Pain Management

Unfortunately, pain is quite common in the general population, especially in older adults living at home and in residential aged care facilities. We aim to manage pain effectively in all the clients we see, young and older clients living at home and who live in residential aged care facilities in Queensland. We are fortunate to have access to multi-disciplinary teams who can work together to ensure that all our clients can aim for a good quality of life.

In this article we discuss specifically pain management programs at home and in residential aged care facilities in Queensland for older clients.

We can help with pain with younger clients as well! Your doctor or your pain management specialist may recommend physiotherapy, occupational therapy, massage, exercise, aquatic therapy or other interventions as part of your pain management care plan.

At Allied Aged Care we understand and work with persistent, ongoing pain on a daily basis. We specialise in treating pain in a best practice and evidence based way.

This means that we

• “Get” pain. We don’t judge. A lot of us have had/have persistent pain ourselves and we understand it is incredibly frustrating having to tell your story again and deal with unhealthy attitudes from other.
• We believe that you are the expert on your pain. You may not have all the medical terminology but you know best what works for you. Our job is to help you with information and techniques we know and have found helpful to others that may help you have a better quality of life.
  
  

We have more information on pain management strategies for different conditions and ages in the “conditions we treat” sections ie lower back pain, hip pain etc.

You may find it helpful even if you are younger to read how we help older clients with pain however, to show how much we can help you as well.

It can be extremely hard to detect pain in older adults either living at home or living in residential aged care, especially those with cognitive impairment. Older adults in residential aged care in QLD do have access to comprehensive pain management. However, their pain needs to be detected first to be treated effectively.

Australian studies are in keeping with overseas research and have shown that up to 86.5% of nursing home residents experience pain (Australian Pain Society – Pain in residential aged care management, 2005)

Clients who can verbally relay pain may do so, but they might still face barriers. Just because a resident can report pain verbally, it should not be assumed that they always communicate their pain.

The Australian pain society and other research institutes suggest that a pain-vigilant culture should exist due to the high underreporting of pain.

Below are some of the signs that carers, staff, families and friends can look out for to detect pain in an older adult:

• Sudden loss of interest (e.g. stop attending activities, especially ones they normally enjoy)
• Grimacing
• Guarding
• Fidgeting
• Becoming more agitated or confused
• Not moving /reluctant to move
• Refusing to eat
• Alteration to normal patterns
• Frowning, looking tense, looking frightened
• Sweating/temperature changes/flushing pallor changes
• Change in Blood pressure/pulse outside normal limits
• Vocalisation (groaning, whimpering, crying)
• Specific limitations during activities of daily living (e.g. shoulder pain limits trying to lift arm overhead)

• Cognitive changes
  • Just because a client does not have dementia, or scores indicating cognitive changes on assessment scales like PAS (psychogeriatric assessment scale) they may still not be able to accurately report pain.
  • The Australian pain society reports up to 90% of residents show cognitive impairment in residential aged care.
  • Severe cognitive loss severely affects pain reporting ability.
• Other communication barriers i.e. dysphasia, hearing loss, vision loss can also affect pain reporting.
• Cultural/ethnic/language differences
• Different education levels
• Medication may mask pain and pain reporting ability.
• Beliefs about pain i.e. “I don’t have pain, I just have an ache/can’t do something”, “I don’t have any money to spend so I won’t mention pain”, “There is someone worse off than me, you should worry about them”, “ I don’t want to be a bother”, “ There’s nothing you can do about my pain anyway”
• A client’s attitude – A lot of older clients have different attitudes about chronic pain. They may believe that chronic pain will not change.
  • They may believe this is just a normal part of ageing.
  • They may worry about becoming addicted to pain medication.
  • They may be worried about reporting pain showing they are less independent and that pain treatment could take away from treatment of other conditions they feel are more important.
• Staff being busy/not seeing more subtle signs of pain. Staff reporting high workloads which can make it difficult to assess pain fully at times.
• Staff asking a resident in residential aged care what their pain is at rest, not during movement or particular activities. E.g. a client with shoulder arthritis may not have pain at rest sitting or walking but may with overhead movement/combination movements.

Assessing pain for management in an older adult at home or in residential aged care can be complex.

Nursing staff are generally well trained in assessing pain in older adults and discussing with their doctor, carers, allied health staff, families and the residents themselves, who all work together to manage pain.

However, as mentioned before, there are often barriers to assessing pain accurately.

The Royal Australian College of GPs and The Department of Health ACFI (Aged Care Funding Instrument) recommends the following evidence-based pain assessments:

• Modified Brief Verbal pain inventory
• Abbey pain scale/PAINAD
  
  

At Allied Aged Care we use these assessment tools, alongside many others, when assessing pain in an older adult.

