British Pain Society and British Geriatrics Society guideline will help to improve identification of pain and produce a more considered approach to management, says Dr Pat Schofield


TThe guideline on The assessment of pain in older people was developed collaboratively by the British Pain Society (BPS) and the British Geriatrics Society (BGS) and was published in November 2007.1 Its purpose is to provide healthcare professionals with a set of practical skills to assess pain as the first step towards managing it effectively. The guideline does not differentiate between acute and persistent pain, as evidence from the literature relating to pain in older people renders such distinction impractical.

Prevalence of pain

Several reports have suggested age-related increases in the incidence of persistent pain,3,4 recurrent pain,5 musculoskeletal pain,6 and fibromyalgia.7 It has been estimated in small population-based studies that between 25% and 50% of older people living in the community suffer significant pain problems.8 Estimates of prevalence are higher in samples of older people living in care homes, where 45% to 83% of patients reported at least one current pain problem.2,9,10 Many painful conditions including osteoarthritis, degenerative spinal disease, spinal stenosis, osteoporotic vertebral factures, peripheral neuropathy, central post-stroke pain, post-herpetic neuralgia, temporal arthritis, polymyalgia rheumatica, cancer, and peripheral vascular disease are known to affect older people commonly.2

Types of pain

There are important differences between acute and persistent pain. Persistent pain is:

  • often underreported as a symptom by older people10,11
  • more difficult to cure or lessen as it is not always possible to identify the cause or causes—it may require a multidimensional approach to treatment1
  • associated with more pain sites, usage of greater number of pain descriptors, less response to interventions, more sleep disturbance, and greater emotional distress, including anxiety and depressive symptoms, compared with acute pain.12,13

Acute pain is pain of recent onset and probable limited duration, usually having an identified temporal and causal relationship to injury or disease.

Development and aims of the guideline

In order to assist clinicians in their assessment and care of pain in older people, improvements in practice and strengthening of the evidence base are urgently needed. The majority of research to date has been descriptive and/or qualitative. Therefore, it was not possible to produce a guideline based on graded evidence. However, in order to improve practice for this fundamental aspect of care, the guideline was developed based on best available evidence and practice.1

The aims of the BPS/BGS guideline1 are:

  • to highlight for all involved in the care of older people that pain is an important and common problem
  • to encourage best practice in the identification and assessment of pain in these patients.

Assessment of pain

Only the person suffering from pain can really know what it feels like as it is a subjective personal experience. The experience of pain is multidimensional and can be described at various levels:1

  • sensory: the intensity and nature of the pain—for example, crushing, sharp
  • affective: the emotional component of pain and how pain is perceived—for example, exhausting, frightening
  • functional: the disabling effects of pain on the person’s ability to function and participate in society—for example, physically, functionally, psychocially.

Assessment can be made more difficult in older people with severe cognitive impairment, communication difficulties, or language and cultural barriers.1 The guideline contains an algorithm that has been developed for use in practice to help with assessment (see Figure 1).1 The algorithm is based upon evidence from the literature such as behavioural signs, along with good practice points which should be used by all staff, for example, taking a more detailed history when pain is identified.

Figure 1: Algorithm for assessment of pain in older people

Algorithm for assessment of pain in older people

*If there is doubt about ability of person to communicate, assess and facilitate as indicated in recommendations 4 (Communication) and 5 (Assessment in people with impaired cognition/communication) from the guideline

Adapted from: British Pain Society, British Geriatrics Society. Guidance on: the assessment of pain in older people. BPS, BGS, 2007.

The algorithm was developed by Professor Jose Closs

Screening for pain

Pain has been referred to as the ‘fifth vital sign’, which demonstrates the importance of systematically assessing and monitoring pain.1 Any health assessment of older people should include asking whether they experience pain and the single assessment process should include a question to identify the presence of pain.1,14 The most effective way of determining the presence of pain is to pay attention to complaints of pain within the patient’s history.15

Intensity rating scales can also be used, which enable assessment of the response to treatment, and are suitable for use in older people with no cognitive impairment or mild-to-moderate levels of cognitive impairment.1 Where possible, using the patient’s own words to document the pain is preferred, however, if a patient denies any pain, follow-up questions about aching or soreness may elicit a response.15

The guideline noted an increased stoicism and reticence about reporting pain in the older population, which is further compounded when older adults live in care homes as they do not want to be seen as complaining.11

