Pain isn’t an inevitable part of aging but it is very common. Research suggests that pain is often poorly reported within the elderly population within long term care, even though the incidence may be as high as 60%. This number is significantly higher in those with cognitive impairement, with an estimated rate as high as 80% in those with dementia.
Accurately identifying and managing pain can be difficult when communication is impaired. Health professionals responsible for monitoring and managing pain should have the necessary expertise to effectively identify it’s presence in the absence of verbal expression. In addition, they must know effective strategies to manage it.
The term Chronic Pain Management has become somewhat tarnished within the Aged Care Industry. This is due to its progression towards ‘tick box’ revenue raising, rather than it being truly focused on individualising and tailoring pain management strategies to improve quality of life for residents in long term care.
There is a very real need for appropriately focused pain management for those living in aged care who don’t have easy access to chronic pain specialists and pain management programs. So what are the key elements of an effective pain management program?
Here is what the evidence says:
- Multi factor approach – An effective program should combine pain prevention, pain relief, treatment and rehabilitation.
- Regularly reviewed analgesia – A stepped approach from simple painkillers like paracetamol to opiates is most effective, with evidence showing that regular prescribed painkillers are more effective than those given as required, especially in individuals with dementia whom may lack the understanding and communication skills to ask for pain relief when it is required. Regular reviewing of the effectiveness of prescribed medications and titration of dosages is strongly recommended.
- Non-pharmacological and self-management strategies – The American Geriatrics Society has described non-pharmacological treatments as an “integral part of care plans for most chronic pain patients.” Techniques including regular exercise and activity, education, stretching, heat or ice therapy can make a real difference, as can therapeutic massage and soothing touch.
- Psychological Support – Pain is complex, with the senses and emotions interacting. Some individuals with minimal disease may suffer excruciating pain, whereas others with severe disease may not complain of any discomfort. Successful strategies may include relaxation, music therapy, distraction techniques and cognitive behavioural therapy. Depression and anxiety should be identified and treated, with quality time with family and friends being a large component of management.
- Rehabilitation and re-enablement – Restorative therapy can prevent pain from secondary injuries and help those managing chronic pain live a more independent and functional life. Rehabilitation can also decrease pain perception, treat functional deficits, and help promote physical and psychological adaptation to disabilities. Postural care like checking that chairs and beds have sufficient body and neck support can also have a dramatic effect.
- Interventional Treatments – Interventional pain treatments such as nerve blocks may alleviate the need for stronger medication, reducing both sedation and side effects.
So how do our current ACFI funded program and industry practices stack up?
The majority of physio providers within the industry would agree that the current way in which ACFI pain management programs are carried out is not inline with evidence based best practice, however providers hands are somewhat tied by the existing ACFI model. The guidelines dictate that only the provision of massage or electrotherapy is part of the funded therapy.
Currently there is no provisional funding for psychological support, education or essential rehabilitation approaches such as exercise, stretching or other self management techniques. Under the current ACFI funding arrangement aged care providers are rewarded for disability rather than the proactive promotion of functional re-enablement.
When it comes to medication management of pain somehow in aged care we seem to struggle to get it right, with many residents either being over medicated or grossly under medicated – few are optimimally medicated. Interventional treatment options are rarely considered in the elderly population especially those in residential care, despite there being a proportion of residents that may well be suitable and would derive great benefit from moderately invastive procedures. The lack of easy referral processes and access to such specialist services is poor and while I would like to think that age alone isn’t the deciding factor, a more thorough assessment and screening process by consulting GP’s could assist residents in receiving these therapy options.
So on the whole it seems like we have a way to go when it comes to pain management within residential care and whilst the current ACFI funded model isn’t perfect, it at least offers access to qualified therapists that can provide much needed alternatives to what would otherwise be a purely medication based strategy for chronic pain management for those in residential care. Equally important as the funding of programs is having an experienced provider, that not only understands compliance requirements from running an ACFI based pain program but also delivers high quality assessments plus value added opportunities to support resident choice, education, active engagement, self management and specialised pain management for those living with dementia.