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NICE (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

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NICE (2021) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

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This guideline covers assessing all chronic pain (chronic primary pain, chronic secondary pain, or both) and managing chronic primary pain in people aged 16 years and over. Chronic primary pain is pain with no clear underlying cause, or pain (or its impact) that is out of proportion to any observable injury or disease.

This guideline should be used alongside NICE guidelines for other chronic pain conditions, including the NICE guidelines on headaches, low back pain and sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain and irritable bowel syndrome.

The recommendations in this guideline were developed before the COVID-19 pandemic.

Recommendations

This guideline includes recommendations on:

Who is it for?

Healthcare professionals

Commissioners and providers of services

People with chronic primary pain and chronic secondary pain, their families and carers

Guideline development process
How we develop NICE guidelines
This guideline was commissioned by NICE and developed in partnership with the Royal College of Physicians (RCP).

Your responsibility

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

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Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

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This guideline covers assessing all chronic pain (chronic primary pain, chronic secondary pain, or both) and managing chronic primary pain in people aged 16 years and over. Chronic primary pain is pain with no clear underlying cause, or pain (or its impact) that is out of proportion to any observable injury or disease.

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NICE guidelines. Neuropathic pain (2020)

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NICE guidelines. Neuropathic pain (2020)

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Overview | Neuropathic pain in adults: pharmacological management in non-specialist settings | Guidance | NICE

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Evidence-based recommendations on the pharmacological management of neuropathic pain in adults in non-specialist settings

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sign136 Management of chronic pain (2013)

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British Pain Society: Resource for people living with pain

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British Pain Society: Resource for people living with pain

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People living with Pain | British Pain Society

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For the majority of people, attending a Pain Management Programme reduces the disability and distress caused by chronic pain by teaching physical, psychological and practical techniques to improve quality of life. It differs from other treatments provided in Pain Clinics in that pain relief is not the primary goal, although improvements in pain following participation in a Pain Management Programme have been demonstrated.

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QUTENZA (Capsaicin) For DPN and PHN | QUTENZA

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Learn about QUTENZA for diabetic nerve pain treatment and post-shingles nerve pain treatment. Find a QUTENZA Specialist near you. Explore patient savings

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Faculty of Pain Medicine: Clinical Guidelines

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Faculty of Pain Medicine: Clinical Guidelines

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Clinical guidelines and publications, including competencies, procedures, outcome measures and safety checklists

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The British Pain Society aims to promote education, training, research and development in all fields of pain. It endeavours to increase both professional and public awareness of the prevalence of pain and the facilities that are available for its management. The Society is involved in all aspects of pain and its management through the work of the Council, various Committees, Special Interest Groups and Working Parties and via its publications, Annual Scientific Meeting and educational seminars.

The British Pain Society has a membership of over 750 and is involved in all aspects of pain and its management through the work of the Council, Committees and Working Parties. Further information can be found within the About section.

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An alliance of professionals advancing the understanding and management of pain for the benefit of patients

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The British Pain Society aims to promote education, training, research and development in all fields of pain. It endeavours to increase both professional and public awareness of the prevalence of pain and the facilities that are available for its management.

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Reed et al (2015) Management of Pain in the older adult.

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Reed et al (2015) Management of Pain in the older adult.

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Management of Pain in the older adult

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The bottom line

Chronic pain in later life is a worldwide problem

All older adults with chronic pain should undergo a comprehensive geriatric pain assessment

A comprehensive assessment can guide selection of treatments most likely to benefit the patient and identify targets for intervention besides pain relief

A multimodal approach that includes both drug and non-drug modalities for pain is recommended

Given the limited reach of cognitive behavioral and exercise approaches to manage pain in later life, patients should be encouraged to engage in and adopt these techniques

Involve and engage family members and paid caregivers and seek out other resources that can help to reinforce adherence to treatment and maintain gains from treatment

Chronic pain is one of the most common conditions encountered by healthcare professionals, particularly among older (≥65 years) patients. Pain is associated with substantial disability from reduced mobility, avoidance of activity, falls, depression and anxiety, sleep impairment, and isolation. Its negative effects extend beyond the patient, to disrupt both family and social relationships. Chronic pain poses a significant economic burden on society. Prevalence rates for pain are expected to increase as populations continue to age-by 2035 an estimated one quarter of the population in the European Union will be 65 or older-thereby increasing the public health impact of pain. Healthcare providers, irrespective of specialty, should develop competencies to assess and manage chronic pain in their older patients. In this review we summarize recent evidence on the assessment and management of pain in older patients. Evidence is taken from systematic reviews, meta-analyses, individual trials, and clinical guidelines.

Sources and selection criteria

We searched Medline, Embase, and the Cochrane Database of Systematic Reviews using the search terms "chronic pain", "older adults", "prevalence", "diagnosis", and "treatment". We specifically focused on identifying and reviewing systematic reviews, meta-analyses, high quality randomized controlled trials, and clinical guidelines published during the past five years whenever possible.

What is chronic pain and how is it caused?

Although no universally accepted definition exists for chronic pain, it is often defined as pain that persists beyond the expected time of healing (typically 12 weeks) and may or may not be associated with an identifiable cause or actual tissue damage. Musculoskeletal disorders are common in later life, and increasingly common are painful neuropathies from diabetes, herpes zoster, chemotherapy, and surgery. Other types of pain are also prevalent among older adults, including pain due to cancer as well as cancer treatments. Pain is also common in the advanced stages of many chronic diseases, including congestive heart failure, end stage renal disease, and chronic obstructive pulmonary disease. Furthermore, millions of joint repair and replacement surgeries are performed annually, and an important minority of patients undergoing these procedures report chronic pain despite surgery. Finally, vertebral compression fractures are highly prevalent and cause substantial pain and discomfort, particularly among older women. Box 1 lists other common diseases where pain is a major symptom.

Box 1 Diseases associated with chronic pain in later life, by system or specialty

Dermatology -pressure or ischemic ulcers, burns, scleroderma

Gastrointestinal -constipation, irritable bowel disease, diverticulitis, inflammatory bowel disease

Cardiovascular -advanced heart disease, peripheral vascular disease

Pulmonary -advanced chronic obstructive pulmonary disease, pleurisy

Rheumatology -osteoarthritis, rheumatoid arthritis, gout, pseudogout, polymyalgia rheumatica, spinal stenosis and other low back syndromes, myofascial syndromes, osteoporotic related fractures

Endocrine -diabetic neuropathy, Paget's disease

Nephrology -chronic cystitis, end stage renal disease

Immune -herpes zoster, post-herpetic neuralgia, HIV/AIDs neuropathy

Neurology -headache, peripheral neuropathies, compressive neuropathies, radiculopathies, Parkinson's disease, post-stroke pain

Miscellaneous -depression, tendonitis, bursitis

Who gets it?

Chronic pain in later life is a worldwide problem. In one nationwide survey of older adults (n=7601) in the United States, 52.8% reported experiencing bothersome pain in the preceding month. Similar findings have been reported in studies conducted in Europe, Asia, and Australia and in both developed and less developed countries. Risk factors include advancing age, female sex, lower socioeconomic status, lower educational level, obesity, tobacco use, history of injury, history of a physically strenuous job, childhood trauma, and depression or anxiety.

Factors predicting poor outcomes (that is, higher pain scores, disability, depression) among people with chronic pain include higher levels of pain severity and disability, longer duration of pain, multiple pain sites, history of anxiety or depression, maladaptive coping strategies (for example, worry, avoidance), and low social support at the time of diagnosis. In one study of older adults (n=403) with musculoskeletal pain, three brief items assessed at the initial clinical encounter-degree of interference from pain, pain in multiple body sites, and duration of pain-predicted lack of patient improvement at six months and helped general practitioners predict this outcome above clinical judgment alone. Simple risk stratification approaches like this could help to tailor care.

