practice review KEywORdS ACUTE PAIN 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 pain management. 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. 14 Nursing Times 27 July 2010 Vol 106 No 29 www.nursingtimes.net practice review 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) analgesic 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 analgesics, 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