Worldwide, the population over the age of 60 years will double by 2050 [11]. As people live longer, increasing numbers will live with and die from multi-morbidity, frailty, and chronic health conditions such as renal or cardiac failure. In addition, older people may experience significant psychosocial stressors such as bereavement and loss of independence.
What is palliative care?
Palliative care aims to maintain or improve quality of life and alleviate suffering, through early identification, detailed assessment, and treatment of symptoms [4]. In older people this:
- Combines geriatric medicine and palliative care focusing on comprehensive assessment to integrate social, spiritual, and environmental factors.
- Requires an understanding of multi-morbidity, safe prescribing, and a multidisciplinary approach.
- Prioritizes good communication, considering autonomy, involvement in decision‐making, and the existence of ethical dilemmas.
- Works with older people and their families across settings (home, long‐term care, hospices, and hospital) and during transitions [7].
Pain assessment
How older people experience and report pain is mediated by a range of social and psychological factors, including stoicism, which may lead to under-reporting of pain [2]. The ‘gold standard’ remains self-report. [3]. Questions about pain include three key dimensions: 1) sensory, 2) affective and 3) impact [8].
Dementia and cognitive impairment
Reporting pain can be challenging for older people with cognitive impairment secondary to dementia and other neurodegenerative diseases, strokes, cultural, or language factors. Many people with dementia can report pain reliably [12], but it is essential to obtain collateral history. Direct observation or validated observational pain scales recognize how pain or discomfort may lead to behavioral change [9]. The American Geriatrics Society Guidelines [3] include a range of indicators:
| Domain | Example | |
| 1 | Facial expressions | Frowning |
| 2 | Verbalizations and vocalizations | Moaning, grunting |
| 3 | Body movements | Guarding an area of the body, pacing |
| 4 | Changes in interpersonal interactions | Becoming withdrawn, agression |
| 5 | Changes in activity patterns or routines | Appetite, activities of daily living, sleep |
| 6 | Mental status changes | Delirium, tearfulness, crying |
Most observational pain tools contain items from these domains. Commonly used tools include the Abbey Pain Scale [1], Pain Assessment in Advanced Dementia (PAINAD) [10], and the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) [5].
Principles of management
Non-pharmacological management, such as exercise, assistive devices or relaxation [2], or topical preparations, including NSAIDS for localized musculoskeletal pain [2], may be effective as a first choice. Pharmacological treatment of pain in older people may be challenging. Polypharmacy is common and changes in how drugs are metabolized and excreted increase the risk of interactions and side effects. Recommendations have been made [2] (AGS 2009) to lessen the risk of adverse events:
- Prescribe using the WHO pain ladder (http://www.who.int/cancer/palliative/painladder/en/).
- Start low with one drug and increase the dose slowly to achieve response.
- Use the least invasive route of administration.
| Indication | Notes | |
| Paracetamol/ acetaminophen | Musculoskeletal pain and osteoarthritis | Effective and safe analgesic |
| Non-steroidal anti-inflammatory drugs i.e. naproxen, ibuprofen | Musculoskeletal pain and osteoarthritis where paracetamol not effective | Higher risk of adverse events. GI bleeding, cardiovascular side effects (increased risk of arterial hypertension, heart failure) and worsening of chronic kidney disease. |
| Codeine | Weak opioid for moderate pain | Sedation, hallucinations, delirium, nausea, vomiting, constipation, urinary retention, falls, fractures. Fentanyl or buprenorphine available as patches but cannot be used in opioid naïve patients |
| Morphine, oxycodone, fentanyl | Strong opioids for severe pain in cancer and non-cancer pain | |
| Amitriptyline | Neuropathic pain | Postural hypotension, cardiac arrhythmias, urinary retention, glaucoma and worsening cognitive functioning |
| Pregabalin, gabapentin | Neuropathic pain | Anxiolytic and sedative effect |
Conclusion
A palliative care approach ensures symptoms and goals of treatment are regularly reviewed. Discussing a “ceiling of care” with the person or their family to develop a treatment escalation plan supports good pain management by considering decisions such as discontinuing painful interventions. It may reduce the risks of people undergoing distressing transfers towards the end of life, particularly into hospitals [6]. In palliative care, we consider the concept of ‘total pain’ exploring psychological distress, which may influence the perception of pain and suffering.
REFERENCES
[1] Abbey J, Piller N, De BA, Esterman A, Parker D, Giles L, Lowcay B. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. IntJPalliatNurs 2004;10(1):6-13.
[2] Abdulla A, Bone M, Adams N, Elliott AM, Jones D, Knaggs R, Martin D, Sampson EL, Schofield P. Evidence-based clinical practice guidelines on management of pain in older people. Age Ageing 2013;42(2):151-153.
[3] American Geriatrics Society. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(6 Suppl):S205-224.
[4] Davies E, Higginson IJ. Better palliative care for older people, 2004.
[5] Fuchs-Lacelle S, Hadjistavropoulos T. Development and preliminary validation of the pain assessment checklist for seniors with limited ability to communicate (PACSLAC). Pain ManagNurs 2004;5(1):37-49.
[6] Obolensky L, Clark T, Matthew G, Mercer M. A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process. J Med Ethics 2010;36(9):518-520.
[7] Pautex S, Curiale V, Pfisterer M, Rexach L, Ribbe M, Van Den Noortgate N. A common definition of geriatric palliative medicine. J Am Geriatr Soc 2010;58(4):790-791.
[8] Royal College of Physicians, British Geriatrics Society, British Pain Society. The assessment of pain in older people: national guidelines. Concise guidance to good practice series, Vol. 8, 2007.
[9] Scherder E, Herr K, Pickering G, Gibson S, Benedetti F, Lautenbacher S. Pain in dementia. Pain 2009;145(3):276-278.
[10] Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. JAmMedDirAssoc 2003;4(1):9-15.
[11] World Health Organisation. Global Health Observatory (GHO) data; mortality and global health estimates, Vol. 2017, 2017.
[12] Zwakhalen SM, Hamers JP, Berger MP. The psychometric quality and clinical usefulness of three pain assessment tools for elderly people with dementia. Pain 2006;126(1-3):210-220.
AUTHORS
Elizabeth L Sampson, PhD
Marie Curie Palliative Care Research Department,
University College London
London, United Kingdom
Sophie Pautex, MD
Division of Palliative Medicine
University Hospital Geneva, Geneva University
Geneva, Switzerland