The recent Health Service Ombudsman report Care and Compassion? revealed examples of the appalling way some of the older people in our care are treated.
In addition to starving, dehydrating and disrespecting people, it seems we are also incapable of managing their pain. If this were in any other circumstances, we would call it torture.
If you treat your patients as individuals, you will notice their pain and you will be able to treat it, and them, correctly. Less torture - more common sense
Much of the time poor pain management is blamed on poor education. A British Pain Society (BPS) survey found vets have about two and a half times more pain education than nurses. As a dog owner, I feel obliged to point out this does not necessarily make them any better at managing pain. But I don’t doubt pain education in nursing and healthcare can be strengthened, and groups like the BPS have active special interest groups because of their commitment to this.
To inform my own pain teaching, I carried out a small anonymous survey about pain and the older person among some willing student nurses. About 40% of the 52 respondents thought pain was a normal part of growing old.
It isn’t. Although some disorders such as osteoarthritis predominantly affect older adults, not everyone who is older has pain. The presumption that pain and ageing go hand in hand may be one of the reasons that we fail to address it properly - it’s normal so it isn’t something to be challenged.
A similar number of students thought older people didn’t complain about their pain. It is true that in general older people have a more stoical attitude to pain - but this can mean that they suffer in silence, and unnecessarily. We need to detect pain actively, not wait for it to be made obvious to us. Patients of all ages are likely to not want to bother a busy nurse but if pain is a priority for us then dealing with it surely is no bother.
Or perhaps this is the problem. Perhaps we don’t look for pain because we are unsure of how to treat it.
My mini-survey revealed some confusion about pain thresholds, tolerance, side-effects and opioid dosing. For practical purposes, older people don’t have a greatly different pain threshold from younger people, although the presence of something such as diabetic neuropathy will have a local effect. Older people do have a lower pain tolerance in experimental conditions but how this translates to practice is difficult to tell.
Older people have a greater problem with side-effects and, when side-effects are dose-dependent, as they are with morphine, they may tolerate less of the drug. Poorer renal function in older age may also mean that lower doses are required.
But here are the really important things about old people - they are people, and they are all different. Whether you understand the physiology of ageing or not, if you treat your patients as individuals, you will notice their pain and you will be able to treat it, and them, correctly. Less torture - more common sense.
Amelia Swift is a lecturer, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham