own pain. Self report is the most reliable indicator of location and intensity of pain. |
2. |
Pain is a natural part of ageing. |
Pain is not a normal state, and is usually associated with pathology. |
3. |
Aggressive treatment is unwarranted in older people. |
Older people are equally entitled to have pain relieved as their younger counterparts. |
4. |
People with dementia are unable to use assessment scales. |
When an appropriate pain rating scale is used and the person is given adequate time to process and respond, many cognitively impaired people can use rating scales. |
5. |
Clinicians should rely on their own personal beliefs as to whether the resident is telling the truth about the status of her/his pain. |
Pain is a subjective experience, different for each person. The resident’s self report therefore is very important in establishing what the pain means to her/him. |
6. |
When there is no physical cause identified there is no reason for a resident to have pain. |
Pain is a multidimensional phenomenon which is little understood. It is better to accept that a resident has pain if that is what she/he says. |
7. |
Analgesia should only be given for pain that is currently present. |
It is better to give analgesia prior to activities or movement in order to control incident pain. Maintaining a therapeutic dose in the blood stream avoids the peaks and troughs of sporadic analgesic administration. |
8. |
Use of opioids will cause addiction. |
Opioids rarely cause addiction or other aberrant behaviours in older people. |
9. |
Older people complain more about pain. |
Older people tend to under-report pain even though they have more pain related pathologies [13]. |
Health care professionals may inadvertently reward stoic behaviour by giving praise when residents don’t complain about their pain. Silence is not necessarily indicative of a pain free state. Older people tend to under-report pain for a variety of reasons. Many older people believe that:
They should only take analgesia for severe pain; Reporting pain may result in hospitalization and investigations; Their reports of pain may not be taken seriously; Pain is a natural outcome of the ageing process, and don’t expect that anything can be done; and Analgesia may have side effects and cause them to have a fall.
Assessment
Aims of assessment are to identify the nature, type and severity of pain, to help develop a management and monitoring plan. Assessment includes [11, 14]:
Measure pain severity; Identify the pain mechanism; Detect acute pain syndromes, underlying pathology, or features that predict progression to chronic pain; Identify patterns of baseline, breakthrough and incident chronic pain; and Document co-morbidities, medication, drug and alcohol history.
Assessment of pain should be carried out on admission of the resident to the facility, after a change in medical or physical condition and as symptoms arise. Assessment includes input from the resident, family, and RACF staff. Pain assessment should be carried out during periods of rest, mobility and social activities; take into account pre-existing medical conditions. (Refer to Reference Card: Pain Assessment and Management). Regular reassessment is required to determine changes and the effect of interventions.
Pain is a subjective experience and cannot be measured directly. Patient self-reporting is the best way to assess pain. When measurements are taken using reliable methods the results are sensitive and consistent. In some situations, e.g. cognitive impairment, psychiatric pathology, observer assessment of non-verbal behaviour is necessary.
Self report
Self-report is the usual method of assessment of pain location, duration and intensity. Begin with a general question, e.g. Are you 100% comfortable?. Inquire where the pain is, and if there is more than one pain. Then proceed to a more detailed consideration. If a resident denies pain or minimises its severity, ask about ‘discomfort’ rather than pain, and if [14]:
Discomfort prevents them from going to sleep; They wake with pain or discomfort; Discomfort prevents normal activities of daily living; and They are ever ‘completely comfortable’
Older people whose communication skills are compromised by illness or cognitive impairment may still be able to communicate their pain to others. Asking about the pain in the present is a reliable method of assessment. People with dementia may not be able to remember how their pain was yesterday, or half an hour earlier.
Physiological changes
Changes in physiological factors may indicate pain, e.g. raised heart rate, pulse, temperature, respiratory rate, blood pressure or sweating. Other changes associated with pain are:
Abnormal colour of skin, discharge from eyes, nose, vagina or rectum; Lesions to oral or rectal mucosa, skin; Distension of the abdomen, swelling of limbs, swelling of body joints; Abnormal urinalysis; Decreased functional ability e.g. mobility, range of movement, activity, endurance; note which activities give rise to pain; and Changes in posture; standing, sitting, reclining.
