practice review

Keywords Acute management | Older people | Pain assessment How to ensure acute pain in older people is appropriately assessed and managed Older people often need pain relief yet age related changes can influence drug pharmacokinetics. An awareness of both drug and non-drug interventions is vital

AUTHOR Jasmina Banicek, BSc, RGN, The VAS has “no pain” at one end and is clinical nurse specialist acute pain “worst pain” at the other (Fig 1). Patients practice points management, Whittington Hospital mark the point that best represents their Adequate pain relief is necessary to avoid Trust, London. pain. This method can be confusing, further medical complications. ABSTRACT Banicek J (2010) How to ensure especially for older people who may have Appropriate pain assessment is an essential acute pain in older people is appropriately visual impairment. part of . assessed and managed. Nursing Times; 106: The VNRS is similar to the VAS. Patients Consider multimodal analgesia but also use 29, 14–17. are asked to give a number that best non-pharmacological techniques. The increasing ageing population and the represents their pain on a scale between Analgesia in older patients must be prescribed common occurrence of acute and chronic 0 (no pain) and 10 (worst pain) (Fig 2). and administered with caution due to an pain in this group means that nurses are They may still have difficulty rating their increased risk of side effects. likely to come into contact with many older pain as a number. patients who need pain management. This The categorical rating scale uses different article examines the assessment of acute pain words, such as “none”, “mild”, “moderate”, recognition of pain, appropriate assessment in older people, as well as different approaches “severe”, to rate pain. This can be used in tools, and education and training to and challenges in pain management. combination with the VNRS. For example, (McAuliffe et al, 2009). Several strategies patients can be asked to describe their pain have been suggested to address these issues: Introduction as “none (0)”, “mild (1)”, “moderate (2)” or l Getting to know the person; Pain management is likely to become “severe (3)”. l Involving friends, family and carers; increasingly important given the expected It is important to note that severity is only l Education and training; rise in the number of older people. In 2005, one aspect of pain assessment. SOCRATES l Use of adequate assessment tools more than 11 million people in the UK (Box 2) is a pain assessment framework (McAuliffe et al, 2009). were of pensionable age, and this is expected commonly used by healthcare professionals When working with people with dementia to rise to 15.3 million by 2031 (Age Concern, that uses a range of different factors. and cognitive impairment, nurses also need 2007). to make an observational assessment of pain Pain is a common problem for older people People with cognitive behaviour. Tools such as the Abbey Pain as they may suffer from long term impairment or dementia Scale (Abbey et al, 2004) and Pain conditions, such as degenerative joints, Those with dementia or more than mild Assessment in Advanced Dementia osteoarthritis, leg ulcers and many others; it cognitive impairment may find it difficult to (PAINAD) help practitioners assess pain by is also under recognised and undertreated in articulate their pain. Barriers to effective observing behavioural indicators such as: the older population. Some authors suggest pain assessment in these groups include l Facial expressions (frowning, grimacing); that altered physiology of peripheral and misdiagnosis or late diagnosis, and lack of l Vocalisation (crying, groaning); central pain mechanisms, combined with psychological attitudes, such as stoicism and Box 1. physical responses to pain reluctance to report pain, are key factors (Schofield, 2007). Respiratory: if patients are unable to cough or because of pain are at increased risk of developing The body responds to pain in many take deep breaths due to pain, their recovery rate deep vein thrombosis and/or pressure ulcers. adverse ways (Box 1). This means accurate is significantly reduced. They also have an Gastrointestinal: pain can lead to delayed pain assessment and management is vital for increased risk of developing chest infections, gastric emptying and reduced intestinal motility, high quality patient care. hypoxia and possible respiratory failure. resulting in nausea, vomiting and constipation. Cardiovascular: the increased sympathetic Endocrine: pain leads to the stress response Pain assessment chain activity in response to pain causes an caused by a release of a number of hormones. The assessment of pain is a vital prerequisite increase in hormonal activity which, in turn, For example, release of cortisol causes for achieving effective pain management. produces an increase in blood pressure. hyperglycaemia, which can lead to There are various reliable assessment tools. Tachycardia also occurs, which can lead to a immunosuppression and delayed wound healing. In adults, the three most common are: degree of myocardial ischaemia, especially in Psychological: pain can lead to anxiety, l The visual analogue scale (VAS); people with pre-existing cardiovascular disease. depression, worry, sleep deprivation and mistrust l The verbal numerical rating scale (VNRS); Those who are reluctant or unable to mobilise of healthcare professionals. l The categorical rating scale.

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This article has been double-blind peer-reviewed

l Behavioural change (refusing to eat, alteration in usual patterns); fig 1. visual analogue scale l Change in body language (rocking, guarding); l Physiological change (blood pressure, No pain Worst pain heart rate); l Physical change (skin tears, pressure areas).