How are older patients with chronic pain assessed?

A comprehensive pain assessment can increase the likelihood of identifying a specific diagnosis for the pain, guide selection of treatments most likely to benefit the patient, and identify targets for intervention (for example, unrealistic treatment goals) besides pain relief. Office based assessment can be challenging, however, because of constraints on time. Having patients complete parts of the assessment before the visit (or in the office over multiple visits) can be helpful.

Clinicians often struggle with the question of how comprehensive the assessment needs to be to establish a specific cause of pain. Unfortunately the literature provides little guidance on this but does indicate that a specific cause is not found in a large number of patients, despite comprehensive evaluation. Potential benefits to identifying a cause of pain include earlier initiation of an appropriate treatment and providing reassurance as patients often worry about the cause of their pain. These putative benefits must be weighed against the risks of extensive investigations, which often uncover incidental findings, are expensive, and can increase patient worry.

History

Chronic pain is more than just a sensory event; it has affective (emotional responses to pain), cognitive (attitudes and beliefs about pain), behavioral (for example, behaviors manifested in response to pain by patients and their family members or caregivers), as well as sensory components (for example, quality, location, temporal pattern). Assessing for the presence and severity of pain captures only a small part of the pain experience. All older patients with chronic pain should undergo a comprehensive pain assessment (box 2 outlines the key elements).

Box 3 lists these and other core elements of the assessment along with sample questions that can be employed during the interview. Additional guidance about assessment approaches can be found in UK and US guidelines and in an international consensus report on this topic.

Examination

A physical examination should be conducted, focusing on the musculoskeletal (is there evidence of inflammation?) and neurologic (is there evidence of weakness or neuropathy?) systems. Because many older adults with chronic pain report the presence of weakness, it is important to distinguish pain induced weakness from true motor weakness. This can be done by documenting abnormal results from nerve conduction studies or by treating pain successfully and seeing if the muscle weakness improves. Tackling physical functioning and risk of falls is critically important, given that pain is associated with these outcomes. This part of the assessment should include self report and performance based measures such as gait speed, timed up and go test, balance. The results provide a baseline against which the functional impact of treatment can be evaluated.

Imaging

Diagnostic imaging is often overused and does not indicate better care. In one study of Portuguese adults (n=5094) more than half of all respondents with chronic pain reported undergoing a diagnostic imaging procedure in the previous six months. Such imaging often uncovers incidental findings, leading to more testing, costs, and worry for patients. An additional concern is the low correlation between pathologic findings identified by imaging and the extent to which patients report experiencing pain. Many patients with major disease identified by imaging report no pain, whereas others without major disease often report severe pain. Diagnostic imaging is appropriate when the history or physical examination identifies abnormalities that suggest a specific diagnosis for the pain. Imaging procedures should also be strongly considered in the presence of "red flags," to include worsening pain in patients with a history of cancer, risk factors for infection (injecting drug use, immunosuppressive therapy), and worrisome constitutional signs or symptoms such as unexplained weight loss, fever, or loss of appetite.

Assessing pain in older patients with major cognitive impairment

Patients with limited verbal or cognitive abilities require modified approaches to assessment. A hierarchy of techniques is recommended, the first including an attempt to obtain self report data followed by a search for potential causes of the pain, observing patient behavior (for example, facial expressions, vocalizations, guarding), obtaining proxy data from family members or caregivers who know the patient well and can report on whether changes in behavior or activity are very different from baseline, and conducting an analgesic trial to see whether the behavior resolves with treatment. Several tools for behavioral pain assessment have been developed to assess for pain in non-verbal patients and are reviewed elsewhere.

What is the approach to management?

Management of pain in later life can be complex; problems with both nociceptive and neuropathic pain are common and often coexist. Nociceptive pain arises from actual or threatened damage to non-neural tissue through activation of nociceptors, whereas neuropathic pain occurs as a consequence of abnormalities in the central or peripheral somatosensory nervous system. Management is further complicated by age related physiologic changes, which lead to altered drug absorption and decreased renal excretion, sensory and cognitive impairments, polypharmacy, and multimorbidity, particularly chronic conditions such as disorders of gait and balance, and kidney, lung, and cardiovascular disease. Other barriers to management include a limited evidence base to guide decisions, physician concerns about the potential for treatment related harm, as well as older adults' beliefs about pain and treatments for the pain. However, it is important to note that these barriers are not universally present in older adults; an important tenet of geriatric medicine is that chronologic age does not equal biologic age.

Chronic pain in older patients most often occurs in the setting of multiple comorbidities, limiting treatment options. A comprehensive management approach should deal with common sequelae such as depression, isolation, and physical disability, and include both drug and non-drug treatments. UK and US guidelines on the management of pain in later life strongly endorse this approach. Recent data provide support for multimodal treatment approaches. In one randomized clinical trial (n=454) of overweight or obese older adults with osteoarthritis of the knee, intensive weight reduction combined with exercise training produced significant improvements in pain, functional status, and physical performance over an 18 month period when compared with exercise only (and diet only) control groups.

In terms of care delivery, collaborative approaches have proved efficacy in the primary care setting. One recent randomized clinical trial involving older primary care patients (n=250) with chronic musculoskeletal pain found that a telephone based collaborative care management intervention delivered by a nurse care manager, physician pain specialist, and the patient's primary care provider led to improved patient outcomes at 12 months, largely through optimizing non-opioid analgesics by using a stepped care approach. Given the complexities of managing most older patients with chronic pain, a multidisciplinary approach that includes physician, nursing, and social work perspectives is strongly recommended.

Social aspects of management

Clinicians are advised to take family responses and dynamics into account when formulating treatment plans. Older patients' chronic pain often affects their close relatives and caregivers.

Spouses typically play an important role in caring for older patients, often times delivering emotional and instrumental support. However, when an older spouse experiences chronic pain, problems of communication and commitment to the marriage can occur.

Therapeutic interventions directed at patients with chronic pain increasingly involve the family, most often by including relatives in cognitive behavior therapy (CBT) or self management training. Although evidence is mixed, several well conducted, randomized trials suggest that spousal participation in the treatment process can yield measurable benefits for patients, including enhanced emotional wellbeing and reduced pain levels.

Home visits

We are not aware of any literature that has examined the value of home visits for older adults with chronic pain. Despite a lack of evidence supporting the use of home visits, clinicians should consider them on a case by case basis because of several potential benefits, which include clarifying reasons for non-adherence to drug and behavioral interventions, gathering proxy data that may not be available during an office visit, and preventing the use of old prescription drugs often stored by patients. Perhaps the most important benefit is a strengthening of the doctor-patient relationship. From the physician's perspective, observing the patient's environment often offers intangible but valuable insights into the patient's condition. From the patient's perspective, most feel enormously supported by a physician who cares enough to make a home visit.

What drug interventions are available?

Table 2 summarizes current UK and US guideline recommendations, highlights key safety concerns about analgesics, and provides guidance on specific drug treatments for both nociceptive and neuropathic pain disorders. The use of drug combinations often results in enhanced analgesic effectiveness, with lower toxicity than is seen with the use of a single agent at higher doses, and is encouraged.

Table 2

Analgesic class

Recommendation*

Safety concerns

Quality of evidence†

Paracetamol

Because of its favourable safety profile, paracetamol (acetaminophen) is the preferred treatment for older patients with mild or moderate pain. In one meta-analysis of seven randomized controlled trials comparing paracetamol with placebo, paracetamol (up to 4 g daily) was found to be modestly effective in reducing pain, which decreased on average by 4 points on a scale of 0-100. The number needed to treat ranged from 4 to 16. Paracetamol did not improve physical function or stiffness when compared with placebo.. While it is not associated with significant cardiovascular, renal, or gastrointestinal effects, unintentional overdose of paracetamol is an important cause of hepatotoxicity. Patients should be counseled to not exceed the maximum recommended daily dose.