Behavioural symptoms
Pain is often expressed through behavioural symptoms even in residents whose verbal communication skills are intact. Observation of behavioural symptoms relies on the skills of the caregiver and a comprehensive knowledge of the resident’s usual behaviours. It is useful to include the family in the assessment process to gain a more complete picture of the resident and her/his responses to pain.
Behaviours presenting as pain may be:
Changes in the resident’s usual behaviour patterns or living routines; Aggression, resistance, withdrawal, restlessness; Facial expression of grimacing, fear, sadness, disgust; and Verbalizations: Self-reports of pain; requests for analgesia or help; sighing, groaning, moaning, crying; and unusual silence.
Pain Assessment Scales
Studies show that the use of assessment scales results in more successful assessment of pain.
For acute pain, a scale can monitor pain intensity and treatment response.
For chronic pain, multidimensional scales are recommended rather than measuring only pain intensity. It is important to use a scale that is suited to the resident’s abilities. Once a scale has been selected for an individual resident, continue to use this for monitoring pain.
The Reference Cards include two multi-dimensional scales developed specifically for use in older people:
Management
Approach to management
Treat pain early and effectively, before it can become established and more difficult to treat. A multidisciplinary and multimodal approach is often required for both acute and chronic pain. Management includes:
Analgesics and adjuvant medications; Local anaesthetic techniques; Disease specific treatments; Non pharmacological strategies; and Attention to psychosocial issues.
Management of pain should be individualised taking into account the resident’s type of pain, culture, beliefs and treatment preferences. The resident or their representative should actively participate in the assessment and treatment process.
Before beginning treatment, establish realistic treatment goals with the resident and relatives. Is the aim to eradicate the pain or reduce it to tolerable levels so that mobility and independence can be restored or maintained? For example, a resident receiving End of Life care may require complete pain relief even though mental and physical function is compromised, whereas a resident with degenerative arthritis requires a balance between pain relief and the maintenance of function. Adequate pain control can avoid secondary consequences such as: confusion, depression, sleep disturbance, reduced appetite and nutrition, impaired mobility, social isolation, worsening pain, slowed rehabilitation and increased risk of falls.
Care planning
The GP and nurse are responsible for assessing the resident with pain and developing a written pain management plan, including, conditions causing pain, goals of therapy, interventions, regime for monitoring/reassessment. A pain care plan will reduce the incidence and severity of uncontrolled pain and alert all care givers to the treatment regime. This will help to eliminate the need for seeking after hours assistance. See Reference Card: Example of a Pain Care Plan.
Education of resident and family
Family input into pain management of the resident is important and should be encouraged. Some relatives become concerned about adverse effects or dependency from morphine. Education will improve their understanding that:
Adequate pain relief is important as a pre-emptive measure rather than waiting for the pain to become severe when larger does of the drug may be required; Pain can in most cases be controlled and has subsequent benefits to the resident’s quality of life; Adverse effects can be prevented or treated; AND If the pain improves or resolves the opioid can be reduced or withdrawn.
Non pharmacological strategies
Non-pharmacological strategies may be used by themselves or in conjunction with pharmacological strategies. The combination of the two approaches often results in lower drug doses being used.
Showing an interest in and having a sincere concern for the person’s pain can have a therapeutic effect. Usually the resident will benefit from family involvement and the emotional support that it provides.
Physical Therapies
These are generally free of significant adverse effects and are best provided in consultation with a physiotherapist. They include TENS; walking programs; specific strengthening exercises and massage. Heat or cold packs need to be used with care to avoid burns or hyperalgesia. Surgery or nerve blocks are other options.
Cognitive- Behavioural Therapies (CBT)
There is good evidence that individual and group CBT programs are beneficial for older adults with persistent pain, including long term care residents who have no dementia or very mild dementia. Alleviating concerns, explaining the cause of pain as well as teaching behaviours and positive thoughts will enhance their capacity to manage their pain. Psychologists and many GPs have training in these CBT techniques.
Other Strategies
Alternative or complementary therapies are useful in many cases e.g. aromatherapy, guided Imagery (not usually suitable for cognitively impaired residents), acupuncture, music. Diversional therapies should be initiated to the extent the resident can tolerate. Offer nutrition and fluids, ensure the resident is warm and comfortable, and reduce lighting and surrounding noise.
Medication
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Drug therapy needs to be flexible and tailored to the resident, and the mechanism and severity of pain. Adequate pain relief is more important than strict adherence to a fixed regime [11]. Placebos should never be used to assess or treat pain.
