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Tuesday, May 17, 2022

New pain management toolkit to help comprehend and address complex nature of pain in aged care

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Sadly, pain is a symptom faced by almost all older persons living in residential aged care, with Pain Australia suggesting up to 80 per cent experience the condition chronically.

But despite it’s omnipresence, there is much work to be done to ensure systems of care facilitate best-practice approaches to its management.

In a workshop for aged care providers and staff last week, researchers from the National Ageing Research Institute (NARI) provided insights on how pain management can best be optimised, as well as sharing news of their new toolkit, which will complement their Pain Management Guide released in late 2021.

Dr Christa Dang, a NARI researcher focusing on quality of care for older persons, says that the new, free resource was developed in partnership with the Australian Pain Society and aims to include all members of the residential aged care workforce.

Pain is more than activity in muscle receptors … it really comes back to that experience of pain being in the brain.

NARI geriatric science researcher, Dr Steven Savvas

“The key point here is that pain is everyone’s business.

“Everyone working in aged care has a role to play, so it contains resources that are tailored to everyone’s role.”

Dr Steven Savvas, NARI geriatric science researcher with industry experience in the aged care sector, says that a paradigm shift is needed to fully comprehend and address the complex nature of pain in aged care.

“Pain is more than activity in muscle receptors … it really comes back to that experience of pain being in the brain,” he says.

Dr Steven Savvas, geriatric science researcher at NARI, says that the latest advice for managing pain in residential aged care emphasises the role of addressing psychological and social factors affecting a patient, not merely injury or disease.

In recent times, there has been criticism of the dominant model that underpins how pain is understood and treated.

The biomedical model, which largely sees pain as a purely physiological experience influenced only by local damage to tissue and organ systems, harks back to the philosophical works of the 16th century French philosopher, Rene Descartes.

Proposing that the mind and body are two distinct, separate entities, the Cartesian theory of pain popularised the idea that pain can be addressed simply by targeting the ailment in question, with little attention to how mental health or social factors could contribute to, or exacerbate, the problem.

“In aged care this is the model that they are most used to, and have lived with most of their lives, but the biopsychosocial model sees this as an incomplete picture,” Savvas says.

The biopsychosocial model was developed as an alternative to the Cartesian model by American psychiatrist Dr George Engel in 1977.

Pain is always a personal experience. I think this really important for resident engagement – in home or in the community – that their experience of pain should be respected… not minimised or dismissed.

Dr Steven Savvas

Engel posited that, in contrast to the mind-body dualism that had dominated approaches to pain management for hundreds of years, psychological and social factors were, in fact, major contributors to how severely a person experiences pain.

According to Savvas, the biopsychosocial model is now regarded as the most accurate theory, underpinning the approach taken by his team in developing the new pain toolkit.

“Pain is always a personal experience,” he notes.

“I think this is really important for resident engagement — in home or in the community ­— that their experience of pain should be respected… not minimised or dismissed.”

According to Pain Australia, 92 per cent of aged care residents are taking at least one pain medication, but the biopsychosocial model emphasises that incorporating other approaches may reap better outcomes.  

The NARI toolkit materials note that best practice pain-management regimens are those that include a multi-dimensional, long-term plan comprising pharmacological treatments; movement and physical activity; psychological and educational supports; and complementary and integrative medicines (for example: vitamin supplements, naturopathy, yoga and acupuncture).

The biopsychosocial model is now considered the most accurate representation of the multi-factorial nature of pain, with biological, psychological and sociological factors all contributing to a person’s unique experience of the condition.

With more than half the residential aged care population living with dementia, Savvas emphasises that aged care workers must be attuned to the subtle signs of pain presentation.

“Inability to communicate does not negate the presence of pain, and this is important for residential aged care and those living with dementia.

“There are non-verbal cues … facial expressions are probably one of the most reliable pain indicators.”

Such expressions include narrowed eyes, furrowed brows and an open mouth.

We need to move beyond medication and know the individual resident: their psychosocial, spiritual and physical experience in response to pain.

Geriatrician at Austin Health, Dr Marie Vaughan

Verbalisations — including shouting, groans and swearing — are also common signs, as are changes in routines relating to eating and sleeping.

Dr Marie Vaughan, a geriatrician at Austin Health, reiterates the importance of moving towards the biopsychosocial model.

“We need to move beyond medication and know the individual resident: their psychosocial, spiritual and physical experience in response to pain,” Vaughan says.

She emphasises the hypocratic oath, noting that merely relying on medication to address pain has a history of causing unintended, negative consequences.

“Every day in Australia there are over 150 hospitalisations and three people die after using an opioid.

“One in five Australians are prescribed antipsychotics in aged care, and they are 2.5 times more likely to do within 90 days, from falls or other incidences.”

When a resident was prescribed an antidepressant, they didn’t want to take it because they thought the doctor was implying that the pain was in their head. So we need to be clear in communication with patients why we are using these adjuvants… to progress patients from passivity to empowerment.

Dr Marie Vaughan

However, she also notes that a lack of adequate consultation with older patients often causes them to reject appropriately-prescribed medications, due to a lack of understanding of the biopsychosocial approach.  

“When a resident was prescribed an antidepressant, they didn’t want to take it because they thought the doctor was implying that the pain was in their head.

“So we need to be clear in communication with patients why we are using these adjuvants… to progress patients from passivity to empowerment.”

Core takeaways for aged care nurses and personal care workers

According to the NARI pain management toolkit, person-centred care is essential to effective treatment of residents’ pain.

What this means is that the resident is considered as an individual, with all care and treatments tailored to their specific needs and preferences.

Source: NARI pain management guide toolkit, 2nd edition.

Furthermore, it is essential that pain management is carried out by a multidisciplinary team, with communication occurring through all levels of care, for example:

  1. A senior nurse, doctor or allied health clinician, can lead the team.
  2. Organisational support is needed from senior management.
  3. Diversity: At least three different disciplines should attend each meeting.
  4. Routine: Meet regularly (eg. fortnightly). Set a time and location in advance.
  5. Sharing knowledge: Findings from the team need to be communicated to other staff, residents and families.

No matter how skilled, one person alone cannot provide every aspect of care included in a person-centred pain management plan.

The Pain Management Toolkit, 2nd edition, provides more than 70 pages of valuable insights into how practitioners and support staff can identify pain in aged care residents, as well as organisational management structures to create a best-practice, pain-vigilant culture in your residential aged care facility.

To access the free toolkit, follow this link.

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