Non-steroidal anti-inflammatory drugs

Oral non-steroidal anti-inflammatory drugs (NSAIDs) have established gastrointestinal, cardiovascular, and renal risks, which increase with age. Oral NSAIDs can be effective in some patients but are safest when used for pain flares (transient increases in pain that typically persist for hours to days). The current evidence base provides little guidance about the NSAID for safest use in this patient population. A network meta-analysis examined the cardiovascular safety of various NSAIDs and found that naproxen was the least harmful compared with other non-selective (for example, ibuprofen) and selective (for example, celecoxib) NSAIDs. These data indicate that naproxen is most appropriate (compared with other NSAIDs) for patients with cardiovascular risk factors. Risk of renal and gastrointestinal injury must also be weighed, however, before initiating any trial involving NSAIDs. If a trial of an NSAID is undertaken, have the patient return to the office within two weeks to ask about treatment benefit and gastrointestintal side effects, check blood pressure, and carry out renal function tests.

Topical NSAIDs represent an alternative to oral NSAIDs, are generally well tolerated, and should be considered, especially for patients with localized pain.

Opioids

Opioids may be considered when an older patient's pain has not responded to other treatments or when major functional impairment persists despite treatment. The short term efficacy of opioid use (≤12 weeks) among older adults has been established. In a retrospective cohort study of (n=133) older patients (mean age 82) newly started on an opioid because of pain due to chronic musculoskeletal conditions, reductions in pain were recorded in 66% of participants. However, opioids were discontinued in 48% of the participants, mostly as a result of poorly tolerated side effects, including constipation, changes to mental status, and nausea. Given the established risks associated with opioid use, the potential negative effects must be weighed against the consequences of untreated or partially treated pain. A recent systematic review found limited evidence in support of long term opioid treatment, and the risk for serious harm increased in line with opioid dose. If an opioid trial is undertaken, it is important to closely monitor (that is, biweekly during the initiation and dose titration phase of treatment) whether treatment goals are being met. If not, the drug should be tapered and discontinued.

There is no evidence to support the use of one weak opioid (for example, hydrocodone, codeine) over another when the response to paracetamol or a NSAID is lacking. Selection of a specific opioid depends on the clinician's clinical experience and knowledge, the patient's previous experiences, and availability of the drug in local pharmacies. Strong opioids (for example, morphine, hydrocodone) should not be given to patients who have never used opioids. Efforts to reduce opioid related risks are particularly appropriate given dramatic increases in and complications associated with opioid use. These include the use of screening tools (for example, the screener and opioid assessment for people with pain, opioid risk tool) that can be used to assess risk for the likelihood of opioid misuse, as well as guide decisions about the extent of monitoring needed if an opioid trial is undertaken. Such monitoring might extend to the use of urine toxicology screens on a periodic basis. Before older patients are prescribed opioid analgesics, physicians should be satisfied with arrangements for safe storage of the drug, given the risk for drug diversion (that is, use of the drug for a purpose other than pain reduction). In terms of initiating a given opioid trial, no special dosing guidelines exist for older patients. Beginning at the lowest possible dose and titrating upwards based on tolerability and efficacy is recommended, given that age is associated with a greater incidence of treatment related adverse effects. This risk is increased by the presence of multiple comorbidities, polypharmacy, and physiologic vulnerability. Careful surveillance is necessary after beginning an analgesic trial. Frequent telephone or email contact is recommended to assess for and deal with any adverse effects.

What psychological interventions are available?

There is optimism about the role of psychological interventions as treatment for older patients with chronic pain.

Cognitive behavioral therapy

The use of CBT is promising. CBT is used to enhance patients' control over pain, based on the premise that an individual's beliefs, attitudes, and behaviors play a central role in the experience of pain. Standard CBT protocols instruct patients in the use of specific cognitive and behavioral techniques, teach them how certain thoughts, beliefs, attitudes, and emotions influence pain, and highlight the patient's own role in controlling and adapting to chronic pain. CBT techniques are underutilized, particularly among older adults with chronic pain. Few providers have been trained to deliver the protocols for pain, particularly in less developed countries. Early innovation in remote therapy that makes use of communication technology may help to overcome this barrier. Although the quality of the early trials in this area is poor, the use of ehealth and mhealth technologies can improve access to treatments and could improve the treatments. Particularly promising are efforts to train non-psychologists in CBT delivery and related therapies, which could increase the reach of these treatments. In addition, two recent high quality trials broaden the scope of treatment to include sustainable self management practices in primary care. In one trial, investigators evaluated a CBT based self management program for use by older patients with chronic pain in primary care. Significant improvements in distress from the pain, disability, and self efficacy were found in patients who received CBT training compared with an exercise only and wait list control group. Communicating with older patients-particularly those who are reluctant to try behavioral treatments-that using non-drug as well as drug treatments is the standard of care can be helpful. Routinely inquiring about and dealing with patient barriers to engagement with treatment (for example, belief that non-drug treatments are ineffective) is also recommended.

Self management programs

Self management programs merge physical, psychological, and social dimensions and adopt a largely educational approach, teaching patients specific strategies to reduce pain by changing their behavioral, cognitive, and emotional responses to pain and building self efficacy for managing pain and its sequelae. These programs combine education about pain and its consequences and training in relaxation and communication skills. Among the best known of these programs is the Arthritis Foundation self help program ( http://patienteducation.stanford.edu/programs/asmp.html). Evidence about the value of self management programs for pain is mixed. Several reviews have reported positive treatment outcomes, whereas others have not. Despite the conflicting data, we believe it is reasonable to encourage patient participation in self management, and a clearer matching of tailored treatment content to specific outcomes.

What rehabilitative and exercise approaches are available?

Exercise interventions for older adults with chronic pain are evidenced based, underutilized, and should be a core component of any long term treatment plan. Primary components include training in balance, flexibility, endurance, and strengthening, the mix of which should be tailored to best meet the needs of each patient. Clinicians can refer patients to physiotherapists to develop an exercise program. Physiotherapists can also reinforce related concepts to include coaching on risk of falls, balance training, body mechanics, and pacing. Simple physician advice to remain physically active despite pain, in the absence of a specific exercise routine, is ineffective.

Community based programs include the evidence based Arthritis Foundation exercise program ( www.cdc.gov/arthritis/interventions/physical_activity.htm), which is delivered in a group format. Classes are held 1-3 times a week for eight weeks. Health or fitness trainers (such as exercise therapists) lead the groups, which focus on specific exercises appropriate for patients with arthritis or arthritis related diseases. In a recent uncontrolled study (n=110) of a group based exercise training program for older adults with arthritis, participation led to significant improvements in physical functioning. Tai Chi and yoga programs should also be considered, with the caveat that the instructor should be properly qualified. Exercise based programs are low cost and accessible in many communities. Healthcare providers should familiarize themselves with these resources.

Practitioners should consider the preferences of individual patients when prescribing exercise, including the preferred location (for example, gym, home) as well as type of exercise. Older patients with chronic pain may not have access to facilities for exercise or may lack the motivation to engage. It is important to address these barriers or adherence will be low. In support of this approach is a randomized controlled trial of community dwelling older adults (n=56) with chronic pain. In this study, participants randomized to an eight week group based exercise program that included motivational interviewing techniques delivered by a physiotherapist showed significant improvements in pain intensity, self efficacy, anxiety level, and mobility compared with a group based activity control group.

When should patients be referred to a pain specialist?