The World Health Organisation ladder for cancer pain is often also used for acute and chronic non-cancer pain. The WHO analgesic ladder recommends that choice of medication is based on the mechanism and severity of the pain. Treatment starts at the step appropriate for the severity of the pain, e.g. a mild analgesic such as paracetamol, and builds up stepwise to opioids for severe unrelieved pain, as shown in Figure 1.
A regimen of analgesia ‘round the clock’ is more beneficial than administering analgesia when the resident asks for it or as the nurse considers it necessary. This will have the effect of maintaining a therapeutic level of the drug in the blood stream achieving more constant pain relief and avoiding the peaks and troughs associated with ‘as required’ administration. It also circumvents the need for the resident to request analgesia. Analgesia ‘as required’ can be added once a pain treatment regime has been established.
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Figure One: Three-step analgesic ladder, World Health Organisation |
Elderly people usually require lower doses of analgesics. NSAIDs should only be used with caution. Paracetamol and/or low dose opioids are generally preferred. Opioid dose requirement decreases progressively with age. In the elderly, use a lower initial dose and titrate to effect. There is an increased risk of adverse effects including cognitive impairment and falls [11].
Acute Pain [11]
Acute pain has a defined pattern of onset, site, character and duration. It is commonly associated with trauma, acute medical illness and surgery.
Aims of medication are to:
Relieve suffering;
Reduce harmful effects of acute pain, and transition to chronic pain; and
Assist rehabilitation by physiotherapy and mobilisation.
Acute abdomen
Give effective analgesia early. Early administration of opioids does not reduce the detection rate of serious pathology but may facilitate it.
Renal colic
NSAIDs (first line treatment) and opioids (preferably morphine) provide effective pain relief, particularly if given parenterally.
Biliary colic
Parenteral NSAIDs and opioids appear to have similar efficacy in relieving pain. All opioids may cause spasm of the sphincter of Oddi.
Postoperative pain
Aim for early control, and assess regularly as pain changes over time. Even minor surgery can be associated with substantial pain lasting up to a week. Prevent pain by giving regular paracetamol and/or NSAIDs, often with opioids ‘as required’. Titrate the dose of analgesic to the patient's response. Codeine 60 mg added to paracetamol produces additional pain relief even as a single dose.
Acute herpes zoster
Antiviral agents relieve the acute pain and decrease the risk of post-herpetic neuralgia if given within 72 hours of onset of rash. Opioids may be necessary for relief of severe pain. Amitriptyline is also used and may reduce the duration of pain. [11] A combination of topical agents and anticonvulsants may need needed for more severe cases.
Acute back pain
Use paracetamol or short term NSAIDs. There is conflicting evidence about the place of muscle relaxants, e.g. baclofen, diazepam, and adverse effects are common. [11] Antispasmodic doses of these drugs usually cause sedation and adverse cognitive effects.
Dislocations and fractures [14]
Dislocations or fractures will require pain relief. This may be by morphine IV. Oral analgesia can be used if no operative intervention is planned for the next 24 hours. For mild pain use paracetamol, and for moderate to severe pain use an oral opioid, e.g. oxycodone immediate release. [11] Regional nerve blocks are appropriate for some fractures if the clinician is familiar with them.
Chronic pain [11]
Chronic pain management requires understanding of physical, emotional, cognitive, and psychosocial factors. Treat identifiable pathology if possible.
Aims of medication are to:
Titrate medication dose against patient response and adverse effects, and review regularly. After initial titration and stabilisation, give analgesics at regular intervals to allow continuous pain relief. Oral medications are preferred, unless there is a problem with swallowing or a need for rapid pain control. Patches are appropriate for stable chronic pain.
Breakthrough and incident pain should be identified and treated with ‘as required’ analgesia over and above the regular regime for chronic pain. Breakthrough pain is managed primarily with short acting oral opioids. For incident pain, give NSAIDS or short acting opioid 30 minutes prior to activities such as pressure area care, dressings, physiotherapy, and hygiene procedures [11]. It is the incident and breakthrough pains that are usually cause for concern requiring management after hours (Refer to Reference Card: Breakthrough Pain Management).
