Chronic pain is a major issue in our elderly population and is frequently under managed in Long Term Care facilities and thereby decreasing the resident’s Quality of Life (QOL). When chronic pain is not managed properly, other medical problems can worsen and the risks of immobility, falling, dehydration and malnutrition increase.
Health care providers must have resources and knowledge to assess and treat pain and therefore meet residents’ needs as every resident has the right to be pain-free.
Research has identified the presence of chronic pain to be as high as 50% to 80 % in elderly people, with the majority experiencing pain on a daily basis. It is twice as common in women and the problem increases with age. Dementia, sensory impairment, and stoicism are frequently the consequences of poor pain management. Anxiety, insomnia, decreased functional ability and activity as well as social withdrawal and increased behavioral problems may also be signs of chronic pain.
Nurses must have a good understanding of pain and be able to identify those signs especially when the resident is unable to communicate. Having completed a good pain assessment, an individualized plan of care must be developed, ensuring more optimal pain management.
Pain is an unpleasant emotional and sensory experience and is highly individualized.It can be localized, such as a backache, or after an injury or surgery or it may be widespread. Conditions that can cause widespread pain in the body are arthritis and fibromyalgia.
Acute Pain may occur after injury or surgery and as a result of illness and should be resolved after treatment, within a short period of time. However, symptoms of pain may remain active in the nervous system for years and become chronic. Any unresolved pain may lead to Chronic Pain. This pain may wax and wane or be constant and can take a severe physical and emotional toll on the resident.
The emotional toll can then worsen the pain. Anxiety, depression, stress, anger and fatigue may decrease the body’s production of natural painkillers called Endorphins and may increase the substances that amplify sensations of pain known as Prostaglandins. This can cause a vicious cycle of pain. The body’s most basic defenses can become compromised and there is considerable evidence that the immune system can be suppressed by unrelenting pain.
There are many different types of pain; sharp or dull, constant or intermittent. Nociceptive pain occurs when specific receptors are stimulated. The receptors are somatic and visceral. The receptors sense chemicals released from damaged cells, vibration, stretching or temperature. Somatic pain is felt in the skin, muscles, bones or joints.It is usually sharp and localized. Chronic somatic pain includes arthritis, fibromyalgia, and tension headaches.
Visceral pain is felt in the organs of major body cavities. The receptors sense inflammation, Ischemia and stretching within the organ. It presents as deep aching pain and occurs with irritable bowel syndrome (IBS), interstitial cystitis and vulvodynia, which can occur in women after menopause.
Neuropathic pain is caused by the nerves themselves. There are two types, sympathetic and neuropathic. Sympathetic pain is caused by the sympathetic nervous system and occurs after injury to an extremity. It can be severe and intense and renders the person incapable of moving the injured extremity. Neuropathic pain can cause tingling, aching or numbness.It's the type of pain that occurs with Shingles, Sciatica, Peripheral (diabetic) Neuropathy and Multiple Sclerosis .
Psychogenic pain is associated with mental health issues. There is no physical cause of this pain identified, but none the less it feels very real to the affected patient. Traditional methods of treatment are ineffective but treating the underlying mental health problems may be beneficial. Some conditions which may cause psychogenic pain are Anxiety Disorder, Somatoform Disorder and Depressive Disorder.
Idiopathic pain cannot be traced to any known cause however it is very real. People susceptible to this type of pain usually have been diagnosed with some painful condition such as Temporomandibular joint disorder or Fibromyalgia. These patients are often diagnosed with Chronic Idiopathic Pain Syndrome. (CIPS).
All residents admitted to the Long Term Care facility should have an initial pain assessment. This should include accurate historical and clinical information and a direct appropriate examination observing the resident’s facial expression for grimacing or frowning and for lack of mobility and guarding. Resident’s behavioral symptoms, such as agitation, resisting care or restlessness may all be indicative of pain. Direct verbal communication with the resident is very important. “Do you have pain?” This question should be asked frequently and reassurance that help is available should be given readily to the patient.
The most important factor is the resident’s own perception of pain. Again, this can be determined through verbalization or by the use of scales. The numerical scale with severity listed from zero to ten, or the face scale showing faces smiling to frowning or grimacing. It is also relevant to learn of any previous beneficial pain management strategies. The goal for pain relief and/or tolerance must be individualized, realistic and a timeframe set for reevaluation. Complications and side effects of treatments, and medications must be observed, reported and documented immediately.