Practitioners should refer patients when pain is unresponsive (or poorly responsive) to standard treatments, a psychiatric condition (for example, active substance use disorder, excluding nicotine) or medical condition (for example, hepatic or renal dysfunction) would complicate management, there are concerns about misuse of opioids, and procedures (for example, nerve block) may help to clarify a diagnosis or are indicated for the treatment of a given pain disorder.

What is the role of mobile health technology?

Recent advances in mobile health technologies suggest these devices may play a role in the near future by facilitating the collection and transmission of information for the assessment of pain. These devices could potentially improve patient care through more effective monitoring of treatment outcomes, enhanced patient-provider communication, and by providing new ways to deliver treatment. For example, a recent SMS text message based social support intervention delivered by mobile phone was found to reduce pain and pain interference levels among patients with chronic pain.

What limitations exist in the evidence base about treatment?

Although the number of well designed studies evaluating drug or non-drug treatments for older adults with chronic pain is growing, there are important limitations in the existing evidence base. Factors limiting the generalizability of findings include the use of various outcome measures, which make it difficult to compare across studies, short duration of most trials (≤12 weeks), lack of diversity in study populations (inclusion of mostly white, non-Hispanic patients), and greater enrolment of young-old participants (with few participants aged ≥80) without major comorbidity. Questions about treatment adherence, as well as the long term safety and efficacy of these modalities in older populations remain inadequately defined. In terms of behavioral treatments, patient factors that positively (or negatively) impact treatment outcomes remain inadequately defined. Identifying optimal strategies for the delivery of behavioral treatment (for example, individual versus group based and online versus mobile health approaches) warrant further attention.

Despite these knowledge gaps, we recommend that healthcare providers educate older patients about diverse treatment approaches and encourage their use, to include both drug and non-drug modalities, as a way of broadening their "pain management portfolio." Lack of evidence does not mean evidence of no effect; clinicians must make treatment decisions based on the interaction of individual needs and existing evidence. Given low rates of use of many non-drug management approaches in older patients, encouraging engagement in and adoption of these modalities, to include cognitive behavioral therapy and exercise is particularly recommended.

Questions for future research

What are the implications of ethnic and cultural diversity on the experience of pain among older people, and the effectiveness of interventions?

What are the best ways to measure outcomes in geriatric pain research, including both observable and subjective dimensions?

Can access to psychological therapies be improved by training non-psychologists in delivering them and by using mhealth and ehealth solutions?

What effect does pain have on cognitive ability and motivation in older people, and how can this be best managed with cognitive behavioral therapy?

How can the evidence base in trials of pharmacologic, physical, and psychological treatments be improved for older people?

Should the inclusion of older people in the design of novel interventions be mandatory?

What evidence based approaches work best to maximize treatment adherence?

Tips for non-specialists

Pain is more than just a sensory event; assessing for the presence and severity of pain captures only a small part of the pain experience

Diagnostic imaging is often overused and does not equal better care

Consider specialist referral for older patients who have complicated psychiatric histories, debilitating pain, or pain that does not respond to customary treatments

Use combinations of analgesic drugs to enhance analgesic effectiveness

Non-drug approaches to include exercise and cognitive behavioral approaches are underutilized. Educate older patients about these approaches and identify local practitioners or agencies that provide them

Implement surveillance plan to assess treatment efficacy, tolerability, and adherence with each new treatment

Additional educational resources

A patient's perspective

I have lived with chronic back pain for over 30 years. Early on I had surgery on my back that helped for maybe six months, but then the pain returned and has been with me ever since. It has affected my life in many ways: I don't have as much energy as I would like, I can only do housework for short periods before my back starts to hurt, and my kids only know me as a person with chronic back pain. I use different techniques to help me manage it. First off, having a supportive spouse and family is very important. I also find massage, which I get several times a week, to be incredibly helpful. I also go to the gym where I do stretches, walk on the treadmill, and do the exercise bike and elliptical for short periods (five minutes each) before my back starts to bother me. I do take pain medications; I will take ibuprofen for short periods. I also take hydrocodone when the pain is really bad but don't like taking it regularly because my mother had an addiction problem, which is a concern. I would say I have learned to live with the pain and won't let it defeat me.

Sally Smith, New York City

Web Extra. Extra material supplied by the author

Notes

Contributors: All authors conceived and designed the article, participated in its drafting and revision, and approved the final version. MCR is guarantor.

Competing interests: We have read and understood the BMJ policy on declaration of interests and declare that: MCR has received funding from the National Institute on Ageing (P30AG022845), the Agency for Healthcare Quality and Research (R01HS020648), Howard and Phyllis Schwartz Philanthropic Fund, and Endo Pharmaceuticals. KP has received research funding from the National Institute on Ageing (P30AG022845). CE has received a grant from the UK National Institute for Health Research Cochrane Program.

Patient consent obtained.

Provenance and peer review: Commissioned; externally peer reviewed.

Notes

Cite this as: BMJ 2015;350:h532

References

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17. Royal College of Physicians, British Geriatrics Society, and British Pain Society. The assessment of pain in older people: national guidelines. Concise guidance to good practice series, No 8. Royal College of Physicians, Oct 2007.

35. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health pathways to prevention workshop. Ann Intern Med 2015; published online 13 Jan. [ PubMed]

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Management of chronic pain in older adults

# data[].attributes.attachment_link.description
Chronic pain in later life is a worldwide problem All older adults with chronic pain should undergo a comprehensive geriatric pain assessment A comprehensive assessment can guide selection of treatments most likely to benefit the patient and identify targets for intervention besides pain relief A multimodal approach that includes both

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Pain Toolkit Academy Courses for Healthcare Professionals and People living with Persistent Pain

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Pain Toolkit Academy Courses for Healthcare Professionals and People living with Persistent Pain

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Pete Moore, Pain Toolkit - info@paintoolkit.org

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Pain Self Management by Pete Moore | Pain Toolkit

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Is pain self management your first choice, or last resort? The Pain Toolkit by author Pete Moore, helps people all over the world self manage persistent pain.

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Patient Publications | British Pain Society

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The British Pain Society aims to produce contemporary guidance, supported by available evidence, on clinical and other pain matters. Most British Pain Society guidelines have an accompanying information for patient leaflet. Documents are updated three yearly to incorporate relevant new information.

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TEDxAdelaide - Lorimer Moseley - Why Things Hurt

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Executive summary

We are facing a huge increase in the older population over the next 30 years. This brings an anticipated increase in the prevalence of chronic pain and with this comes the challenge of assessment of pain in many varied settings. Our first iteration of this document was published in 2007. But there has been a proliferation of literature and research since then, so we have developed a new set of guidelines.

1. Different patterns and sites of pain were seen in men and women.

2. Age differences suggest that pain prevalence increased with age up to 85 years and then decreased.

3. The available studies on barriers and attitudes to pain management point towards an adherence to bio-medically orientated beliefs about pain, concern amongst clinicians in relation to activity recommendations, and a negative orientation in general towards patients with chronic painful conditions.

4. A multidisciplinary approach to the assessment and treatment of pain is essential, but the assessment is a complex process which is hampered by many communication issues, including cognitive ability and socio-cultural factors. Such issues are part of the UK ageing population.

5. Structured pain education should be implemented that provides all health professionals (whether professionally or non-professionally trained) with standardised education and training in the assessment and management of pain according to level of experience.

6. Although subjective, patient self-report is the most valid and reliable indicator of pain and it may be necessary to ask questions about pain in different ways in order to elicit a response.

7. A number of valid and reliable self-report measures are available and can be used even when moderate dementia exists. The Numerical Rating Scale or verbal descriptors can be used with people who have mild to moderate cognitive impairment. For people with severe cognitive impairment Pain in Advanced Dementia (PAINAD) and Doloplus-2 are recommended.