Musculoskeletal pain, including osteoarthritis
In musculoskeletal pain the aim is to improve function and provide symptom control. Medications for OA include oral analgesia, topical preparations, and intra-articular injections. Consider a one-month trial of glucosamine. Current recommendations are to [15]:
Use regular paracetamol as ongoing therapy in adequate doses for control of mild to moderate pain; Add NSAIDs where cardiovascular, renal and gastrointestinal risk is acceptable, at the lowest effective dose for the shortest possible duration; and Consider an opioid when non-opioids offer inadequate pain control or NSAIDs are unsuitable.
For further information, see Osteoarthritis Clinical Information Sheet.
Inflammatory pain, e.g. rheumatoid arthritis
NSAIDs are effective. Paracetamol is effective but has no anti-inflammatory effect. Opioids may be effective, depending on dose. [11] Joint rest with splinting may be more beneficial than drug therapy.
Neuropathic pain
TCAs and antiepileptics are the drug treatments of choice, but opioids, e.g. morphine, oxycodone, tramadol, methadone, are also effective in relieving neuropathic pain, particularly in peripheral pain syndromes. Even within a drug class, some patients who fail to respond to one medication will respond to another.
Cancer pain
In cancer, the aim is to alleviate pain even if function is decreased.
Cancer pain can be controlled using the WHO analgesic ladder in >80% of patients. For the remainder a multimodal approach is required. Choose treatment according to the severity, type and cause of pain. In cancer pain, addiction is rare; fear of this problem should not prevent early use of opioid medication. Once adequate pain control is achieved with conventional release preparations, consider conversion to controlled release formulations. Adjuvant analgesics such as TCAs, antiepileptics, are used with non-opioid/opioid treatment for additional pain relief. Radiotherapy is the treatment of choice for localised metastatic bone pain. For widespread bone pain NSAIDs, bisphosphonates, dexamethasone, and radioactive strontium-89 can be used. Bisphosphonates are effective in multiple myeloma and bone metastases from breast cancer, and may also reduce pain from other bone metastases. Radioactive strontium-89 is used for pain due to widespread bone metastases from prostatic cancer. Pain due to inflammation and oedema in confined spaces, e.g. raised intracranial pressure, hepatic capsular pain, nerve compression or infiltration, may be treated with dexamethasone; high doses may be required. Pain in cancer due to bowel colic may be treated with antispasmodics and opioid antidiarrhoeal; consider stimulant laxatives as possible contributory factors. Muscle spasm may be relieved by muscle relaxants, e.g. diazepam.
End-of-life care
Opioids and benzodiazepines are appropriate for managing pain and anxiety in palliative care, including for diseases in which respiratory depression is generally avoided, e.g. COPD. Increasing doses of opioids and benzodiazepines are often required in end-of-life care. See End-of-Life Care Clinical Information Sheet.
Use of Medication
Analgesics
Paracetamol is the preferred analgesic for older people and is effective for musculoskeletal pain and mild neuropathic pain. Doses for older people are the same as for younger people but a ceiling dose of 4gm (eight 500mg tablets) in 24 hours should not be exceeded. Sustained release tablets are also available. Lower doses should be used in patients with hepatic or renal impairment. Fasting, dehydration, poor nutrition, high alcohol intake or underlying liver dysfunction increases the risk of hepatotoxicity.
Drug interactions: anticoagulants, chloramphenicol, drugs affecting gastric emptying, hepatic enzyme inducers including alcohol, anticonvulsants. Aspirin is not recommended for use as an analgesic in older people because of the risk for gastro-intestinal bleeding and age associated changes such as reduced renal or liver function. Codeine has a short half-life and is suitable for incident pain or predictable mild to moderate short lasting pain. Starting dose is 15-60mg every 4 hours. Do not exceed 60 mg single dose. Drug interactions: Metabolism of codeine is inhibited by some other medications, e.g. cimetidine, quinidine, haloperidol, and amitriptyline, fluoxetine, paroxetine and fluvoxamine. About 10% of people lack the enzyme that converts codeine to the active opioid form and these individuals will have no analgesic benefit. Tramadol is a centrally acting analgesic that also acts on opioid receptors to some extent. In addition it acts as an inhibitor to noradrenaline and serotonin reuptake. Tramadol should be used with caution in older people because of the high incidence and type of side effects (up to one third experience nausea, vomiting, sweating dizziness, hallucinations). Low doses are recommended (25-50mg per day) for the first three days. Patients over 75 should not have more than 300mg per day.