Pharmacological approaches fig 2. verbal numerical rating scale Kaasalainen et al (2007) highlighted the importance of appropriate pain assessment in older people and difficulties in choosing 1 2 3 4 5 6 7 8 9 10 drug treatment. A common misconception No pain Worst pain is that patients who do not complain about pain have no pain (Pasero et al, 1999). There is also fear of prescribing opioids because of Paracetamol can be combined with some be achieved for up to three weeks. This is side effects. weak opioids such as codeine (8mg, 15mg, particularly significant for prescribers when Pharmacological treatments are not without 30mg) known as co-codamol, or managing patients’ expectations about pain risks, so awareness of the age related changes dihydrocodeine (10mg, 20mg, 30mg) relief (Waterfield, 2008). that can influence drug pharmacokinetics is known as co-dydramol. The British National The application of large amounts of topical vital. Drug absorption, distribution, Formulary notes that compound preparations NSAIDs may result in systemic effects metabolism and excretion can all change are less suitable in general as they increase including hypersensitivity and asthma. with age. Age related changes apply the risk of overdosage; it also states adding The interaction section of the BNF (BMA specifically to body composition, adipose the low dose of opioid may be enough to and RPSGB, 2010) states that NSAID tissue distribution, and water and muscle cause side effects without providing interactions do not generally apply to topical volumes. Evidence suggests sensory neurons significant pain relief (British Medical formulations. decrease in number and sensitivity (Schofield Association and Royal Pharmaceutical and Simpson, 2009). Listening to patients’ Society of Great Britain, 2010). Opioids perspectives and respecting their decisions is Paracetamol is available in caplets, tablets, Naturally occurring opium based substances vital for achieving optimal concordance. solutions and dispersible tablets. It is vital to such as the alkaloid morphine are called In line with the long established World check which preparation patients prefer; opiates, while all drugs that act on opioid Health Organization (1990) ladder, some may not take their paracetamol because receptors, natural or synthetic, are called the usual pharmacological process for pain the tablets are too big or because they do not opioids. These receptors are found in the management is to start with mild , like the taste of dispersible solution. brain, spinal cord and some in the peripheral such as paracetamol. If the pain is still not Many over the counter products, such as nerve endings. Opioid drugs are classified adequately managed, the next step is to add cold and pain relief preparations, contain according to their action: non-steroidal anti-inflammatory drugs, paracetamol. It is therefore important to l Agonists, such as morphine and fentanyl, before progressing to mild opioids such as take a full medication history to avoid bind to and stimulate an opioid receptor and dihydrocodeine, codeine or tramadol. If the duplication and potentially serious overdose. are capable of producing a maximal pain is still moderate to severe, the next step response from the receptor; is to introduce stronger opioids such as Non-steroidal anti-inflammatory drugs l Partial agonists, such as buprenorphine, morphine and fentanyl. NSAIDs are a large group of drugs used to stimulate opioid receptors but have a ceiling treat pain and inflammation. Common effect, that is, they produce a submaximal Paracetamol examples include ibuprofen, diclofenac response compared with an agonist; Paracetamol is simple and effective and has and naproxen. l Agonist antagonists, such as pentazocine, minimal side effects. Its significant advantage NSAIDs inhibit the formation of act as agonist at one type of receptor and is the lack of stomach irritation; as such, it is prostaglandin, which is responsible for antagonist at another; the non-opioid analgesic of choice, especially modulating inflammation. Prostaglandin l Antagonists, such as naloxone, bind to, for treating older people. Its main drawback also reduces acid production, and increases but do not stimulate, the opioid receptor is that overdosage may cause hepatic mucus in the stomach and blood flow to the and may reverse the effect of opioid agonists. damage; sometimes, this does not become kidneys. Some of the side effects of NSAIDs Once the drug has bound to the receptor, apparent for 4-6 days (Waterfield, 2008). therefore include peptic ulceration and salt the function of the cell is changed. This may The mechanism of action of paracetamol is and water retention. When prostaglandin is alter neurotransmission and therefore action not completely understood, but it is believed inhibited by NSAIDs, less blood reaches the potential. Strong opioids such as morphine to reduce pain by interrupting or tubules in the kidneys; conditions such as exert a strong change within the cell, while suppressing pain signals along the nerves. chronic heart failure, hypertension and renal the weak opioids such as codeine act on the Paracetamol has no significant action on disease are exacerbated (Waterfield, 2008). receptors to a lesser extent. Cox-1 and Cox-2 enzymes, which explains A single dose has analgesic activity similar Commonly used weak opioids (codeine, its lack of anti-inflammatory action and the to that of paracetamol. In regular full dosage, dihydrocodeine and tramadol) are used for lack of gastrointestinal (GI) side effects NSAIDs have a lasting analgesic and an anti moderate to severe pain. Strong opioids (Waterfield, 2008). inflammatory effect. The full effect may not (morphine, diamorphine, oxycodone and