8. PAINAD and Doloplus-2 scales continue to show positive results in terms of reliability and validity. There has been no recent evaluation of the Abbey pain scale although it is widely used throughout the UK.

9. There is a need for more research into pain assessment using the collaborative role of the multidisciplinary team in all care settings.

10. Self-report questionnaires of function are limited in their ability to capture the fluctuations in capacity and ability. The concentration on items of relevance to the population of interest means that issues of personal relevance can be obscured.

11. Strong associations were seen between pain and depressed mood with each being a risk factor for the other. Additionally, loneliness and social isolation were associated with an increased risk of pain.

12. Clinicians should be cognisant that social isolation and or depressive signs and symptoms may be indicators of pre-existing pain or a predictor of future pain onset.

13. There are a number of evidence based guidelines on pain assessment in older people with or without cognitive impairment from around the world, including Australia and Europe.

Editor

Professor Patricia Schofield - RGN PhD PGDipEd DipN

Deputy Dean, Research & Income Generation, University of East Anglia

Contributing Authors

Dr Rachael Docking MA(Hons) PhD

Senior Evidence Manager, Centre for Ageing Better, London

Ms Felicia Cox FRCN MSc (ECP) RN

Lead Nurse Pain Management, Royal Brompton & Harefield NHS Foundation Trust, London

BPS representative

Ms Karin Cannons MSc RGN

Nurse Consultant Pain Management, Frimley Health NHS Foundation Trust, Camberley, Surrey, RCN representative

Dr Aza Abdulla FRCP(UK) FRCP(I) MSc (Brunel) MSc (Med Ed - Cardiff)

Consultant Physician, South London Healthcare NH Trust, Kent

BGS representative

Dr Gary Bellamy BN(Hons) MA PhD

Research Fellow, Centre for Positive Ageing, University of Greenwich, London

Ms Sonia Cottom BA(Hons)

Deputy Director Pain Association Scotland, Perth, Scotland

Dr Jonathon Davis BA(Hons) DipSW MA PhD

Sessional Instructor, School of Social Work, University of British Columbia, Vancouver, BC, Canada

Ms Anneyce Knight FRSA MSc BA(Hons) PGCE RN SFHEA

Senior Lecturer in Adult Nursing, Bournemouth University, Bournemouth

Prof Denis Martin DPhil MSc BSc(Hons) - Professor of Rehabilitation, Health and Social Care Institute, Teesside University, Middlesbrough

Dr Carlos Moreno-Leguizamon BA MA PGCHE PhD - Senior Lecturer and Programme Leader MSc Research in Health and Social Care, University of Greenwich, London

Dr Louise Tarrant DClinPsych MSc BSc(Hons) CPsychol - Senior Clinical Psychologist,

Bath Centre for Pain Services, Bath

Literature Review Update - 2017

Miss Joanna Malone

Dr Brendon Stubbs

Declarations of interest

Members of the group have registered all competing interests as follows:

Aza Abdulla, Gary Bellamy, Sonia Cottom, Jonathon Davies, Rachael Docking, Anneyce Knight and Denis Martin have reported that they have no conflicts of interest.

Karin Cannons has declared that she is a member of the editorial board of the British Journal of Pain, and has received honoraria as an advisor and speaker to Napp Pharmaceuticals, White Pharmacy, Dallas Burston Ashbourne, Grunenthal, Smiths Medical and Pfizer.

Felicia Cox has declared that she is a Co-Editor of The British Journal of Pain, has acted as Editor for e-learning modules and professional publications for Napp Pharmaceuticals, has co-authored e-learning modules for King's College London, and has received honoraria as an advisor and speaker to Napp Pharmaceuticals, Grunenthal, Cephalon, Dallas Burston Ashbourne and Pfizer.

Patricia Schofield has received honoraria for acting as a speaker and advisor to Napp Pharmaceuticals.

This publication was supported by an unrestricted educational grant from Bupa.

Declaration of sources of funding

Funding for this document has been made possible through Anglia Ruskin University. We are grateful for an unrestricted educational grant from the Bupa Foundation which has enabled us to publish this supplement on an open access basis.

Timetable

Dissemination; These guidelines will be distributed to all stakeholders as described in the Publication Process Manual [ 1] and as an electronic version available for download from the British Pain Society and British Geriatrics Society websites. An executive summary of these guidelines will be published in Age & Ageing.

Review of this edition to commence: March 2019

External peer review of draft next edition to commence (Anticipated): July 2019

Reissue date: Anticipated: December 2019

Foreword from Prof Pat Schofield

This guidance highlights the problems in assessing and managing pain in an ever increasing older population. The prevalence of pain has been established to be in the order of one in four of the adult population, with between 25-30% having pain that leads to other co-morbidities, resulting in a very poor quality of life.

These problems become more frequent with advancing years, and are often associated with difficulty in conveying the intensity and quality of the pain, as well as the impact that it has on the patient's life. As we describe pain as the 'fifth vital sign' a fundamental principal underpinning this is that we should measure the pain alongside routine observations.

Just because someone does not have the ability to tell us that they have pain in a language that we can understand, does not mean that we should not measure it, as we would with any other adult or patient in our care.

These guidelines provide a range of tools which demonstrate good validity and reliability for clinical practice in assessing pain in older people. There is permission to use them and so they should be implemented from this formal documentation by all healthcare providers in every care setting across the UK.

Dr Eileen Burns, President, British Geriatrics Society

Older people often live with pain, and in many cases, its management is imperfect. Pain is frequently an especially important issue for very frail older people, including those living in care homes, and people living with dementia frequently experience pain which they find difficult to express. Hence pain and its management is a hugely important issue for older people.

In 2007 we published the first national pain assessment guidelines which was a collaboration between the British Pain Society and the British Geriatrics Society. This document is a new version of the guidance and has taken a thorough and systematic approach to reviewing the literature which has been read and graded by a group of experts representing both societies; clinical practice and academia have been combined thereby ensuring a high quality and up-to-date best evidence document which can be used to guide practice and future research. This is a timely document and the guidance therein will be welcomed by practitioners around the UK.

Table of Contents

1. Glossary of terms 3

2. Glossary of scales 4

4. Methodology 6

4.1. Criteria for considering studies for inclusion in this guidance document 6

4.2. Types of studies 7

4.3. Types of outcomes measures 7

4.4. Search strategy 7

4.5. Evaluations of the literature 7

4.6. How recommendations were made 7

5. Background 7

6. Introduction 8

7. Attitudes and beliefs 8

8. Communication 9

9. Interpersonal interaction in pain assessment 9

10. Self-report measures of pain assessment 10

11. Clinical assessment 10

12. Self-report measures of function for older people with chronic pain 11

13. Pain assessment of older adults with mental health and psychological problems 11

14. Pain assessment in cognitive impairment 12

15. Pain assessment guidelines for older adults 12

16. Acknowledgements 15

17. Matrices 15

17.1. Attitudes and beliefs 15

17.2. Communication 16

17.3. Interpersonal interaction in pain assessment 20

17.4. Self-report measures of pain assessment 24

17.5. Clinical assessment 34

17.6. Self-report and physical function 39

17.7. Pain assessment of older adults with mental health and psychological problems 40

17.8. Pain assessment in cognitive impairment 47

17.9. Pain assessment guidelines for older adults 53

18. References 54

19. Appendices 60

1. Glossary of terms

The gradual increase/decrease of medication to reduce or eliminate pain while allowing the body to accommodate the side effects or toxicity [2].

2. Glossary of scales

Bolton Pain Assessment Tool (BPAT)

A behavioural observation tool based on PAINAD and the Abbey Pain Scale

Geriatric Depression Scale (GDS)

A screening test for depressive symptoms in older adults

Pain-O-Meter Visual Analogue Scale ( POM-VAS)

- A plastic tool that measures 8 × 2 × one inches. Two pain tools are located on the POM: a 10 cm visual analogue scale (POM-VAS) with a moveable marker, and a list of 15 sensory and 11 affective word descriptors

3. Aims

The primary aim of this revised systematic review was to examine the evidence for the effectiveness of pain assessment strategies in older people with or without cognitive function.

The objectives were to:

1. Explore the attitudes and beliefs of older people with pain about the assessment of their pain and interactions with carers

2. Evaluate the effectiveness of the assessment of function as a measure of pain in older people

3. Evaluate the effectiveness of self-assessment to quantify pain in older people

4. Determine if changes in pain assessment strategy are required for people with cognitive impairment, mental health or psychological problems.

4. Methodology

The overall methodology for this assessment document follows the procedures in the British Pain Society Publication Process Manual [ 1].

4.1. Criteria for considering studies for inclusion in this guidance document

The strategies to identify and evaluate, and the methods used to identify recommendations were based upon the Scottish Intercollegiate Guideline Network SIGN 50 guidance document [ 3].

4.2. Types of studies

All pain assessment interventions in adult humans with malignant and non-malignant pain over 65 years of age were considered. Patients with and without cognitive impairment, mental health and psychological problems were included. Pain assessment methods included the use of patient self-report, behavioural studies, plus observation by clinicians and carers. All care settings were considered including: the acute hospital setting, geriatric hospitals, and the community including: retirement apartments, residential homes, nursing homes and other long term care settings.

4.3. Types of outcomes measures

Outcome measures were chosen that were considered pertinent to the assessment of older patients in pain:

1. Patient- or observer-rated pain intensity, or pain relief, or both

2. Patient compliance with pain assessment strategy

3. Impact of cognitive impairment, mental health or psychological problems upon self-report

4. Barriers to effective pain assessment.

4.4. Search strategy

All publications on acute and chronic pain screening and assessment in adults over 60 years of age including case reports, cohort studies, review papers, observational studies, randomised controlled trials and systematic reviews in all languages in all care settings were identified from searches of Medline (PubMed), CINAHL, Amed, PsycINFO, Embase, Google Scholar and Cochrane Library between 01.01.2002 and 30.04.2017.

The archives of the British Pain Society, European Pain Society, Irish Pain Society, The British Geriatric Society and the Steinberg Collection were reviewed together with published conference papers and abstracts for the same time period. Professional and patient related internet sites were searched by section contributors. Searches were undertaken by specialist medical librarians in consultation with section contributors who were then provided with abstracts. Search strategies are described in Section 17 with an example of a detailed search provided for the section that explores pain assessment in older adults with mental health and psychological problems. Duplicate abstracts were removed by the librarians in collaboration with the section contributors. Additional references and abstracts were included at this point by the subject experts.

The section contributors then reviewed all abstracts and selected for inclusion those that met the working party pre-defined criteria, search terms and the clinical questions posed by the section editors. Seminal work, published prior to 2002 was included in the subject review section. Individual section contributors applied the NHMRC levels of evidence criteria to publications [4]. The decision to include a paper within a section was made by consensus between the authors and project lead where appropriate. All section papers are identified in a specific reference list and are tabulated by section.

4.5. Evaluations of the literature

The selected publications were considered as potential sources of evidence. Each publication was assessed independently by two individual raters using an agreed method ensure to its methodological quality including study design, statistical analysis and validity of conclusions. Observational studies were assessed using MERGE guidance [5].

4.6. How recommendations were made

The recommendations made by the section contributors were explicitly linked to the supporting evidence that resulted from the search strategies for individual topics. Recommendations were made based on the NHMRC designation [ 4] levels of evidence (see Table 1), and these recommendations were further confirmed through agreement between two reviewers.

I

Evidence obtained from a systematic review of all relevant randomised controlled trials

II

Evidence obtained from at least one properly designed randomised controlled trial

III-1

Evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method)

III-2

Evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case-controlled studies or interrupted time series with a control group

III-3

Evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group

IV

Evidence obtained from case series, either post-test or pre-test and post-test

5. Background

Pain is described as an 'unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage' [7]. It is classified as acute - associated with trauma or injury - or chronic (lasting longer than three months).

Millions of people who live in the United Kingdom experience chronic pain and as we go into older age, it is suggested that up to 93% of people have pain which is often 'expected to be part of ageing' or something that they have to 'learn to live with'. One of the fundamental issues regarding pain management in any age group is assessment of pain. This can be particularly challenging in older adults due to the age related changes in vision, hearing and cognition. Literature has suggested in the past that we have around 50% of the older population who live in the community experiencing uncontrolled chronic pain. However, what is more worrying is the fact that this number increases significantly to 80% when we look at care home populations. This is really worrying considering that our oldest, often most frail, members of society often live in care homes and yet it appears that they are experiencing more moderate to severe uncontrolled pain. Furthermore, it seems accepted that this population are often cared for by the least experienced and non-professionally qualified members of staff.

Recent systematic reviews of epidemiological studies suggest that the estimates of prevalence of chronic pain in the older population are not in fact accurate, and range from between 0 and 93% [8]. Clearly, more work needs to be done in terms of prevalence studies.

If we focus specifically on those who are unable to articulate their pain, thus adults with dementia or other cognitive impairments, we estimate that we have over 700,000 people in the UK with dementias and this is expected to rise significantly. Over the next few years we expect there to be 44 million people worldwide with dementia.

As far back as September 1990 [ 9], the Royal College of Surgeons, Faculty of Anaesthetists published their report - Pain after Surgery. In that report, it was suggested that pain should be assessed along with other routine observations of blood pressure and pulse. Since then, we have seen recommendations from around the world regarding pain assessment, suggesting that it become the 5 th vital sign.

We published national guidance on pain assessment in the older population in 2007 [10]. The purpose of the original version of this document was to focus on the assessment of pain in older people (aged 65 years of age and above) in chronic pain. These new guidelines seek to build upon the original guidelines and to add some new areas of interest which seem to be emerging from the literature, such as the role of interpersonal interaction. It is interesting that things have moved on since our original publication and the recommendations herein are different from those made in 2007.

The management of pain in older people has been addressed elsewhere: Abdulla A, Adams N, Bone M et al. 2013 Guidance on the management of pain in older people. Age and Ageing 42 (Suppl 1) 1-57 ( http://ageing.oxfordjournals.org/content/42/suppl_1.toc) [Accessed 11.09.2017]

6. Introduction

Until relatively recently our knowledge of the prevalence of pain in older people, particularly the oldest old, was relatively poor. Pain tended to be considered as part of the ageing process and was rarely investigated in its own right. There have however been an increasing number of studies into the prevalence of pain in older persons in the last decade.

6.1. Prevalence of pain in older persons

The work on prevalence has been published recently within the Management of Pain Guidelines [ 11], but there are some take home messages that have been incorporated within this document. The prevalence of any type of pain ranged widely from a low of 0% to a high of 93%, clearly illustrating how variations in the population, methods and definitions used can affect prevalence estimates. The vast majority of studies found that women had a higher prevalence than men.

Different patterns of pain prevalence were seen in men and women and in different sites of pain, however the age differences could be broadly categorised into four groups:

A continual increase in pain prevalence with age

An increase in prevalence with age up to 75-85 years and then a decrease with age

A decrease in pain prevalence with age and

No difference in pain prevalence with age

Chronic pain was most frequently reported in knees, hips and back.