Drug interactions: CNS depressants incl. anaesthetics, alcohol, mixed opiate agonists/antagonists, e.g. buprenorphine, pentaxocine, drugs which lower seizure threshold e.g. SSRIs, TCAs, antipsychotics, MAOIs, carbamazepine, quinidine, ketoconazole, erythromycin, drugs that increase serotonin. Morphine is suitable for moderate-to-severe acute or chronic pain in older people, and is available in forms suitable for most routes of administration. Starting doses for severe acute pain are PO 10-30mg 3-4 hourly; IM 2.5-5mg 4-6 hourly; IV 2.5-10mg 2-6 hourly; SC 2.5-10mg 2-6hourly. Side effects may include CNS depression, nausea, constipation, respiratory depression.
In chronic severe pain, unresponsive to other interventions, long acting morphine (MS Contin) can be introduced once 24 hour dosage needs are established.
Drug interactions: alcohol, CNS depressants, MAOIs, muscle relaxants, mixed agonist/antagonist opioids, (e.g. pentazocine, buprenorphine), cimetidine, diuretics. Oxycodone is used for moderate-to-severe acute or chronic pain. It is available in immediate release (endone, oxynorm) and sustained release form (oxycontin) for oral administration.
Endone or oxynorm (immediate release) may be used for initial establishment of dosage needs, and later for breakthrough pain. Recommended dose for endone is 5mg QID ‘as required’. Oxynorm liquid, 1-2mg of oxycodone, may be of benefit in the elderly. Drug interactions: acidifying/alkalising agents, amphetamines, chlorpromazine, methocarbol, CNS depressants. MAOI’s, pyrazolidine,antihistamines, beta-blockers, alcohol, coumarin anticoagulants. Oxycontin (sustained release) is recommended for chronic pain and recommended doses are 5-20 mg bd.
Drug interactions: MAOI’s, anticholinergics, antihypertensives, CNS depressants, coumarins, metoclopramide, neuromuscular blockers, other opioid agonists.
Transdermal fentanyl is not indicated for management of acute pain. It is used for moderate-to-severe acute or chronic pain; preferred in renal impairment [11].The drug is potent and long acting and the risk for delirium and respiratory depression is high. Dose escalation and tolerance are also potential problems. It should be used only when the resident has had opioids previously and high dosage needs are established.
Drug interactions: `MAOI’s, CNS depressants, neuroleptics, conduction anaesthesia, nitrous oxide, amiodarone. Buprenorphine is a partial opioid agonist used for management of opioid dependence. Its role in the management of chronic pain is currently unclear. It is available as tablet, injection and patches for chronic severe disabling pain not responding to non-narcotic analgesics. Low dose patches may be useful in chronic stable mild-moderate pain where short-acting opioids are frequently used and overall analgesia is unsatisfactory. However, it may precipitate withdrawal symptoms in people dependent on other opioids [11].
Adjuvant medications
Adjuvant medications used in pain management are those that are not primarily used for pain treatment but have analgesic properties. They may be given alone or in conjunction with analgesics.
Tricyclic antidepressants are suitable for use in neuropathic pain, e.g. painful diabetic neuropathy, post-herpetic neuralgia, central post stroke pain. They are effective at lower doses than those prescribed for depression, e.g.. starting with 10mg nocte, and titrating slowly upward over 3-7 days to between 30-50mg. Amitriptyline is the best researched agent. Nortriptyline may be better tolerated. Side effects include: anticholinergic properties, postural hypotension, sedation, constipation, urinary retention, exacerbation of cardiac conditions. Fibromyalgia syndromes may also benefit from tricyclics. Anticonvulsants, e.g. carbamazepine are suitable for trigeminal neuralgia but require careful titration over period of one month to reduce adverse effects of the drug. Pregabelin may work more quickly and gabapentin may be as effective and better tolerated than older antiepileptic drugs and tricyclics but does not currently have PBS approval for pain management. Corticosteroids are indicated in the treatment of inflammatory conditions such as rheumatoid arthritis. NSAIDS are used for nocioceptive pain that accompanies musculoskeletal disorders. Caution should be exercised because of the associated high risk of G.I. Tract bleeding and are contraindicated for residents with a history of renal impairment, CCF, concurrent volume depletion or diuretic use. Cox II Inhibitors may cause fewer GI complications than traditional NSAIDS but have the same renal, hypertensive and fluid retaining effects. Assess for the following adverse effects of NSAIDs:
Combined Regimes
In general it is desirable to use a minimum number of drugs to maintain a simple regimen, promote compliance and minimise adverse effects. There are situations in managing pain in older people when adverse effects limit the ability to use a therapeutically effective dose of one or more drugs. Particularly in neuropathic pain, using small doses of drugs from different classes in combination will provide an additive effect that cannot be achieved with a larger dose of a single drug.