The treatment of chronic pain is varied and requires a multidisciplinary approach. Even if it cannot be cured, the impact can be greatly reduced.
No single treatment is appropriate for everyone and there can be much trial and error before a beneficial course of treatment is reached. The goal for those suffering from chronic pain should be a reduced focus on pain and improvement in QOL.
It is frequently recommended a non-pharmacological approach be first attempted. Simple remedies and cognitive and behavioral therapies are often suggested. These may be used in combination with pain medications. Ice usually used for acute pain reduces swelling and due to its numbing effect, can provide relief from chronic pain. A combination of rest, ice, compression and elevation (RICE) may provide relief based on the location of the pain.
Heat increases the blood flow and provides relaxation to muscles and joints. Heat is very helpful in treating arthritis. Hot packs can relax tight muscles caused by muscle spasm and tension. Massage may be superficial or deep and can relax muscles. The type of massage depends on the resident’s tolerance.
TENS is transcutaneous electrical stimulation. This is performed by placing electrodes on the skin over the painful area, these create a small
current that feels like pins and needles.
Relaxation techniques like guided imaginary can be done by listening to an audio recording. Relaxation provides distraction and helps muscles to relax, thereby reducing pain.
Complementary approaches to chronic pain include chiropractic care, hypnosis, specialized diets, energy medicine, yoga, herbal remedies, and acupuncture. Aromatherapy and homeopathy are sometimes beneficial.Their effectiveness has not been verified by scientific research but are becoming more acceptable. Their goal is to relieve the pain adequately to prevent being the focus of everyday life.
Counseling may also be beneficial. Stress often increases muscle tension. Providing pain psychology education helps lessen worry and provide a more positive outlook. The resident may feel more in control with the appropriate information.
Breathing exercises and Physical therapy (PT) treatments are other approaches to pain relief. Distraction can be a powerful mind over matter technique for pain relief.The brain can only focus on so much at one time. The pain does not go away but the resident’s awareness of it can be decreased. Involving the patient in activities, such as music therapy, reminiscing or storytelling may also provide a similar outcome. PT may also recommend a variety of balancing and strengthening exercises to improve the patient’s tolerance and endurance. Exercise increase the ability to ambulate safely, increase circulation and prevent falls.
Ultrasound is a treatment modality that provides high or low-frequency sound waves. As well as providing relaxation, the warming effect of the sound waves cause dilation of the blood vessels (vasodilation) which increases circulation to the area that assists in healing.
Iontophoresis is a form of electrical stimulation provided by PT that can push medication through the skin to the affected muscles, ligaments, and/or tendons. This is usually used for anti-inflammatory purposes. However, a variety of medication can be used for different conditions.
In addition to the above-stated remedies, analgesic pain relievers are usually needed and frequently advance to stronger pain medication for relief of chronic pain. Acetaminophen can relieve mild pain. NSAIDS(non-steroidal anti-inflammatory drugs) such as ibuprofen and aspirin can be very effective in reducing swelling that often contributes to pain. All have side effects involving the liver, stomach, kidneys, heart, and blood pressure.
Stronger pain killers such as, codeine and tramadol, have more side effects, such as drowsiness and constipation and can also be addictive. Regular use can cause chronic daily headaches. Opioids are narcotics that include codeine and morphine. They cause sedation that can be life threatening when used inappropriately and are also addictive.
Corticosteroids are a class of steroids such as prednisone and cortisone that reduce swelling and therefore decrease pain. Antidepressants: Tricyclic antidepressants increase the body’s production of seratonin, which reduce the number of pain signals reaching the brain.Examples are Amitriptyline and Imipramine.
Anticonvulsants are used to treat pain caused by neurological disorders These drugs inhibit certain nerve transmissions and are beneficial in treating neuropathy and migraines. Gabapentin is frequently prescribed to curtail neuropathic pain.
Topical analgesics are creams and patches which disrupt the pain cycles and gives the sensory nerves another distraction such as cold and tingling.
Capsaicin (made from chili peppers) is available in cream and patches and is frequently prescribed for local application.
It is very important to monitor the benefits and sideeffects of all prescribed medications. Reporting and documenting any changes is mandatory. Pain is now considered the fourth vital sign and the resident has a right to have it monitored and treated appropriately.
(I must give credit to Coursera for much of the information I have provided in this blog. Last year I took courses on Preventing Chronic Pain and on Vital Signs which were incredibly informative.)
