Pain is all too frequent for the elderly – however it should be noted that pain is not a natural part of ageing.

If pain is not treated adequately it can lead to other clinical consequences – such as functional impairment, a higher risk of falls, mood changes such as depression and anxiety, disturbed sleep, lower levels of socialisation and behaviour changes such as agitation and aggression.

When managing pain, it is important to understand the cause of it and to treat not just the pain but the underlying condition too.

Pain and the Three D’s – Dementia, Delirium and Depression

Dementia

Dementia is not a single specific disease, but is an umbrella term describing a syndrome associated with more than 100 different diseases that are characterised by the impairment of brain functions, including language, memory, perception, personality and cognitive skills.

Dementia is very common amongst residents of aged care facilities affecting approximately 30% of residents in low care and 60% of residents in high care.

People living with dementia retain the ability to perceive pain – however what is compromised is their ability to communicate that they are actually experiencing pain.

Pain is highly prevalent in people with dementia with epidemiologic studies showing that up to 80% of residents in aged care facilities who have dementia also experience chronic pain.

Pain is often unrecognised and undertreated in residents with cognitive impairment. For instance, behaviour changes in aged care residents with dementia should not be automatically assumed it’s due to their dementia diagnosis. Instead, it should receive a thorough investigations which includes a pain assessment.

Delirium

Delirium is common in the elderly. Delirium at the end of life – which sometimes is referred to as terminal delirium – is also very common affecting up to 88% of people with advanced dementia during their final week of life.

Delirium is characterised by rapid onset of impaired attention that fluctuates together with impaired cognition and/or altered consciousness, perceptual disturbances and behaviour.

The cause of delirium is complex and multifactorial and relates to the interaction of predisposing factors that increase the risk of delirium and factors that trigger or cause the acute episode of delirium.

Predisposing factors to increased pain include;

  • Dementia
  • Severe illness
  • Frailty
  • Polypharmacy – when a person is taking more than 3 medications
  • Visual or hearing impairment
  • Excessive alcohol consumption
  • Dehydration
  • Old age

Factors that cause or trigger pain:

  • Uncontrolled pain
  • Infections – in particular chest and urinary
  • Constipation
  • Use of physical restraints
  • Medication use/withdrawal
  • Metabolic abnormalities such as electrolyte disturbances and hypoxia.

It should be noted that when considering the cause or triggers always look for more than one factor.

The management of delirium is largely nurse-based care. The initial management step is to treat any medical causes of agitation such as pain, constipation, hypoxia, urinary retention or infection if present.

At the same time, use non‐pharmacological measures to manage symptoms. These include adjusting the resident’s environment and adding in any clinical measure where appropriate.

If these strategies are not helpful, the resident’s doctor should be called.

Depression

Depressive disorders are common and disabling, particularly amongst residents of aged care facilities. Depression amongst residents is associated with recent bereavement, physical illness and the quality of the nursing home environment.

One survey estimated that 51% of high care residents and 30% of low care residents without dementia have major depression.

Depression is also common amongst patients receiving palliative care and is often not identified and so residents don’t receive appropriate treatment.

Many older people with chronic pain also experience symptoms of depression. There is some evidence to suggest that the stress due to chronic pain leads to the development of depression.

Conversely, the chemical changes that occur because of depression may make the individual more sensitive to uncomfortable stimuli and more vulnerable to pain.

In addition, emotionally negative mood states may also reduce tolerance to stimuli that cause pain.

One study found that there was a relationship between pain and depression in older adults – pain is a predictor of becoming depressed two years later and depression was a predictor of developing pain two years later.

People with a limited mobility and poor eyesight were at risk of developing depression and pain.

Pain and depression have an additive effect on adverse health outcomes and treatment responsiveness of one another. When present both conditions need to be managed to optimise care and improve outcomes.

When treating pain in an older person, it is important to differentiate depression from dementia and delirium, noting that these conditions can co‐exist.

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