Exploring how to assess and manage pain at the end of life

Author
Sharon Wood, MSc, diploma in healthcare research studies, RGN, is lecturer in Nursing, School of Healthcare, University of Leeds.

End of life (EoL) pain in older people is often associated with multiple pain sites and concurrent medical problems. The psychological and physical consequence of unrelieved pain may result in additional problems (Box 1).

Some approaches to daily care and certain equipment, particularly hoists, may also contribute to, or actively cause, pain (Cairncross et al, 2007).

Pain in older people is a personal, complex, subjective and multidimensional phenomenon, which makes diagnosing the cause(s) of pain difficult. In addition, many misconceptions and barriers influence the assessment and management of EoL pain.

Older people are more likely to experience pain in more than one site with different sensations. They also do not always recognise their sensations as pain and use descriptions such as 'sore', 'hurting' and 'aching' (Royal College of Physicians et al, 2007). Self-reported pain is considered the gold standard and should be assessed using a tool that is suitable for older people (Box 2).

The initial assessment should include a physical assessment to identify causes as well as the location, quality, intensity, onset, duration and frequency of pain and exacerbating factors.

EoL pain in older people in care homes can remain unrelieved. It is then vital that a referral to a specialist is sought as the individual may require more complex interventions, such as epidural analgesia, nerve blocks or patient-controlled analgesia.
Pain in older people may be:

• Nociceptive: somatic (for example, musculoskeletal or in skin or bone) and visceral (for example in bowel obstruction);

• Neuropathic: primary lesion or dysfunction in the central or peripheral nervous system;

• Breakthrough or procedural (for example, while moving).

These distinctions must be made to ensure appropriate interventions are implemented.

Communication and cognitive impairment

Information and scales should be presented in good lighting where extraneous noise is minimal, and should have large clear letters (lower case) and numbers in plain text, with adequate spacing, on non-glare and buff or yellow paper (RCP et al, 2007).

People with visual and hearing impairments may require modified pain-assessment scales. Those with a motor impairment may need help holding a pen and paper, while those who lack verbal and numeracy skills may require a pictorial scale (RCP et al, 2007). A speech and language therapist or psychologist may be able to help if impairment is severe (RCP et al, 2007).

Observation/behavioural scales can be used in patients with cognitive impairment. These assess changes in autonomic responses, facial expressions, body movements, verbalisations/vocalisations, interpersonal interaction, activity patterns and mental status (RCP et al, 2007). Increased confusion or aggression may indicate an increase in pain.

Pharmacological management

Analgesia should be prescribed and administered according to the type of pain(s) described by the individual. However, there is a lack of evidence about the safety and efficacy of using analgesics in EoL pain management in older people, particularly in the long term.

Older people are more sensitive to adverse analgesic side-effects because of a decreased liver metabolism, leading to slower excretion of analgesics and their metabolites (The Australian Pain Society, 2005). There is also an increased risk of drug interactions in older people.

The fundamental principle of EoL pain management is regular analgesia according to the World Health Organization's analgesic ladder (Fig 1). WHO recommends oral administration where possible. When oral analgesics are no longer tolerated, it will be necessary to change the route (and dose) to transdermal, subcutaneous, intramuscular and intravenous.

Nociceptive pain

NSAIDs can be effective for somatic pain. Older people are vulnerable to toxicity and adverse events from long-term use. Opioid analgesics are underused by older people, underprescribed by doctors and underadministered by nurses. All of these factors can contribute to ineffective management of EoL pain. Exaggerated fears over adverse effects are evident in patients and nurses.

Neuropathic pain

Assessment and management should be guided by Clinical Resource Efficiency Support Team (2008) guidelines. Adjuvant drugs may include tricyclic antidepressants, systemic local anaesthetics and anticonvulsants.

Breakthrough pain

This may occur when regular sustained release (SR) analgesia becomes less effective as a result of a new acute pain or the sudden increase of existing pain. An immediate release (IR) analgesic should be prescribed with the SR analgesia. If this is not effective, a parenteral route (transdermal, subcutaneous, intramuscular and intravenous) - may be necessary.

Procedural pain

This may occur as a result of activities such as washing. Pre-emptive IR breakthrough analgesia should be given before the activity is carried out.

Non-pharmacological interventions

Pain management is often more effective when it uses both pharmacological and non-pharmacological approaches (The Australian Pain Society, 2005). Simple interventions such as bathing, showering, heat and the use of special beds and mattresses can relieve pain (Cairncross et al, 2007).

Encouraging older people to take an active role in pain management is beneficial. This can include gentle exercise
or distraction activities (Cairncross et al, 2007).

Other interventions include relaxation, hypnosis, massage, aromatherapy and electrical nerve stimulation. These require knowledge and skill; however, the evidence base for their use in EoL pain management in older people is not well established.

Evaluation of interventions

Nurses never or rarely review patients' pain (Cairncross et al, 2007). If pharmacological and non-pharmacological interventions are not evaluated, EoL pain may remain uncontrolled.

Once a pain assessment scale has been identified, a systematic assessment should be undertaken (RCP, 2007). The older person should be consulted about which outcome measures - such as pain intensity, nausea or sedation - should be used to determine whether pain interventions have been successful (Department of Health, 2001).

Conclusion

Although a wide range of pharmacological and non-pharmacological interventions is available, EoL pain in older people in care homes remains a significant problem. This can be addressed by educating nurses and doctors as well as having a proactive approach to both pain assessment and management (Cairncross et
al, 2007).

References

The Australian Pain Society (2005) Pain in Residential Aged Care Facilities: Management Strategies. Sydney: The Australian Pain Society.

Cairncross, L. et al (2007) A Hidden Problem: Pain in Older People. Oxford: Picker Institute Europe.

Clinical Resource Efficiency Support Team (2008) Guidelines on the Management of Neuropathic Pain. Belfast: CREST.

Department of Health (2001) National Service Framework for Older People. London: DH.

Royal College of Physicians, British Geriatrics Society, British Pain Society (2007) The Assessment of Pain in Older People: National Guidelines. Concise guidance to good practice series, No 8. London: RCP.

WHO (2008) WHO's Pain Relief Ladder. Geneva: WHO.

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