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sensitivity to medication such as NSAIDs, circumstances, the chance of an ADR is Box 2. SOCRATES pain assessment which increase the risk of GI bleeding. relatively high, and the risk rises with an framework Although ageing is associated with increased number of medications. S – severity: none, mild, moderate, severe increased gastric pH and delayed gastric Drug interactions may increase or decrease O – onset: when and how did it start? emptying, there is little evidence to suggest the activity of one or more drugs. Drugs may C – characteristic: is it shooting, burning, that intestinal drug absorption changes with interact by enhancing or blocking activity at aching? Ask the patient to describe it age (Reid et al, 2001). Age related changes in a specific binding site (receptor or ion R – radiation: does it radiate anywhere else? body composition, protein binding and channel or transporter molecule or enzyme) A – additional factors: what makes it better? organ blood flow can affect drug (Morris, 2008). For example, a patient with

T – time: is it there all the time? Is there a time distribution. A relative increase in adipose asthma taking an inhaled beta2 agonist such of day when it is worse? tissue and corresponding bodily water as salbutamol may find this less effective if E – exacerbating factors: what makes it worse? reduction also affects the volume of also taking a beta blocker such as atenolol. S – site: where is the pain? distribution. The volume of distribution of Beta blockers are therefore contraindicated water soluble drugs is smaller, and this causes in asthma and alternative therapy should be an increase in initial drug concentration. sought (McGavock, 2002a). When fentanyl) are used for severe pain and can be Lipid soluble drugs tend to have an increased prescribing a new drug, check BNF administered in different ways (Box 3). volume of distribution, which prolongs their appendix 1 for possible interactions. elimination half life (Reid et al, 2001). The key sites of drug metabolism and Limitations of opioid use There is evidence for age related changes in elimination are the liver and kidneys, and The side effects associated with opioids limit the rates of metabolism of some drugs (Reid people with impaired liver and/or kidney their use and sometimes cause patients to et al, 2001). For example, drugs that undergo function are at greatest risk of an ADR from stop treatment despite benefiting from pain oxidation are likely to be metabolised more high drug concentration (due to relief. Dizziness, nausea and constipation are slowly. Also, older people have reduced first accumulation). all common, while constipation can be the pass metabolism. Drugs that undergo most problematic; it can cause bloating, extensive first pass metabolism may therefore Types and causes of ADRs abdominal cramping, nausea and vomiting. show considerably increased bioavailability ADRs can be classified into two types: type A For many patients, constipation can have a (Reid et al, 2001), and reduced doses may be and type B. profound negative impact on quality of life. indicated in older people. Overall, this effect Type A reactions are often predictable, Before starting opioid treatment, prescribers is amplified by the presence of liver disease. depending on the mode of action of the drug, should always warn patients about side effects, Renal blood flow and renal function and are more likely to occur at higher dosage provide dietary advice and suggest remedies decrease in older people. The glomerular (Courtney and Griffiths, 2008). For example, to prevent constipation, such as laxatives. filtration rate falls by approximately 30% NSAIDs can cause dyspepsia; opiates cause Many patients who benefit from pain relief by the age of 65. Some drugs that are constipation. These common examples of but suffer from constipation wonder excreted mainly by glomerular filtration will ADRs can be avoided by either stopping or whether to continue taking opioids or stop therefore accumulate and their dose should reducing the drug dosage or, if necessary, by the treatment and go back to milder, less be reduced (British Medical Association and using an alternative drug (McGavock, 2002b). effective analgesics. Prescribers should Royal Pharmaceutical Society of Great An adverse reaction may also occur therefore weigh up the risks and benefits Britain, 2010). Moreover, older people are following sudden cessation of a drug, with patients; they may need to accept some potentially more likely to suffer renal tract causing withdrawal symptoms. For example, patients prefer to be in pain rather than disease, which reduces drug clearance. antidepressants and benzodiazepines should experience side effects. It is highly likely that older patients are be slowly reduced before completely stopping. already on a number of medications. Type B ADRs are idiosyncratic in nature, Other medications and Multiple drugs (polypharmacy) can lead to not predictable and unrelated to the drug considerations an increased risk of side effects as well as dose. An example is an anaphylactic reaction Other medications, used primarily in reduced concordance. Older patients are to penicillin. , change the way in which more likely to develop adverse reactions to Many drugs, such as NSAIDs, should be messages are sent along the nerves, or how different types of analgesic drugs at much used with caution when treating older people. they are processed by the brain and spinal lower doses (Popp and Portenoy, 1996). Diuretics are often poorly tolerated, and cord. These include some antidepressants electrolyte disturbances are common (Morris, such as amitriptyline and some antiepileptic Adverse drug reactions 2008). Drugs with a narrow therapeutic medicines such as gabapentin. A significant adverse drug reaction (ADR) is window, such as warfarin and digoxin, are It is important to consider different ways experienced by around one third of older particularly likely to cause problems for of delivering medication. NSAIDs can be patients taking multiple medications (Hanlon older patients. Regular measurements of given as gels, and opioids can be administered et al, 1997). ADRs are unpleasant, can lead drug levels should be undertaken. as skin patches. People with constant pain to hospital admissions and, in exceptional generally find it easier to manage modified cases, may be fatal (Pirmohamed et al, 2004). Reporting and avoiding ADRs release formulations such as MST Continus. Certain long term conditions are common Suspected adverse reactions should be in older people – such as hypertension, reported to the Medicines and Healthcare Challenges with medication ischaemic heart disease and chronic products Regulatory Agency, using the Analgesia must be prescribed for older people obstructive pulmonary disease – and require yellow card at the back of the BNF or MIMS with caution as there is a high incidence of multiple medications. In these or online (yellowcard.mhra.gov.uk). The