Guidelines for opioid use
Establishing a dosage regime
Opioids should not be withheld if pain is moderate to severe and unresponsive to other interventions.
In general, commence with low doses of short acting opioids and titrate the dosage slowly. In very severe pain, cancer pain and palliative care, more rapid dosage escalation is appropriate. In these situations increase titration by 25% of the prescribed dose until pain ratings are 50% less or the resident reports satisfactory relief. In moderate to severe non-cancer pain, dosage increments are usually less frequent and the target degree of pain relief may need to be modified in respect of the patient’s function and goals.
Tolerance to opioids may develop necessitating an increase in dose or decreased interval of administration to achieve the same pain relief. Short acting opioids can be used in conjunction with long acting opioids to treat incident pain. [16]
Start treatment with the equivalent of controlled release morphine 5–30 mg twice daily and adjust dose according to the response after 1 week or less. Use regular (by the clock) dosing. Review weekly at first and then monthly. When changing the route of administration adjust the new dose accordingly, e.g.. morphine (PO) 30mg , (S/C) 10mg.
Before prescribing opioids on a long term basis, conduct a trial over 4–6 weeks. Agree on criteria, e.g. pain control, function, quality of life, for success or failure with the patient. Assess pain intensity, cardiorespiratory status, level of sedation and other adverse effects frequently to guide ongoing treatment. If the expected outcomes have not been achieved or there are unacceptable adverse effects, taper the dose over a few days before ceasing (to avoid withdrawal symptoms).
Management of adverse effects
Risk of adverse effects from opioid use is higher in older people because of the reduced ability to distribute and excrete drugs.
The best strategy in treating significant opioid side effects is to reduce the dose by 25-50%.
Constipation: Persists and laxatives are needed for as long as opioids are used. Initiate dietary measures and a laxative and stool softener at the same time as commencing opioid therapy, e.g.. Metamucil 1 tsp daily, coloxyl with senna ii nocte. Movicol may be needed when opioid induced constipation is difficult to control. Monitor bowel function daily. Metoclopramide may also be effective. Confusion: If cognitive impairment or confusion occurs when opioids are started further doses should be withheld until the delirium resolves. If sustained release agents are being used, the short acting drug should replace these until safe 24 hour dosages for that individual are established. Especially in palliative care situations, acute confusion is not necessarily caused by the new opioid treatment. Other factors should be investigated before ceasing the analgesic, e.g.. Electrolyte abnormalities, hypoxemia, dehydration, infection, sensory impairment, elimination problems, sleep deprivation etc. Nausea: Improves within the first few days in most patients. Anti-emetics should be used with caution because of their anticholinergic properties. Metoclopramide (Pramin) is most appropriate for use in aged care except in Parkinsons Disease when Domperidone (Motilium) is more appropriate. Respiratory depression (Respirations<8 per minute): Is usually preceded by sedation. Sedation should be monitored so that excess dosing of opioids can be identified. Refer to Reference Card: Sedation Scale. Opioids are contra-indicated for residents with respiratory depression. The presence of Cheyne Stokes respirations during sleep without other adverse symptoms does not require opioid reduction. Paranoia and fear - short term use of Haloperidol may be effective, e.g.. 0.5mg daily – bd, or use quetiapine 25-50mg daily in the palliative care context. Tolerance to the analgesic effect is uncommon; a stable dose can usually be achieved in responsive patients. Physical dependence: i.e. withdrawal syndrome when the drug is stopped suddenly or an antagonist is given, is common, predictable and not unique to opioids. The risk of psychological dependence (a compulsion to use the drug) and addiction (compulsive use to the detriment of physical and/or psychological and/or social function) developing in patients without a history of substance misuse is low. Drug interactions: Drug interactions are common not only between drugs prescribed for pain management, but also with drugs prescribed for comorbidities. Prescription of warfarin, which interacts with NSAIDs, carbamazepine and many other drugs, contributes to the complexity of pharmacotherapy.