While previous evidence suggests that chronic pain typically affects those of working age, there is growing evidence to demonstrate that chronic pain continues to increase into the oldest old. [ 12] found that, although older people experience a decrease in non-disabling back pain, described as benign or mild pain, they experience increased prevalence of disabling back pain, described as severe. This work is further supported by the findings of Thomas et al. [ 13] who reported that the onset of pain that interferes with everyday life continues to increase with age.

7. Attitudes and beliefs
Derek Jones
Research into beliefs which are of an ontological nature is limited. Investigation into 'just world' beliefs indicated that older participants had stronger beliefs in a personal and general just world and experienced less pain, disability and psychological distress. The influence of spiritual/religious beliefs (and coping) has been the subject of more investigation but with mixed findings regarding positive outcomes for different elements of the pain experience; cultural differences need particular consideration. Stoicism has been implicated in the underreporting of pain in older people, although pain related stoicism has been subjected to limited empirical investigation. There is some evidence from qualitative and quantitative research to support the existence of age related differences in attitudes of stoicism in the face of pain, its role in influencing pain reporting, and in mediating the chronic pain experience in general.

A bio psychosocial model of pain and a cognitive behavioural approach to its management highlight, in particular, the potentially important roles of the attitudes and beliefs of informal caregivers and professionals in mediating the pain experience. There has been little research conducted into the attitudes and beliefs of these groups; the evidence that does exist suggests that reduced function and increased psychological distress are related to maladaptive spousal beliefs about pain. Whilst investigation of health and social care professionals' attitudes has been more extensive, it has focused on attitudes and beliefs in relation to working age populations and low back pain. It has also suffered from a lack of conceptual clarity, has not differentiated between cancer and non-cancer pain, and is limited by the absence of well-established robust measures. The available studies point towards an adherence to bio medically orientated beliefs about pain, a degree of fear-avoidance amongst clinicians in relation to activity recommendations, and a negative orientation to chronic pain patients in general.

Extract taken from Abdulla A et al. [ 11].

8. Communication
Carlos Moreno-Leguizamon and Pat Schofield
The literature on pain in older people acknowledges the fact that the process of communication between those in pain and their care givers, either professionals or family, is a complex and difficult process to be grasped. In this context the strong tendency in the literature is to generate tools, mainly scales, which would contribute to an effective diagnosis, expression, assessment and management of chronic pain. Some studies have focused on legitimising the validity and reliability of those scales [ 14, 15].

A second emerging trend in the literature reviewed is to recommend the inclusion of a more comprehensive concept of communication, which includes important and complementary components such as nonverbal communication (facial expressions), kinesics (body movement), and proxemics (use of space) [ 16]. There are difficulties when health professionals conceptualise the process of communication as only verbal communication [ 17]. Again, the latter is, in many ways, the one with which professional caregivers and families are more familiar. Thus a frequent recommendation in the literature is the integration of various components (bio-psycho-social) of the communication process in order to grasp the experiences of those in pain [ 18]. In turn, this recommendation translates practically to training and education for professional (nurses, physicians and others) and family caregivers in how the communication process works [ 14, 16, 18, 19].

In the particular case of those with pain in advanced age, with cognitive impairments or from different cultural backgrounds, the process of communication by caregivers becomes even more complex and uncertain. This is because caregivers face more challenges in grasping the process of communication, the consequence of which is that the probability for those in pain to be undertreated or underdiagnosed becomes higher. Jorge and McDonald [20] highlighted this issue in particular in their study, working with 24 Hispanic community dwellings for elder adults in the United States. They found that, when given the opportunity to do so, these groups are able to describe their pain successfully.

The issue we face in the United Kingdom, given the limitation of time for consultation, is that it is difficult for health care professionals to spend time on discussion or consultation. We need not only to understand how the communication process works between vulnerable groups and their caregivers (professional or family), but also to realise that pain is more than mere biology; it is also a bio-psychological (subjective) and social force [ 18]. Similarly, [ 21] highlighted in their study that, by providing older adults with time to discuss their pain through open-ended questions, more success was achieved in completing the Brief Pain Inventory (BPI). Thus, the key message of both of these studies as well as some others [ 22] is that, assessment is not just about the completion of scales; it should also emphasise that individuals should have an opportunity to talk about their pain experience. In other words, the challenge is how to obtain their pain stories within short time frames.

Finally, while discussing the issue of a multidisciplinary team, Boorsma et al. [23] pointed out the need for a systematic multi-disciplinary approach to managing and treating pain. However, this study did not clarify who those professionals should be. It is recommended that a multi-disciplinary team should comprise not only health professionals but also social scientists. The latter are trained to understand the cultural, social, political, economic and communicational aspects of pain and can, therefore, enrich the clinical views.

9. Interpersonal interaction in pain assessment
Jonathon Davies and Sonia Cottom
Assessing pain in older adults is complex ([ 24]; Level III-2) and in many cases, a lack of caregiver ([ 25]; Level III-2; van Herk et al. [ 26]; Level III-2) and family knowledge ([ 27]; Level III-1) results in half of those living in pain continuing to do so ([ 28]; Level III-2) for longer than necessary, due to a lack of early detection ([ 29]; Level III-1). This failure effectively to identify and manage pain results in a reduced quality of life ([ 30]; Level III-2) and impacts negatively on interpersonal relationships between the older person and the caregiver due to the association between pain and increased aggression ([ 31]; Level IV; Bradford et al. [ 28]; Level III-2).

For specific groups, such as communicative or non-communicative nursing home residents, pain is often not detected ([ 27]; Level III-1) and older people with cognitive impairment have reported more intense pain than their cognitively intact counterparts ([ 32]; Level II). Also, due to the difficulties dementia patients have in communicating their pain, they are at far more risk of being untreated with pharmacological treatments than those without dementia ([ 33]; Level III-2). It has been suggested that approaches to measuring pain should be multi-dimensional ([ 26]; Level III-2) including attempts of self-reported pain for seniors with mild to moderate dementia ([ 25]; Level III-2).

Structured pain education should become a standard training ([ 34]; Level II), including for nursing assistants ([ 24]; Level III-2), to support caregivers in correctly assessing chronic pain in older people and learning how to alleviate it through pharmacological ([ 30]; Level III-2) and non-pharmacological interventions ([ 31]; Level IV). Pain assessment tools should be congruent with the educational levels of those being asked to complete them ([ 35]; Level IV) and further training to understand verbal and non-verbal communication ([ 27]; Level III-1) particularly when working with patients with dementia ([ 36]; Level III-2) should be provided. Systematic records of patient experiences of pain should also be kept ([ 25]; Level III-2) to help improve continuity of care for older people transferred across settings ([ 35]; Level IV) and for information transferred between staff and family ([ 27]; Level III-1; Buffum and Haberfelde [ 37]; Level III-2).

10. Self-report measures of pain assessment
Felicia Cox and Karin Cannons
The literature search was limited to English language papers only. Key search terms included: guidelines, pain assessment, older people, self-report. In addition, citations and references in selected journal articles were screened to supplement the search strategy.

86 papers were identified

73 once duplicates were removed

47 papers were considered relevant to the aim of the review. These were read to identify studies and review publications that described pain assessment that employs patient self-report in older people.

The majority of papers were from the US ( n = 22) with 15 from Europe, four from Australia, three from the UK, two from Canada and one from Brazil. Over 30 different pain assessment tools were described in the included literature. A range of settings were explored including palliative care/inpatient hospice, acute post-operative ward, and long-term nursing home. Most studies explored the accuracy and clinical utility of self-report measures in older patients with and without cognitive impairment.

