End of Life Care in Frailty: Pain

While 80% of people will experience pain at some point as they age, and for more than 60% of people it will be moderate or severe. Pain should not be seen as a ‘normal’ part of ageing to simply ‘put up with’ or ignore. Managing pain in older people living with frailty brings challenges.

Older people experience and perceive pain differently for both physiological and psychological reasons.¹ Pain thresholds are also lowered by mood disturbance, cognitive impairment and how an older person approaches their death, its meaning, their beliefs and the grief and losses of those who have gone before. Social isolation can also impact mood and cognitive stimulation. Psychologically, patients are very vulnerable to underplaying pain and its severity through misconception, stoicism or cultural biases, fear of addiction, comorbidities or the prospect of ‘yet more drugs to take’.

Medication burden increases along with ageing, and drug interactions are inevitable. For this age group, as with other drugs, patients may be more sensitive to the side-effects of opioids, NSAIDS and co-analgesics for neuropathic pain.

The inherent physiological changes of old age, and/or impaired renal and hepatic function alter pharmacokinetics and cumulative anticholinergic burden. This increases the risk of falls and is a particular challenge.

The underlying aetiology of pain is likely to be multi-factorial, due to the presence of multiple co-morbidities and the impact of decreasing mobility/function with increasing frailty.

History and assessment

A comprehensive pain history and assessment is mandatory. Pain control can have a significant impact on morbidity and may itself lead to deterioration in physical and mental health.

Functional assessment, particularly changes in activities of daily living, is key. Conventional questioning may be fruitless and assessment should incorporate a careful look at other behaviours such as agitation, repetitive movements and vocalisation, areas of muscle tension, protective bracing and sleep disturbance.

Because pain is subjective, accurate and trackable self-reporting tools may be very helpful. They range from simple images on a visual analogue scale, to comprehensive tools. Several specifically accommodate cognitive failure.¹

Analgesics are both safe and effective, provided drug interactions, renal and hepatic insufficiency are taken into account in prescribing regimes.

Key points to consider

• ‘Start low and go slow’ is a good rule of thumb, but patients can also end up poorly managed by unnecessary conservatism and inadequate monitoring.

• Initial, frequent review to assess and titrate medications is the safest most effective approach, but a challenge in the community when continuity of care is poor.
• Modified release preparations or transdermal patches help compliance.
• Good communication between practitioners, and support for paid and informal carers is essential. Proactive monitoring of repeat prescriptions improves outcomes.
• Non-pharmacological management is important for chronic pain and especially important in older people given the risks associated with polypharmacy and susceptibility to drug side effects and interactions.²
• Being active, mobile and re-building confidence after a setback requires multi-professional input.

Knowing when someone is in the last days of life can be uncertain. Assumptions that every dying person should be on parenteral opioid regimes or have subcutaneous infusion pumps are very risky and wrong.

• Assessment must be individualised, regular and competent. 
• Whether and how to use parenteral regimes and continuous subcutaneous infusions needs expertise - anticipatory schedules are only safe when supported by consistent training and ready access to competent support.
• Local guidance and protocols are important starting points, especially in opioid naïve patients, which should be readily accessible.
• Many patients can be settled and managed with ‘prn’ regimes in the last days, but there must always be access to expert advice within hours and proper assessment the following day. The use of telemedicine to support good education and training for carers and clinicians at the bedside with emergency advice is becoming more widespread and effective.
• Early access and joint working between local primary, palliative and elderly care teams and services must be in place and properly funded. They are effective, efficient and will reduce bad deaths, individuals’ needless suffering and unnecessary hospital admissions.  

References

1. Schofield P. The Assessment of Pain in Older People: UK National Guidelines, Age and Ageing 47(suppl_1):2018;i1–i22, https://doi.org/10.1093/ageing/afx1922.
2. Hulla R, Vanzzini N, Salas E, Bevers K, et al. Pain management in the elderly. Practical Pain Management 2019;17:1. Available at: www.practicalpainmanagement.com/treatments/pain-management-elderly