We also recommend:

• A full musculoskeletal and pain assessment conducted by an allied health professional (Physiotherapist or Occupational Therapist) specifically trained in an older client pain management assessment at home or in residential aged care facilities in QLD.
• Review of pain medication currently taken/used and effects on activities
• Discussion with all stakeholders, RNs, Facility managers, carers, GP, specialists, allied health, family and friends. Multidisciplinary care meetings can be highly effective to manage pain effectively.
• Ensuring there is sufficient documentation of diagnoses of conditions that may cause pain, such as Osteoarthritis. If the patient suffers from arthritis, we recommend having a record of the joints involved and how severe arthritis is.
• Having a record of surgeries/soft tissue injuries that may have been missed during ACAT and other assessments. Review medical summaries, X-rays and other results, hospital notes
• Discussion with family, especially in cases where client’s reporting of conditions may be limited.
• Discussion with carers on residents 24-hour pain picture (e.g. is their pain worse in the morning when attempting to mobilise, but improves with activity?)
• Relating specific tests of palpation and movement to diagnosis (e.g. a resident with knee pain may not show pain on weight bearing or movement like walking but may show pain at the end of range, knee extension with overpressure or on stairs/inclines. Having an X-ray that showed osteophytes in the knee would also help finetune this assessment.)
• Looking for trigger points and specific areas of tenderness in muscle bulks, as well as specific nerve pathways, related to the pain reporting, diagnosis and/or movement patterns. This can be especially useful to confirm pain in a resident that may have difficulty reporting pain.
• Looking for non-verbal signs of pain that can confirm pain in movements and palpation (in both verbal and non-verbal residents)
• Use of pain logs not just during ACFI documentation times. Allied health staff and carers who are regularly reporting that they are assessing for pain means are less likely to miss signs of pain, especially if assessments show where pain occurs
• Using client centred care goals and assessment to check whether the pain is limiting any functional activities that a resident wishes to participate in.
• Believing a resident with dementia/cognitive impairment when they say they have pain. This is also recommended by the Australian Pain Society.

1. Start with an audit of your clients/residents – How many do you know of that have pain? A good way to start is looking at how many clients are receiving hot packs, massages and regular pain medication (especially S8 medication). If you have less than 80% of your residents on average, chances are you are underestimating pain in your residents. Consider assessing more non-verbal pain signs and patients with dementia especially.
   
   
2. Involving all stakeholders – As mentioned above, speaking to the clients/residents, their care staff, allied health, doctors and families helps to get a clear idea of a resident’s pain and their client centred goals to best manage this pain and provide a good quality of life. Multdisciplinary care and input from other allied health such as podiatry (foot, knee, back pain) can also assist.
   
   
3. Medication is one of the main pain management tools. This can be refined by discussion with allied health and carers to determine when medical pain management may be the most effective to time in with exercise, activities etc.
   
   
4. Medication review should occur regularly with input from GPs and RNs (and pharmacist, if possible). Pain logs can be helpful to show 24-hour pictures and help targeting of pain whilst minimising side effects of medications. Medication reviews can also ensure effective management of resting pain and breakthrough pain.
   
   
5. Consideration of referral and involvement of specialists – If pain management is not effective, referrals to orthopedic surgeons (joint pain), neurosurgeon/pain specialists (especially for neuropathic pain), geriatricians , rheumatologist (polymyalgia, RA, OA and other arthritis) and endocrinologist (diabetic neuropathic pain) should be considered.
   
   
6. Other factors that can help 
   • Position changes
   • Consider/Assess current equipment – Are chairs too low for someone with knee/ankle/back/hip pain? Does someone with neck pain need neck support when seated? Does someone with sciatic pain need more support than a 4WW when walking? Etc.
   • Activities tailored to the client’s level of activity and condition – I.e. a mix of general group activities and individual activities.
   • Being able to stay social and involved is a valid and important part of pain management.
   • Education is an important, but underutilized, resource in pain management. A lot of older adults have beliefs about chronic pain that can limit reporting and effective treatment of pain. All stakeholders can play a role in working together to educate residents.
   • Exercise is highly effective to help with pain management. Exercise releases endorphins (the body’s natural pain killers). It also improves circulation and relieves stiffness and muscular pain in many cases. Allied health can effectively provide exercise programs appropriate to older adults that will not exacerbate medical conditions but assist to manage pain.
   • Counselling, cognitive behavioural therapy and other forms of mental health-based treatments can assist helping an older resident manage their pain more effectively.
   • Massage therapy from carers. It is important to note that carers/family/friends/massage therapists can all give massage and get good results. However, results might be limited or only manage the pain short-term, unless the massage is therapeutic and conducted by trained allied health professionals.

Allied health has a large range of therapeutic interventions that they can provide to older adults in residential aged care facilities in QLD to help manage pain. They can do a lot more than just massage, or at least they should be able to – If your therapist has not used the techniques listed below, encourage them to contact us at Allied Aged Care. We are always happy to assist and provide training.

• Therapeutic massage targeting specific movement patterns/regions
• More advanced therapeutic massage techniques such as trigger point release, friction, traction, joint mobilisations
• Mulligans techniques
• McKenzie exercises
• Arthro-neuromuscular facilitation (finch therapy)
• Proprioceptive neuro-muscular facilitation techniques to restore movement patterns and to switch off overactive muscles
• Postural retraining
• Electrotherapy as an adjunctive treatment (used in combination with other techniques such as TENS, laser, ultrasound, vibration, muscle stimulators etc.)
• Wax therapy
• Taping i.e. kinesio taping, postural taping
• Biofeedback
• Graded motor imagery
• Cognitive behavioural therapy and other counselling techniques if in their scope of practice.
• Pain education
• Therapeutic exercises
• Stretches, especially connective tissue
• Positioning advice
• Equipment advice on aids and devices to reduce strain/pain
• Use of braces/splints/supports to help pain
• Nerve gliding exercises
• Aquatic therapy (hydrotherapy)
  … and many more.