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.

Source: Pain management in residential aged care facilities - AFP (RACGP), Vol44 No.4, Apr 2015

Senior citizens are undertreated for pain far more often than younger patients. According to various studies conducted, 40% to 80% of elderly nursing home residents suffer needlessly due to inadequate pain treatment (Cancer Pain Release; World Health Organization; Facts on Dying, Brown University).

Pain in elderly patients is not always assessed properly, and may be under-reported. Too frequently elderly patients do not report their pain because they fear retaliation, the possibility of addiction, or loss of respect. They may be stoical or believe that pain is a natural part of ageing.

Formal pain assessment should be routine. Such formal assessment can be carried out with a very simple assessment tool that evaluates pain intensity, quality, location, and duration. However, formal pain assessments may not be sufficient for those with speech, hearing or cognitive deficits or who fear reporting pain. Close observations of behaviour may reveal expressions, movements, and activities indicative of pain.

Some health care professionals erroneously believe that the elderly are less sensitive to pain, or give weak doses of pain medications for fear that older patients will not tolerate opioids. They may equate pain management with addiction, or various other avenues of fear authority based.

Pain management and monitoring

Sometimes the elderly are not able to speak about their pain. This may be further complicated with illness or injuries like dementia, brain damage, or a stroke. This makes it very hard for caregivers and family to recognise the existence of pain.

Monitoring the use of analgesics and other pain medication is time consuming. In nursing homes, pain management may be limited if staffing is inadequate. Also, some nursing homes are unwilling to stock restricted drugs that may be useful in the treatment of pain.

Diagnosing a senior’s pain may be difficult. Although grimacing, restlessness, moaning, and agitation may often indicate pain, they are not definitive signs of pain.

The under-treatment of pain has been considered neglect, negligence, or even elder abuse. If you are concerned about the under-treatment of your elderly relative’s pain, talk to his or her physician and nursing team. Also keep records of the problem.

Prevalence of pain in the elderly

Pain is reported to be twice as prevalent in the elderly as in younger individuals (Crook et al., 1984). In community-dwelling elders, the prevalence of pain ranges from 25-50% (Mobily et al., 1994). In the long-term care setting, prevalence can be as high as 85% (Stein et al., 1996).

According to the American Geriatrics Society (AGS) Panel on Chronic Pain in Older Persons (1998), chronic pain in the long-term care setting is generally under-recognised and under-treated.

Treatment of chronic non-cancer pain among those with non-terminal illness especially, has been neglected. Teno et al., in their study “The Prevalence and Treatment of Pain in US Nursing Homes,” found that pain is a common condition in nursing homes, and that nearly one sixth of all nursing home residents were reported to be in daily pain. For residents with cancer, slightly more than one in five was in daily pain.

More problematic was the fact that:

  1. pain symptoms were noted on the last pain assessment in one of five individuals who died and
  2. the final pain assessment of these residents was so long (on average 47 days) before death.

There are several specific reasons rooted in the nature of pain and societal attitudes toward it. Pain is subjective and lacks objective biological markers.

Pain - common misconceptions

Some of the common misconceptions about chronic pain in elderly people include:

  • It is a sign of personal weakness to acknowledge chronic pain.
  • Chronic pain is a punishment for past actions.
  • Chronic pain means death is near.
  • Chronic pain always indicates the presence of a serious disease.
  • Acknowledging pain will lead to a loss of independence.
  • The elderly, especially the cognitively impaired, have a higher tolerance for pain.
  • The elderly and the cognitively impaired cannot accurately self-report pain.
  • Residents in long-term care say they are in pain in order to get attention.
  • Elderly residents are likely to become addicted to pain medication.

The most accurate and reliable evidence of the existence of pain and its intensity is the residents’ self-report. Elderly people often describe discomfort, hurting, or aching, rather than use the specific word “pain.”

Unrelieved chronic pain is not an inevitable consequence of ageing: The presence of pain is always abnormal. Certain conditions that cause chronic pain are more common in the elderly. Some of these conditions include: joint disease, osteoporosis, neuropathic pain, peripheral vascular disease, immobility, and amputations. It is important to not only treat symptoms of pain, but to also understand the underlying foundation of pain.

Describing your pain

Caregivers want you to talk to them about your pain. This helps them learn what may be causing the pain and how best to treat it. You need to tell caregivers if you have trouble hearing their questions or seeing things. Caregivers can use special tools and ways to help you better understand their questions about your pain.

  • Keep a pain diary- Sometimes it may be easier to answer caregiver's questions by making a pain diary or book. A pain diary or journal will help you remember exactly what happened each day because it is all written down. This will help you to tell caregivers about your pain and may help them understand what causes it. Write down all the words that come to you to describe your pain. A diary also helps track pain cycles. This will help you be more aware of when pain is bad and how to make it better.

When you see your caregiver, he/she will ask you to answer the following questions.

  • Where does it hurt? Where does it not hurt? Does the pain move from one area to another?
  • How would you rate the pain on a scale of 0 to 10? (0 is no pain, and 10 is the worst pain you ever had.) Then decide what number you want your pain goal to be.
  • How does the pain feel? Try to choose words that tell caregivers what type of pain you have. Is the pain sharp, cramping, twisting, squeezing, or crushing? Or, is the pain stabbing, burning, dull, numb, or "pins-and-needles" feeling? There are no right words for pain, so use any words you know to describe how your pain feels to you.
  • When did the pain start? Did it begin quickly or slowly? Is the pain steady or does it come and go?
  • How often does the pain bother you and how long does it last?
  • Does the pain affect your daily life? Can you still work or do your favorite activities in spite of the pain? Does the pain wake you from sleep?
  • Do certain things or activities cause the pain to start or get worse like coughing or touching the area?
  • Does the pain come before, during, or after meals?
  • Does anything decrease the pain like changing positions, resting, medicines, or changing what you eat?

What if I cannot talk?

Sometimes you may not be able to speak about your pain. You may have illness or injuries like dementia, brain damage, or a stroke. This makes it very hard for your caregivers and family to know you are in pain. Your family may help caregivers understand your pain by watching for physical signs of pain. When you have had pain for awhile you may also adapt or get used to the pain. This means you may act normal or opposite of how your family thinks you should act even though you are having very bad pain.

Following are some signs that your family can watch for that may tell them you are in pain:

  • If you are normally loud and noisy, you may get very quiet and withdrawn. You may also stop doing activities you used to do.
  • If you are very quiet and withdrawn, you may get loud, act stubborn, and hit people.
  • You may not eat what you normally do. Or, you may only want to drink or eat soft foods.
  • Suddenly, you may not do all the activities you used to do.
  • You may loose control of your bowel and bladder.
  • You may act very depressed and have a sad face.
  • If you do not talk at all, you may blink your eyes very fast much of the time. You may also grimace (make strange faces).
  • If you have been very easy going and happy, you may begin to be very sensitive and cry easily.
  • You might start to walk or move differently than before. You may suddenly stop walking, or start pacing all the time.
  • You may have you knees drawn up to chest and rock like a baby.
  • You may touch, rub, pull or pick at a body part that is hurting.
  • You may start to pull away from peoples' touch and protect your arms or legs.
  • You may suddenly begin to stumble or fall, when you had no problems before.
  • You may sleep more or less than usual.
  • You may start to whimper or groan quietly.
  • You may become very confused suddenly, when there was no problem before.