Medication Management in Residential Aged Care

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Managing chronic pain in residential aged care

The prevalence of chronic pain in residential aged care is estimated to be between 49% and 84%^[1]. Studies of older people in both community dwelling and aged care facilities found that pain is commonly caused by multiple factors.

The consequences of chronic pain in residents of aged care facilities are significant. Chronic pain is associated with depression, social isolation, sleep disturbances, impaired gait, increased use of health services and increased costs.

Adopt a systematic approach to pain assessment

Pain is a subjective experience and staff should, where possible, rely on the residents' self report of pain. It is also recognised that older people under­report their symptoms. Probe for descriptions of pain using other words such as 'discomfort' or 'ache'. Observing pain related behaviours is also important, especially in residents unable to communicate verbally about their pain. 

Consider how the pain interferes with the residents' daily activities, physical and psychosocial functioning and quality of life. Monitor residents daily for fluctuations and flares of pain.

Document a pain management plan

The goals of managing chronic pain are to improve physical and psychosocial function and quality of life and not solely to relieve pain. Involve the resident and their carer, in developing an agreed pain management plan tailored to their needs. Help them to identify realistic treatment goals (for example, improved sleep, walk for 10 minutes a day).

Optimise use of non-drug strategies

Managing chronic pain often involves a combination of medicines and non­-drug strategies. Studies have investigated numerous non­-pharmacological approaches to pain management including physical exercise, cognitive-­behavioural therapy, education, relaxation, massage, re­positioning, distraction techniques and complementary therapies. Many non-drug strategies may be of benefit to residents in aged care facilities in combination with medicines for pain management.

Round-the-clock analgesia is preferred for chronic recurrent pain

Regular rather than 'as required' (PRN) medication is recommended for chronic pain. Round-the-clock pain relief using a long-acting/modified-release analgesic provides a longer duration of effect for residents and avoids the peaks and trough associated with PRN dosing. Using a long-acting agent also means that there are fewer doses for nurses to administer.

Monitor and document adverse effects

Medicines may have increased and prolonged effects in the elderly due to age related changes in absorption and metabolism. As such, older people can be more susceptible to adverse drug reactions and therefore should be monitored closely. 

Therapeutic program activities and resources

The latest NPS therapeutic program Opioid use in chronic pain: use a planned approach
explores ways of optimising the benefits of opioids in chronic pain while minimising the harms associated with inappropriate use.

As part of this program, health professionals are encouraged to:  

• Perform a thorough history and physical examination to determine if investigations are necessary
• Prescribe an opioid as part of an agreed pain management plan
• Initiate an opioid only as a short term therapeutic trial
• Continue an opioid in those who demonstrate benefit from a trial and reassess regularly the need for ongoing therapy
• Discuss options for managing breakthrough pain

Read more in:

Participate in:

• Drug Use Evaluation (DUE) tool: Opioid therapy for chronic non-cancer pain
• Case study(64): Opioid therapy in chronic pain
• Interactive workshop for residential aged care nurses

References

1. Won AB, Lapane KL, Vallow S, et al. Persistent nonmalignant pain and analgesic prescribing patterns in elderly nursing home residents. J Am Geriatr Soc 2004;52:867-74.