Ageing in pain

“The grief my 91-year-old Dad and I have gone through while watching her [Mum] approach death has been magnified by seeing her in pain. We’ve felt pretty ignored. My mum has experienced preventable pain when she can’t advocate for herself. We felt the nurses waited for us and were never proactive themselves to manage her pain. The culture is that pain is normal.”

— Carer of person in residential aged care

After a steadily increasing stream of consumer reports and countless inquiries, aged care is finally getting some much-needed attention and focus through a Royal Commission. The commission’s first report outlines a whole raft of issues and measures, but importantly, it finally highlights a key aspect of adequate care for our older citizens that has until now remained absent from the national conversation: appropriate pain management.

It’s intuitive that pain is a part of ageing, and one would imagine that the issue of effective pain management in aged care is one that has been dealt with comprehensively. Surely, we know how to best respond to the pain experienced by some of the most frail and vulnerable people in our communities?

Sadly, this is far from the case. Untreated, or poorly managed and mistreated pain, is a common thread in the countless stories of neglect and abuse that we have heard across the sector.

Deloitte Access Economics Report on the Cost of Pain found that in 2018, 1.03 million older Australians (65 years and over) were living with chronic pain, with rates almost twice as high as the working age population.

Chronic conditions become increasingly prevalent as people age, with arthritis, bone and joint disorders, cancer and other long-term illnesses becoming commonplace. All of these conditions are associated with acute and/or chronic pain. It is unsurprising therefore that in residential aged-care facilities in particular, the number of people living with chronic pain is estimated to be as high as 80%.^[i]

Untreated or poorly treated chronic pain can perpetuate the pain condition and severely reduce function and quality of life. It impacts personal relationships and can have profound emotional and psychological ramifications.

Pain is also being recognised as a significant factor in behavioural and psychological symptoms of dementia (BPSD). When you consider that people living with dementia account for nearly 50% of those living in residential aged-care facilities, it is easy to see how untreated chronic pain can result in BPSD, which can further lead to inappropriate use of chemical and physical restraints and other forms of elder abuse.^[ii]

And how does the sector respond to this large prevalence of pain? Not very well at all.

There are a lack of protocols for pain assessment and reporting within facilities, and industry guidelines are inadequate to ensure quality care. On the occasions when pain is assessed, there is insufficient provision of allied health support through the Aged Care Funding Instrument to allow for effective multidisciplinary pain management. This leads to an over-reliance on medication to manage pain across aged care.

Two out of three Australians aged over 75 take five or more medicines a day, while around half of all older adults are taking a medicine that is either harmful or unnecessary.^[iii]

This form of long-term use can be dangerous, particularly when it comes to commonly prescribed pain management medication like opioids. As the commission notes in its report, there is widespread overprescribing (often without clear consent) of drugs that sedate residents, rendering them drowsy and unresponsive to visiting family and removing their ability to interact with people.

Painaustralia’s submission to the Royal Commission has made several recommendations that can support best-practice pain management. The evidence now shows that given chronic pain’s individual effects, interdisciplinary assessment and treatment may produce the best results for people with the most severe and persistent pain problems. This can include non-opioid medications, special physical exercises, psychological approaches such as cognitive behavioural therapy and techniques for self-management to mitigate pain.

This holistic, patient-centred, multi-modal approach to treatment is also a key recommendation of Painaustralia’s National Pain Strategy,^[iv] and a critical component of the National Strategic Action Plan on Pain Management. If implemented, the plan will be the world’s first fully funded government response to comprehensively address the burden of pain.

Prioritising pain management is a vital element of improving aged care. As the Late Commissioner Richard Tracey noted in his opening remarks, we have a generational opportunity to create an aged-care environment that affords dignity to the older and frail — some of the most vulnerable people in our society. Appropriate pain management in aged care will go a long way in providing that dignity.

References

[i] Ferrell BA, Ferrell BR, Osterweil D. Pain in the nursing home. J Am Geriatr Soc. 1990;38:409-414.

[ii] Alzheimer’s Australia, Consumer Engagement in the Aged Care Reform Processes, 2012.

[iii] Quality Use of Medicines to Optimise Ageing in Older Australians: Recommendations for a National Strategic Action Plan to Reduce Inappropriate Polypharmacy (2018). NHMRC Cognitive Decline Partnership Centre, University of Sydney, in Collaboration with the Australian Deprescribing Network and NPS MedicineWise. Sydney, NSW, Australia. ISBN: 978-0-6482658-6-3.

[iv] National Pain Strategy 2010.

Image credit: ©stock.adobe.com/au/mrmohock