The Pain Management Challenge of Residential Aged Care

When someone is considering residential aged care, either for themselves or a family member, access to quality health care is usually high on the agenda. However, even with the best  of care, chronic pain – which  is usually complex and occurs  in one in three people aged  over 651  – is often not well managed in residential care, and in some cases may be overlooked completely. 
This is especially true in the case of people  with dementia, which occurs in more than  50 per cent of those in residential aged care.2
According to Professor Stephen Gibson, Director of the National Ageing Research Institute (NARI), there is enormous difficulty is assessing pain in people with dementia, in particular those with impaired verbal communication skills.
Studies undertaken by Professor Gibson and the team at NARI show that dementia and persistent painful conditions often co-exist in the elderly. They also suggest people with dementia living with pain are being under-treated, compared with cognitively intact persons, despite having similar levels of potentially painful disease.3
Other research has demonstrated a significant inverse relationship between pain report and cognitive impairment in nursing home residents.  In another study, pain was detected in just 31.5 per cent of cognitively-impaired residents compared to 61 per cent of cognitively-intact residents, despite both groups being equally afflicted with potentially painful disease. 4
Most of the work has focused on Alzheimer’s Disease, with patients showing a significant decrease in self-reported pain intensity and affect when compared with age matched controls, and routinely receiving fewer analgesics than cognitively intact peers even after controlling for the presence of painful disease. 5, 6
In fact, it has been found that only 33 per cent of patients with Alzheimer’s Disease received appropriate analgesic medication compared  to 64 per cent of non-demented adults.
Most assessment tools have focused on measuring the presence or absence of pain, rather than the pain severity, yet this dimension is critical to deciding upon an appropriate treatment regime.
The exact reasons for reduced pain report are still unknown, but could be related to impaired communication skills, as well as the possibility of less comorbid disease or some alteration in pain processing related to degenerative neurophysiological changes that accompany  many dementing illnesses.
Regardless of the reason and despite the demonstrations of less pain in those with dementia, the findings do not suggest that  pain is less bothersome when it is reported.
The other difficulty with older people is that many do not tolerate pain medications, including opioids, NSAIDS, anticonvulsants and antidepressants.8
In addition, many older people are not able to benefit from an integrated pain management approach, which requires body movement in addition to medication and other treatments, therefore the options for pain management become more limited.
Like all people with chronic pain, the elderly want understanding and assistance to live life to the full, as much as possible.
More research is needed in order to develop evidence-based assessment and management of pain in the elderly, and in those presenting with dementia in addition to chronic pain.
With the prevalence of chronic pain expected to increase as Australia’s population ages – from 3.2 million in 2007 to 5 million by 20509  – there is an urgent  need to investigate this important area of research.
In the meantime, it is important for people caring for the elderly to pay attention to any complaint of pain, whether verbal or through behavioural markers. Where there is marked cognitive impairment, this should require even greater attention and a more proactive treatment response.
References
1 Blyth F et al 2001 Chronic pain in Australia: a prevalence study. Pain 89(2-3), 127-34
2 Gibson SJ 2007 The IASP Global Year Against Pain in Older Persons: Highlighting the current status and future perspectives in geriatric pain. Expert Reviews in Neurotherapeutics 7: 627-635
3 Cohen-Mansfield J & Marx MS 1993 Pain and depression in the nursing home: Corroborating results. Journal of Gerontology 48(2): 96-97
4 Proctor WR & Hirdes JP 2001 Pain and cognitive status among nursing home residents in Canada. Pain Research and Management 6(3): 119-125
5 Scherder 2001 Dementia and Geriatric Cognitive Disorders. Dement. Geriatr. Cogn. Disord. 12(6):400-407
6 Farrell MJ 1996 The impact of dementia on the pain experience. Pain 67(1):7-15
7 Scherder EJ & Bouma A 2007 Is decreased use of analagesics in Alzheimer disease due to a change in the affective component of pain? Alzheimer Disease Assoc. Disord. 11(3):171-4
8 Proctor WR & Hirdes JP 2001 Pain and cognitive status among nursing home residents in Canada. Pain Research and Management 6(3): 119-125
9 MBF Foundation 2007 The high price of pain: the economic impact of persistent pain in Australia. Report conducted by Access Economics in collaboration with the Pain Management Research Institute - The University of Sydney/Royal North Shore Hospital