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“black triangle” symbol identifies newer drugs that are still being closely monitored, Box 3. Administration of strong opioids and all ADRs involving these should be Oral (PO): this is the preferred route for patients butterfly needle may be inserted into the reported through the yellow card system. who are able to eat and drink. Doses need to be subcutaneous tissue and regular injections can be Before starting a new drug, it is important larger than when given by other routes. given through the injection port. May be suitable to consider carefully whether there are safer Intravenous (IV) including patient controlled for those with poor venous access. options for older patients. Detailed history analgesia (PCA): this is the quickest route, and Transdermal: fentanyl and buprenorphine only; taking – including details of current drug 100% of the drug is available. Small boluses can be the opioid is administered in a patch form. Onset of regimen, over the counter drugs and herbal titrated according to patients’ pain, producing a action usually takes 12-24 hours. treatments – is imperative before prescribing. more constant level of drug. PCA allows patients to Submucosal: oral, nasal or pulmonary routes Prescribers should: administer a small amount (bolus) of an opioid via include intranasal diamorphine and fentanyl l Always choose the lowest effective dose of the specifically preset pump. This system has a lozenges. the drug to be used for the shortest possible lockout time (usually five minutes), so patients Epidural/spinal (intrathecal): this method is time; have to wait until the next dose becomes available. used for intra and postoperative analgesia. l Start with a lower initial dose and This prevents them from continuously receiving Rectal (PR): morphine only; this is not a gradually increase if necessary; opioids and potentially overdosing. common route to administer opioids but may be l Take into account renal and liver function; Subcutaneous (SC): not fentanyl; a small necessary if all other routes are inaccessible. l Liaise with other prescribers, for example GPs, and provide adequate information to patients and carers. dissociation (Carr and Mann, 2000), using Conclusion All these measures can help to prevent music, reading, watching television or To become effective practitioners, we need potential errors, polypharmacy and serious talking about pleasant subjects. Relaxation to overcome real or perceived barriers to ADRs. It is important that older patients have techniques can also help patients achieve a good pain management. These include the regular medication reviews (Morris, 2008). state of relative freedom from anxiety and following: muscle tension, a quieting or calming of the l Beliefs among doctors and other Non-drug treatments mind and muscles. These techniques can be professionals that pain management is not Growing evidence supports the use of taught; however, it may difficult to do this important; non-pharmacological interventions for on a busy hospital ward. l Poor assessment techniques and the lack treating pain. These can include cognitive Physical intervention methods and of appropriate tools; behavioural techniques, physical methods complementary therapies to help manage l Inadequate dissemination of available and complementary therapies (Carr and pain include: knowledge; Mann, 2000). l Exercise and mobilisation; l Fear of addiction, tolerance and adverse Behavioural interventions may look at l Correct positioning; effects. altering certain behaviours to reduce the l Application of hot or cold; Effective individual care plans encourage perception of pain. Cognitive interventions l Massage; patients to report their pain freely and take are defined as methods that alter negative l Aromatherapy; into account each person’s willingness to thinking styles related to anxiety about a l Trans electrical nerve stimulation (TENS); take medication or not. Careful assessment painful situation. This may be by using l Acupuncture; and the use of appropriate tools will go a coping strategies to manage pain. Examples l Physiotherapy (Flor and Turk, 2006; long way towards improving the quality care of these techniques include distraction and Gifford et al, 2006). of older patients. l

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