Routes of administration
Route of administration of a drug should always be the least invasive and safest for the resident.
The oral route is the least invasive and in most cases effective method of pain control. PEG tubes may be used to administer oral medications where they can be crushed or given in liquid form. The GP and the pharmacist should be consulted re obtaining the medication in a suitable form. Rectal or per vaginal route may be used for many medications available in suppository form. (Note that rectal NSAIDs may still cause GI toxicity). Sublingual route may be a good alternative for the resident unable to tolerate oral medication. Sub-cutaneous route may be indicated where the resident is nauseated or vomiting. A ‘butter fly needle’ should be inserted to reduce the number of needle pricks associated with administration. Morphine may be administered readily by s/c route. (See Subcutaneous Hydration Clinical Information Sheet). Intra-muscular injection is selected for preparations that require deeper tissue administration. Many older people have reduced muscle tissue and so subcutaneous method is preferred. I/M route should be avoided if resident is on warfarin because of the risk for haematoma. Topical applications are often perceived as beneficial by patients. There is some evidence supporting the use of topical NSAIDS which may have an oral dosage sparing effect. Topical capsaicin may be effective in post-herpetic neuralgia and other neuropathic pain syndromes but requires the patient to remain mindful of the longer-term goal of an initially uncomfortable treatment.
Sources of Information
Where to go for more information
National Palliative Care Program
The National Palliative Care Program, Guidelines for a palliative approach in residential aged care, 2004, are available at http://www.palliativecare.gov.au/pubs/workforce/pallguidea.pdf
Australian Pain Society
The guidelines from the Australian Pain Society: Pain in Residential Aged Care Facilities. Management Strategies, 2005, can be accessed at http://www.apsoc.org.au/owner/files/9e2c2n.pdf
Therapeutic Guidelines
Therapeutic Guidelines have been prepared by writing groups of experienced clinicians, and represent independent consensus opinion based on the evidence available at the time of publication. The guidelines are available as pocket-sized book, CD-ROMs for installation on personal computers, and electronic versions for use on Health Department intranets, integration with commercial prescribing software, and hand-held computers. Website: http://www.tg.com.au
References
Roberts, H C,Eastwood, J, Pain and its control in patients with fractures of the femoral neck while awaiting surgery, in Injury. 1994. p. 237-239. Dehaan, C, Dementia and the perception of experimental pain, in Dissertation Abstracts International. Section B: The Sciences and Engineering. 1996. p. 5165. Farrell, M, Katz, B, Helme, R, The impact of dementia on the pain experience, in Pain. 1996. p. 7-15. Geda, Y,Rummans, T, Pain: Cause of agitation in elderly individuals with dementia, in American Journal of Psychiatry. 1999. p. 1662-1663. Morrison, R,Siu, A, A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture, in Journal of Pain and Symptom Management. 2000. p. 240-248. Rosewarne, R,Opie, J, Care needs of people with dementia and challenging behaviour living in residential facilities. 1997, AGPS: Canberra. Closs, S, Pain and elderly patients: a survey of nurses' knowledge and experiences., in Journal of Advanced Nursing. 1996. p. 237-242. Klinger, L, Spaulding, S, Polatajko, H, MacKinnon, J, Miller, L, Chronic pain in the elderly: Occupational adaption as a means of coping with osteoarthritis of the hip and/or knee, in The Clinical Journal of Pain. 1999. p. 275-283. Liu, D, Raji, M, Twersky, J, Riggs, A, Case report: disruptive vocalization due to gout in an elderly nursing home resident with dementia, in Annals of Long Term Care. 2000. p. 66-70. International Association for the Study of Pain, Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms, in Pain. 1986. p. 1-222. Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006 Australian Government Department of Health and Ageing: The National Palliative Care Program, Guidelines for a palliative approach in residential aged care. 2004. Ross, M, Carswell, A, Hing, M, Hollingworth, G, Dalziel, W, Senior's decision making about pain management, in Journal of Advanced Nursing. 2001. p. 442-451. eTG, Therapeutic Guidelines: Pain, in http://www.tg.com.au(accessed August 2006), eTG. 2006 Cohen, M., Analgesic choice in persistent pain. Prescribing Practice Review, 2006. 35. Herr, K , Titler, M, Sorofman, B, Ardery, G, Schmitt, M, Young, D, Evidence based guideline: Acute pain management in the elderly. 2000, The university of Iowa: Iowa US. p. 1-83. National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
Background information on end-of-life care provided in this Clinical Information Sheet (CIS) was primarily adapted from the Guidelines for a Palliative Approach in Residential Aged Care.
