Pain in Older Adults

Importance of Comfort

• Without comfort, achieving wellness is challenging.

Understanding Pain

• Pain: A distressing sensation that can be physical, emotional, or spiritual.

Communication of Pain & Discomfort

Influences on Communication

• Pain expression can be affected by:

  • Individual's unique history.

  • Cultural expectations.

  • Personality traits.

  • Sensory deficits.

  • Presence of depression.

  • Medication effects.

Essential Skills

• Understanding patients' communication about pain is vital for effective care.

Myths and Facts About Pain in Older Adults

Common Myths

1. Pain is a natural part of aging.

2. Pain sensitivity decreases with age.

3. No complaints indicate no pain.

4. Functional impairment is required to assess pain.

5. Narcotics are unsafe for long-term use in older adults.

Relevant Facts

1. Pain is not normal, though it may increase with age.

2. Some older adults develop a higher tolerance to pain due to prolonged exposure and inadequate management.

3. Failure to report pain may stem from cultural backgrounds or feelings of being a burden.

4. Pain reactions vary widely; some may be stoic.

5. Opioids are often the best treatment for moderate to severe pain and can help restore quality of life.

6. Narcotics can be safely administered to older adults under careful management.

Types of Pain

Acute Pain

• Temporary; can follow surgery, procedures, or trauma.

• Easily managed with analgesics.

Chronic (Persistent) Pain

• Long-lasting, not time-limited, with varying intensity.

• 33-83% of long-term care residents experience chronic pain, often due to degenerative causes.

Classifications of Pain

By Nature

1. Nociceptive Pain:

   • Somatic: Musculoskeletal pain.

   • Visceral: Internal organ pain.

2. Neuropathic Pain: Caused by damage or disease affecting the nervous system.

3. Cancer Pain: Can be nociceptive or neuropathic depending on the type.

Classification by Location

1. Superficial or Cutaneous Pain: Sharp, localized, short duration (e.g., needle-stick).

2. Deep or Visceral Pain: Diffuse, can be sharp or dull, often linked to a specific organ (e.g., burning sensation in gastric ulcers).

3. Referred Pain: Felt in a location different from the source (e.g., heart attack pain in jaw/arm).

4. Radiating Pain: Spreads along a body part; may be intermittent or constant.

5. Neuropathic Pain: Characterized as burning, numbing, or electric-like sensations.

Common Sources of Pain in Older Adults

• Osteoarthritis: Major cause of pain, especially in knees.

• Herpes Zoster (Shingles): Causes painful, blistering rashes originating from reactivation of the varicella-zoster virus (chickenpox).

Nursing Implications

Assessment Factors

1. Function: Assessing ADLs and iADLs affected by pain.

2. Expression: Behavioral changes (pacing, irritability), complaint frequency, sleep/wake changes, movement resistance.

3. Social Support: Evaluate available resources and impacts on social roles/relationships.

4. Pain History: Understand past pain management and cultural factors regarding pain.

Interventions and Evaluations

• Evaluate non-pharmacological and pharmacological interventions.

Pain Assessment in Advanced Dementia Using PAINAD Scale

Non-Pharmacological Measures for Pain Relief

1. Touch and cutaneous nerve stimulation (acupuncture, massage, heat/cold therapy).

2. Transcutaneous electrical nerve stimulation (TENS).

3. Biofeedback.

4. Distraction techniques (relaxation, meditation).

Pharmacological Pain Control

• Non-narcotic analgesics: For mild to moderate pain.

• Narcotic analgesics: Effective for acute and chronic pain management.

End-of-Life Issues

Understanding Loss

• Loss is a universal human experience, encompassing both expected and unexpected occurrences.

• Grief: The emotional response triggered by loss, with mourning being the active process of experiencing grief.

Worden’s Model of Bereavement

The grieving process consists of four tasks:

1. Accept the reality of loss.

2. Work through grief-related pain.

3. Adjust to a life without the loved one.

4. Find a connection with the deceased to move forward.

Types of Grief

1. Anticipatory: Mourning before an expected loss.

2. Acute: Acute crisis with psychological and somatic symptoms.

3. Persistent or Complicated: Intense reactions that may require professional intervention.

4. Disenfranchised: Grief not openly acknowledged or validated.

Stages of Grief (Kubler-Ross Model)

1. Shock

2. Denial

3. Anger

4. Bargaining

5. Depression

6. Testing

7. Acceptance

Nursing Implications for Loss and Grief

Assessment

• Differentiate between effective and ineffective coping mechanisms.

• Investigate recent significant life events and their impact.

Interventions

1. Establish rapport with patients.

2. Offer empathetic listening and support.

3. Encourage storytelling and sharing memories.

NURSE Technique for Providing Support

1. Name: Acknowledge feelings.

2. Understand: Show understanding of their situation.

3. Respect: Validate their experience.

4. Support: Offer consistent presence during their grief.

5. Explore: Engage with open-ended questions.

Dying and Death in Palliative Care

Definitions

• Dying begins at the moment of “crisis knowledge of death” and ends with physiological death.

Implications for Nursing

• Understanding illness trajectories assists in anticipating the needs of patients and their families.

Six Cs Approach

The needs of the dying person according to Weisman:

1. Care: Symptom management;

2. Control: Ensuring patient agency;

3. Composure: Management of emotional extremes;

4. Communication: Different awareness levels;

5. Continuity: Maintaining normalcy;

6. Closure: Opportunities for reconciliation.

Nursing Actions Assisting the Newly Bereaved

• Providing emotional and informational support, being present, facilitating connections, and following through after the patient's death.

Unhelpful Comments to Avoid

• Statements that minimize grief or encourage suppression of emotions such as “she’s in a better place” or “don’t cry” should be avoided.

Palliative Care Overview

• Aims to improve quality of life through managing suffering associated with serious illness.

• Palliative care involves the entire care team, including family and loved ones.

Key Symptoms in Palliative Care

• Common symptoms requiring attention include: delirium, nausea, difficulty swallowing, shortness of breath, fatigue, anxiety, and depression.

Side Effects of Analgesics

• Be aware of side effects such as constipation, drowsiness, confusion, fatigue.

Documentation and Care of the Body After Death

• Nurses play a critical role in certifying and preparing the body after death, ensuring to follow procedural guidelines for respect and dignity.

Signs and Symptoms of Impending Death

• Look for changes in muscle tone, sensory impairment, temperature changes, and other significant body reactions that indicate end-of-life progression.

Conclusion

• Nurses must cultivate an understanding of grief and loss to effectively support patients and families, as well as maintain a strong sense of professional boundaries while dealing with their own experiences of loss.