The Assessment of Pain in Older People
Scope of the guidance
This item sets out the key components of the
assessment of pain in older people, along with pain assessment
scales that can also be used for patients with cognitive or
communication impairment. The guidance is equally applicable to
primary care (including continuing care homes) as hospital
settings.
Source
Royal College of Physicians, British Geriatrics Society and
British Pain Society. The Assessment of Pain in Older People:
national guidelines. Concise guidance to good
practice series, No 8. London: RCP; 2007.
www.rcplondon.ac.uk/pubs/contents/ff4dbcd6-ffb7-41ad-b2b8-61315fd75c6f.pdf
Key Points
1. Background
- Pain is under-recognised and under-treated in older
people.
- Studies have shown that about half of people aged over 65 years
old are in pain or suffer discomfort. There
is a higher prevalence of pain amongst older age groups, and up to
83% of patients in care homes report at least one current pain
problem.
- Pain can limit someone’s functional ability and impair their
quality of life.
- Some patients may not be able to inform their carers about
their pain e.g. those with dementia, some forms of stroke or
Parkinson’s disease, or when there are language or cultural
barriers. In these patients, making an assessment of the
severity of the pain is particularly challenging, and non-verbal
clues are important
adjuncts.
2. Key components of a pain assessment
- Be alert to the possibility of pain in older
people - they are often reluctant to acknowledge or report their
pain.
- Observe the patient for signs of pain.
This is especially important when assessing people with cognitive /
communication impairment.
- Describe the pain in term of its:
sensation:
o nature
of the pain (e.g. sharp, dull, burning etc.)
o pain
location and radiation – for patients with communicative
difficulties, you could ask the patient to point to the area on
their body which hurts, or use a ‘pain map’ (see RCP national
guideline 8 Appendix 3, in Further Reading)
o
severity, using a standardised pain assessment scale
affect:
o their
emotional response to pain (e.g. fear, anxiety, depression)
impact – how the pain is affecting:
o
functional activities (e.g. activities of daily living)
o
participation (e.g. work, social activities, relationships)
- Cause of pain – examine the patient and carry
out the appropriate investigations to identify any treatable cause
of pain.
3. Standardised pain assessment scales
- Examples of pain assessment scales (see RCP national guideline
8 Appendix 4 for reproductions of the scoring sheets, in
Further Reading):
- Self-reported numeric (0-10 pain rating) – suitable for people
with no cognitive / communicative impairment or a mild /
moderate impairment
- ‘Pain thermometer’ or the Coloured Visual Analogue Scale for
patients with moderate to severe cognitive / communicative
impairment
- Abbey Pain Scale, which scores non-verbal clues to pain for
patients with a severe cognitive / communicative impairment.
4. Assessment in people with severely impaired
cognition / communication
- An observational assessment of pain behaviour
is usually required.
- Non-verbal responses to pain differ from
person to person, so include carers and family members in the
assessment, who are able to better interpret the meaning of the
patient’s behaviour.
- The features in Table 1 below are recognised
as being associated with pain:
Table 1- Non verbal feature that may indicate pain
Type
|
Description
|
| Autonomic changes |
Pallor, sweating, tachypnoea, altered breathing pattern,
tachycardia, hypertension |
| Facial expressions |
Grimacing, wincing, frowning, rapid blinking, brow
raising or lowering, cheek raising, eyelid tightening, nose
wrinkling, lip corner pulling, chin raising, lip
puckering |
| Body
movements |
Altered gait, pacing, rocking, hand wringing, repetitive
movements, increased tone, guarding,* bracing** |
|
Verbalisations/vocalisations
|
Sighing, grunting, groaning, moaning, screaming, calling
out, aggressive/offensive speech |
| Interpersonal interactions |
Aggression, withdrawal, resisting |
| Changes in activity patterns |
Wandering, altered sleep, altered rest
patterns |
| Mental status changes |
Confusion, crying, distress, irritability |
guarding* = ‘abnormal stiff, rigid, or
interrupted movement while changing position’.
bracing** = a stationary position in
which a fully extended limb maintains and supports an abnormal
weight distribution for at least three seconds.
5. Re-evaluation
- Once you have chosen a suitable pain
assessment scale and started treatment for the pain, use the same
scale at future consultations to see whether your treatment is
working.
6. Treating pain in the elderly
- Pain should usually be treated as per the World
Health Organisation (WHO) pain ladder (see Further Reading). You make a clinical
judgement (based on a patient’s pain score and risk of therapy with
age) as to what level of the ladder to start at, and move the
patient up the ladder until the patient is pain-free:
EGP 1. May 2008