Pain intensity scales

There are many intensity scales available and many studies that have evaluated the psychometric properties of such scales. Verbal rating scales16 and numerical rating scales17 are best for quantifying the intensity of pain where no cognitive impairment or mild or moderate cognitive impairment exists.18 The Faces Scale19 is less effective for pain assessment and the visual analogue scale17 is the least effective in this group. Several recent studies have demonstrated the psychometric properties of the different pain scales in use.16–18

Whichever scale is selected, attention should be paid to how it is presented to the patient. Large, clear lettering or numbering should be used and the patient should be asked to complete the scale in good lighting conditions.1 The BPS/BGS guideline includes a numerical rating scale (see Appendix 2 in the guideline).1

Observation

Observing the patient can also provide some very useful information on whether he or she patient is in pain, particularly when there are communication difficulties. Behavioural indicators of pain can vary between individuals and even within the same individual. Such behavioural observations include:

  • facial expressions
  • physical reactions
  • negative reactions.

However, some changes can be quite subtle, such as withdrawal, and some can be associated with feelings other than pain. Should these behavioural changes occur, carers should exclude the existence of pain and carry out a more detailed clinical assessment. Physiological cues such as pallor, tachycardia and hypertension can indicate pain, but it is important to remember that with chronic pain, these indicators may not be present.20

Other signs that might be observed include body movement, which can indicate guarding or bracing, and facial expressions, which can also indicate pain. Several facial actions have been documented as indicating pain and include brow raising, brow lowering, cheek raising, eyelid tightening, nose wrinkling, lip corner pulling, chin raising, and lip puckering.1 These are known to increase with pain, particularly in cognitively impaired patients.

It is important also to include carers (formal and informal) in the pain assessment process as they are often more familiar with the older adult and so can recognise subtle changes in behaviour. However, it has been suggested that nursing caregivers underestimate the presence and intensity of pain and family members overestimate it.1

Finding the cause of pain

A full assessment should include collection of a pain history, which covers onset, time course, radiation, aggravating and relieving factors, quality, and associated symptoms, along with a history of co-morbidities. All medications should be reviewed, including over-the-counter, prescribed, and complementary medicines.1 The multidimensional impact of the pain necessitates inclusion of a multidimensional assessment, which includes assessing mood and function, and there are scales available to measure these aspects: the McGill Pain Questionnaire,21 Brief Pain Inventory,22 or the Geriatric Pain Measure.23 Although there is some evidence to support the validity of these scales in some of the older population, further research is still needed. Nevertheless, a clinical assessment of pain should encompass the sensory, affective/evaluative components along with the impact of the pain.1

Locating the pain

Location can be determined by asking the individual to point to the site of their pain or, alternatively, pain maps have been evaluated for use with older people.24 Pain maps have been used in the residential care setting with reasonable test–retest reliability.24 The BPS/BGS guideline includes a pain map (see Appendix 4 in the guideline).

Cognitive impairment

There are a number of behavioural scales that have been developed to determine pain in older adults with cognitive impairment and many are consistent in the seven main indicators. These indicators are:1

  • physiological observations
  • facial expressions
  • body movements
  • verbalisations
  • changes in interpersonal interactions
  • changes in activity or routines
  • changes in mental status.

At this time there is no single instrument that can be recommended for general use, but there are a number of published reviews that examine the properties of such tools.25,26

The guideline recommends two different approaches to pain assessment of the older adult depending upon their ability to communicate (see Figure 1).

Conclusion

Many studies suggest that pain in the older population is poorly managed and failure to manage pain is morally and ethically unacceptable. The first step in the process of improving pain management is for carers (formal and informal) to be able to identify pain appropriately in this group. The BPS/BGS guideline on The assessment of pain in older people has been developed to consolidate the best available evidence. It will in order to enable healthcare professionals to carry out a structured and formal assessment, which will result in a more considered approach to pain management.

The guideline can be accessed at www.bgs.org.uk/Publications/Publication%20Downloads/Sep2007PainAssessment.pdf

 

  • For a small cost, care staff and carers could be trained to use the algorithm to screen for pain in the elderly
  • The treatment of pain is not covered by this article and needs careful consideration as analgesics can cause side-effects in the elderly
  • Most analgesics are available generically at low cost
  • Pain can be an important sign of treatable disease
  • Effective community investigation and treatment of pain will potentially avoid referrals to secondary care
  • Pain clinic outpatient attendance cost:a
      • £194 (new)
      • £85 (follow up)
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