The following table outlines the level of evidence of each reference:
|
|
Reference |
Year |
Level of Evidence |
1. |
Roberts, H C,Eastwood, J, Pain and its control in patients with fractures of the femoral neck while awaiting surgery, in Injury. 1994. p. 237-239. |
1994 |
Level IV C evidence |
2. |
Dehaan, C, Dementia and the perception of experimental pain, in Dissertation Abstracts International. Section B: The Sciences and Engineering. 1996. p. 5165. |
1996 |
Level IV C evidence |
3. |
Farrell, M, Katz, B, Helme, R, The impact of dementia on the pain experience, in Pain. 1996. p. 7-15. |
1996 |
- |
4. |
Geda, Y,Rummans, T, Pain: Cause of agitation in elderly individuals with dementia, in American Journal of Psychiatry. 1999. p. 1662-1663. |
1999 |
Level IV C evidence |
5. |
Morrison, R,Siu, A, A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture, in Journal of Pain and Symptom Management. 2000. p. 240-248. |
2000 |
Level III evidence |
6. |
Rosewarne, R,Opie, J, Care needs of people with dementia and challenging behaviour living in residential facilities. 1997, AGPS: Canberra. |
1997 |
Level III evidence |
7. |
Closs, S, Pain and elderly patients: a survey of nurses' knowledge and experiences., in Journal of Advanced Nursing. 1996. p. 237-242. |
1996 |
Level IV C evidence |
8. |
Klinger, L, Spaulding, S, Polatajko, H, MacKinnon, J, Miller, L, Chronic pain in the elderly: Occupational adaption as a means of coping with osteoarthritis of the hip and/or knee, in The Clinical Journal of Pain. 1999. p. 275-283. |
1999 |
Level IV C evidence |
9. |
Liu, D, Raji, M, Twersky, J, Riggs, A, Case report: disruptive vocalization due to gout in an elderly nursing home resident with dementia, in Annals of Long Term Care. 2000. p. 66-70. |
2000 |
Level IV C evidence |
10. |
International Association for the Study of Pain, Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms, in Pain. 1986. p. 1-222. |
1986 |
Level I evidence |
11. |
Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006 |
2006 |
Level IV C evidence |
12. |
Australian Government Department of Health and Ageing: The National Palliative Care Program, Guidelines for a palliative approach in residential aged care. 2004. |
2004 |
Level I evidence |
13. |
Ross, M, Carswell, A, Hing, M, Hollingworth, G, Dalziel, W, Senior's decision making about pain management, in Journal of Advanced Nursing. 2001. p. 442-451. |
2001 |
Level IV C evidence |
14. |
eTG, Therapeutic Guidelines: Pain, in http://www.tg.com.au(accessed August 2006), eTG. 2006 |
2006 |
Level IV C evidence |
15. |
Cohen, M., Analgesic choice in persistent pain. Prescribing Practice Review, 2006. 35. |
2006 |
Level IV C evidence |
16. |
Herr, K , Titler, M, Sorofman, B, Ardery, G, Schmitt, M, Young, D, Evidence based guideline: Acute pain management in the elderly. 2000, The university of Iowa: Iowa US. p. 1-83. |
2000 |
Level I evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using an adapted version of the NHMRC (1995) [17] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Pain: Assessment and Management
The following reference cards are designed to be used in conjunction with the Pain: Assessment and Management Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
Viewing Reference Cards
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Printing Reference Cards
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Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards:
Breakthrough Pain Management
Pain Assessment and Management
Resident’s verbal brief pain inventory
Abbey Pain Scale for people with dementia or who cannot verbalise
Example of Pain care plan
Sedation scale
Downloads and Printing
See note on viewing and printing documents.
To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
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