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class="card-full-title"> End of Life Care in Frailty: Pain </div> </h1> <span property="dc:title" content="End of Life Care in Frailty: Pain" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="resource-header-details"> <div class="card-resource-type-i"> <div class="card-resource-type"> Clinical guidelines </div> <div class="resource-type-i-icon">i</div> <div class="resource-type-info-arrow"></div> </div> <div class="resource-type-info"><div class="resource-type-info-text"></div></div> </div> <div class="node-header-details"> <div class="card-authors-wrapper"><div class="label">Authors:</div><div class="author-details">British Geriatrics Society</div></div> <div class="card-topics-wrapper"><div class="label">Topics:</div><a href="/taxonomy/term/13">End of life care</a>, <a href="/taxonomy/term/861">Pain</a></div> <div class="node-header-dates"> <div class="card-date-wrapper"><div class="label">Date Published:</div><div class="card-date"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T00:00:00+01:00">12 May 2020</span> </div> </div> <div class="card-date-updated"> <div class="label">Last updated: </div> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T11:31:00+01:00">12 May 2020</span> </div> </div> </div> <div class="card-resource-summary"> <div>The aim of this guidance series is to support clinicians and others to consider the needs of frail older people as they move towards the end of their lives and help them to provide high quality care.</div> <div> </div> <div>This chapter examines the management of pain in older people living with frailty at the end of life. Please <a href="/resources/resource-series/end-of-life-care-in-frailty"><strong>click here</strong></a> to view the other chapters in this series.</div> </div> </div> <div class="view view-sections view-id-sections view-display-id-main view-dom-id-5abaf43ee0a3ad4f6b8fe08c08efb4a0"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first views-row-last section-row palette-default "> <div class="section-inner"> <div class="card-body"> <p>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.</p> <p>Older people experience and perceive pain differently for both physiological and psychological <a name="_Ref18405826">reasons</a>.<sup>1</sup> Pain thresholds are also lowered by mood disturbance, cognitive impairment and how an older person approaches their death, its meaning, their <a href="/resources/end-of-life-care-in-frailty-spiritual-and-cultural-issues">beliefs</a> and the grief and losses of those who have gone before. Social isolation can also impact mood and cognitive stimulation. <a href="/resources/end-of-life-care-in-frailty-psychological-support">Psychologically</a>, 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<a href="/resources/end-of-life-care-in-frailty-medicines-management"> </a>to take’. </p> <p><a href="/resources/end-of-life-care-in-frailty-medicines-management">Medication burden </a>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. </p> <p>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.</p> <p>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.</p> <h2 class="sidebar-nav">History and assessment</h2> <p>A comprehensive <a href="/resources/end-of-life-care-in-frailty-pain">pain history</a> and assessment is mandatory. Pain control can have a significant impact on morbidity and may itself lead to deterioration in physical and <a href="/resources/end-of-life-care-in-frailty-psychological-support">mental </a>health. </p> <p>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. </p> <p>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.<sup>1</sup></p> <p>Analgesics are both safe and effective, provided <a href="/resources/end-of-life-care-in-frailty-medicines-management">drug interactions</a>, renal and hepatic insufficiency are taken into account in prescribing regimes. </p> <table> <tbody> <tr> <td> <p><strong>Clinical tip</strong><br /> These questions will help give a good assessment of pain.</p> <ul> <li>How long have you had the pain?</li> <li>Where do you feel it in your body? What helps? What worsens it?</li> <li>On a scale of 0 – 10 how bad is it at its worst?</li> </ul> </td> </tr> </tbody> </table> <h2 class="sidebar-nav">Key points to consider</h2> <ul> <li> <p class="sidebar-nav">‘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.</p> </li> <li>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.</li> <li>Modified release preparations or transdermal patches help compliance. </li> <li>Good communication between practitioners, and support for paid and informal carers is essential. Proactive monitoring of repeat prescriptions improves outcomes.</li> <li>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.<sup>2</sup></li> <li>Being active, mobile and re-building confidence after a setback requires multi-professional input.</li> </ul> <p>Knowing when someone is in the <a href="/resources/end-of-life-care-in-frailty-last-days-of-life">last days of life</a> can be uncertain. Assumptions that every dying person should be on parenteral opioid regimes or have subcutaneous infusion pumps are very risky and wrong. </p> <ul> <li>Assessment must be individualised, regular and competent.  </li> <li>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.</li> <li>Local guidance and protocols are important starting points, especially in opioid na茂ve patients, which should be readily accessible.</li> <li>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.</li> <li>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.  </li> </ul> <h2 class="sidebar-nav">References</h2> <ol> <li>Schofield P. The Assessment of Pain in Older People: UK National Guidelines, Age and Ageing 47(suppl_1):2018;i1–i22, <a href="https://doi.org/10.1093/ageing/afx1922" rel="nofollow">https://doi.org/10.1093/ageing/afx1922</a>. </li> <li>Hulla R, Vanzzini N, Salas E, Bevers K, et al. Pain management in the elderly. Practical Pain Management 2019;17:1. Available at: <a href="http://www.practicalpainmanagement.com/treatments/pain-management-elderly" rel="nofollow">www.practicalpainmanagement.com/treatments/pain-management-elderly</a></li> </ol> <p> </p> </div> <div class="card-view-4"> <div class="view view-attachment view-id-attachment view-display-id-main view-dom-id-2bc69d718dfb9b2e07fb65cf196aace8"> </div> </div> </div> </div> </div> </div> </article> </div> <div class="content-additional"> <div id="block-webform-client-block-227" class="block block-webform"> <h2 class="resource-feedback-toggle">Feedback on this resource?</h2> <div class="content"> <div id="webform-ajax-wrapper-227"><form class="webform-client-form webform-client-form-227" action="/resources/end-of-life-care-in-frailty-pain" method="post" id="webform-client-form-227" accept-charset="UTF-8"><div><div class="webform-email form-item webform-component webform-component-email webform-component--email webform-container-inline"> <label for="edit-submitted-email">Email 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move towards the end of their lives.</p> </div></div> </div> </a> </article> </div> </div> </div> </div> </div> </div> </div> <div class="views-row views-row-2 views-row-even views-row-last row-max-4 side-row "> <div class="section-inner"> <div class="card-title"> <h2 class="field-content">Special Interest Group</h2> </div> <div class="side-row-wrapper"> <div class="card-view"> <div class="view view-links view-id-links view-display-id-block equal-heights view-dom-id-7c33798964b399922c3a6d4ceab87153"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first views-row-last"> <article id="node-5701" class="node node-group" about="/end-of-life-care" typeof="sioc:Item foaf:Document"> <a href="/end-of-life-care" class="card"> <div class="card-image-wrapper"> <div class="card-image"> <img typeof="foaf:Image" src="https://www.bgs.org.uk/sites/default/files/styles/800-16x9/public/content/group/images/2020-05-07/end_of_life_care_-_card.png?itok=Nys_RN0X&c=ae0d9e98dd6cf6a6f935342a811bede4" alt="End of Life Care" title="End of Life Care" /> </div> </div> <div class="card-text"> <h3><div class="card-title-field"> End of Life Care </div> </h3> <div class="card-summary-wrapper"> <div class="card-summary"> <p>Launched in 2020, this special interest group aims to promote good end of life care for older people.</p> </div> </div> <div class="card-footer"> </div> </div> </a> </article> </div> </div> </div> </div> </div> </div> </div> </div> </div> </section> </div> </aside> </div> </main> <section class="postscript-first"> <div class="postscript_first"> <section class="block block-views postscript-section-row-block"> <h2 class="block-title">Other resources in this series</h2> <div class="view view-resource-series view-id-resource_series view-display-id-block section-row row-max-4 view-card-default-palette view-dom-id-ec0aeadc7d0e87a5f36225df9f306668"> <div class="view-content view-content-main"> <div class="views-row views-row-1 views-row-odd views-row-first"> <a class="card resource-card" href="/resources/end-of-life-care-in-frailty-introduction-and-foreword"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>End of Life Care in Frailty: Introduction and Foreword</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T00:00:00+01:00">12 May 2020</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> Introduction from Dr Eileen Burns, Consultant Physician and Past President of British Geriatrics Society, and foreword by Dr Sarah Russell, family carer. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Clinical guidelines </div> </div></div></a> </div> <div class="views-row views-row-2 views-row-even"> <a class="card resource-card" href="/resources/end-of-life-care-in-frailty-identification-and-prognostication"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>End of Life Care in Frailty: Identification and prognostication</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T00:00:00+01:00">12 May 2020</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> This section of the BGS guidance on end of life care in older people examines how to identify when a person with frailty is entering the last year of life. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Clinical guidelines </div> </div></div></a> </div> <div class="views-row views-row-3 views-row-odd"> <a class="card resource-card" href="/resources/end-of-life-care-in-frailty-advance-care-planning"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>End of Life Care in Frailty: Advance Care Planning</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T00:00:00+01:00">12 May 2020</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> This section of the BGS guidance on end of life care in older people looks at the role of advance care planning (ACP) in helping to make decisions about a persons wishes for the future. </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Clinical guidelines </div> </div></div></a> </div> <div class="views-row views-row-4 views-row-even views-row-last"> <a class="card resource-card" href="/resources/end-of-life-care-in-frailty-urgent-care-needs"><div class="card-text"><div class="card-content"> <div class="card-title"> <h3>End of Life Care in Frailty: Urgent care needs</h3> </div> <div class="card-date-display-override"> <span class="date-display-single" property="dc:date" datatype="xsd:dateTime" content="2020-05-12T00:00:00+01:00">12 May 2020</span> </div> <div class="card-summary"> <div class="card-summary-wrapper"> <div class="card-summary"> This section of the BGS guidance on end of life care in older people examines the management of acute deterioration in the context of frailty at the end of life.  </div> </div> </div> </div><div class="card-footer"> <div class="card-resource-series"> In a series </div> <div class="card-resource-type"> Clinical guidelines </div> </div></div></a> </div> </div> <div class="view-footer"> <div class="card-feed-link"><a href="/resources/resource-series/end-of-life-care-in-frailty">See all resources in 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