The most accurate and reliable evidence of the existence of pain and its intensity is the patient's self-report ([ 38]; Level III-2, Phillips [ 39]) although there are reports of fair agreement between self-report and proxy reports of pain in patients with cognitive impairment associated with dementia ([ 40]; Level II, Leong et al. [ 41]; Level IV). That the patient self-report is the most reliable and accurate is true even for patients with impaired cognition [ 42, 43]. The responsibility for the inclusion of a regular assessment of pain during discussions with the patient lies with the clinician or carer.

Identifying appropriate words that elicit meaningful responses and consistently using this language supported by communication tools is an important part of the comprehensive assessment of a patient's pain. Older people often deny pain, but may respond positively when asked using related terms, such as soreness, aching or discomfort. Re-wording your question to elicit the presence of pain such as 'Do you hurt anywhere?' or 'What is stopping you from doing what you want to do?' can substantiate the presence or absence of pain. The strategies employed to identify the presence or absence of pain that have been successful for this individual patient should be clearly recorded in the patient's care record and Hospital Passport. Behaviours that might indicate unrelieved pain such as vocalising, postures and gestures are also important ([ 44]; Level IV) and should be included. This information must be communicated to the care team.

Using a self-report pain measurement tool for a patient with known cognitive, sensory, or motor deficits can be useful. There are a number of validated and reliable tools and the choice of tool should be based on the patient's ability to use the tool. Many patients with moderate to severe cognitive impairment are able to report pain reliably when prompted [ 45] and there is evidence that supports the assessment being performed by someone who knows the patient well ([ 46]; Level II). By employing the same tool at each pain assessment or using standardised wording during a pain discussion the clinician/carer can elicit a more reliable measure of the effectiveness of any pain interventions. Training and education in the selection of appropriate tools and their use in pain assessment is required ([ 39]; Level III, McAuliffe et al. [ 47]).

One of the key features of facilitating an effective pain assessment or conversation is to ensure that sufficient time is allowed for the older adult to process the question and to formulate a response. Instructing the patient with cognitive impairment on the use of the pain assessment tool each time it is administered can be helpful. Patients that have sensory deficits may require adjustments such as the tool provided in a more accessible format e.g. enlarged font or enhanced lighting.

11. Clinical assessment
Anneyce Knight
There are barriers to delivering optimum pain assessment and management, including practitioners not translating information and knowledge about pain assessment and management into their clinical practice ([ 48]; Level I). Furthermore, severe cognitive impairment and speech difficulties are also well documented barriers to pain assessment ([ 49]; Level IV, Blomqvist and Hallberg [ 50]; Level IV). Nurses' pain assessment skills can also be a potential problem as registered nurses' assessment of pain is seemingly more reliable than that of nursing assistants ([ 48]; Level I, Yi-Heng et al. [ 51]; Level IV). This is a challenge for optimal pain assessment if the majority of care for older people is provided by the latter group. In addition, the level of education of staff seems to influence beliefs and knowledge about pain in older people in residential care settings ([ 44]; Level IV).

Pain management based on medical assessment alone is seen as insufficient and a collaborative multi-disciplinary Team (MDT) approach is perceived to be essential ([ 48]; Level I, Cadogan et al. [ 52]; Kaasalainenen et al. [ 53]; Level IV, Layman et al. [ 54]; Level IV). However, it is recognised that there is a range of knowledge and attitudes to pain management within the MDT and that there is a need to improve this by training/education. This should not be restricted solely to initial introductory education, but should be ongoing to ensure that health care professionals understand the factors that influence the best possible assessment for pain management, alongside time and continuity in pain assessment ([ 55, 56]; Level III-3, Blomqvist and Hallberg [ 50]; Level IV, Mrozek and Steble Werner [ 57]; Level IV, Weiner and Rudy [ 58]; Level IV, Yun-Fang et al. [ 59]; Level IV, Zwakhalen et al. [ 44]; Level IV).

Furthermore, daily recording of pain improves comparison of pain and pain management ([ 60]; Level IV) and nursing home staff should consider self-report as their initial assessment tool ([ 61]; Level IV). Overall there seems to be a need for more differentiated research relating to members of the MDT, in particular in respect of registered nurses and their assistants relating to the assessment of pain.

12. Self-report measures of function for older people with chronic pain
Denis Martin
Chronic pain affects physical function in older people as in people of all ages and it is commonly assessed by self-report questionnaires. A major consensus statement offered recommendations on self-report measures of physical function in older people with pain, based on review of literature and expert opinion ([ 62]; Level II-IV). This section offers an update from that statement.

A range of self-reported measures are available for use with adults with pain. These measures have been used in studies on older people, and specific validity and reliability in older people has been examined in some measures.

Hadjistavropoulos et al. [ 62] provide a list of measures, which they view as performing well psychometrically and practically in clinical and research settings with older people. For assessment of overall function (as opposed to function related to a specific anatomical area) they list:

Functional Status Index

MPI-General Activity Scale

Physical Activity Scale

Human Activity Profile

Groningen Activity Restriction Scale

Sickness Impact Profile

SF36 - specifically in relation to its physical functioning and role limitations-physical scales

Older Americans Resources Service, which is primarily applicable to a USA-based population.

These measures are designed for use in a range of conditions. For a measure of pain and its impact the Pain Disability Index is recommended. Of these measures it is the SF36 that Hadjistavropoulos et al. [62] recommend in their suggested battery of measures for assessing pain and its effects in older adults.

A recent addition to that family of measures is the WHO Disability Assessment Schedule (WHODAS) 2.0 [63]. The WHODAS 2.0 (replacing the WHODAS II) addresses physical function within its domains of mobility, self-care, getting along, life activities, cognition and participation. It has a possible added value of being directly linked to the theoretical basis of the well-recognised WHO International Classification of Functioning, Disability and Health. As well as a straightforward procedure for analysis, broadly similar to that in the other measures, it also features the facility to conduct an advanced (and complex) analysis using Item Response Theory. This has yet to be validated on older people over 65 with chronic pain.

Measures are also available for assessing function related to specific anatomical areas. The major consensus statement [ 62] is listed the Oswestry Disability Scale and the Roland Morris Disability Questionnaire for back pain; the Neck Pain and Disability Scale for neck pain; the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for hip and knee pain; and the Disabilities of the Arm, Shoulder and Hand (DASH) for the upper limb. The statement does not include any measure for the foot, which is an oversight given how commonly foot pain features in older people and how disabling it can be. For assessment of function in the foot the Manchester Foot Pain and Disability Index (MFPDI) has demonstrated good psychometric properties in older adults over 65 years ([ 64]; Level II+). A large scale study, which was not exclusively focused on adults over 65 as it also included adults over 50 years, also supported the use of the MFPDI ([ 65]; Level II).

Self-report questionnaires of function are limited in their ability to capture the fluctuations in people's capacity and ability; the concentration on items of relevance to the population of interest means that issues of personal relevance can be obscured [ 66]. In large research trials and surveys the high numbers involved can iron out such limitations. Innovative uses of technology are also beginning to combine self-report measures with more direct observation (e.g. Wilson et al. [ 67]). However, in a one to one clinical assessment these limitations should be acknowledged and taken into account. It should also be acknowledged that self-report questionnaires are open to biases from such factors as recall and interpretation. For example, in a study on young/middle aged adults with acute back pain, discrepancies were found between self-reported reports of function and more direct measures, with depression noted as influencing the self-report [ 68]. Therefore, in assessment of an individual any self-report measures should be used alongside a thorough physical examination [ 62].

13. Pain assessment of older adults with mental health and psychological problems
Rachael Docking & Louise Tarrant
The literature search (Jan 1990-April 2017) identified 5,766 papers, of which 539 were duplicates and 32 were relevant. Three UK papers were included, with the remainder from US, Germany, Australia, Canada, China, Czech Republic, Greece, Jerusalem, Denmark, Sweden, Holland, Hong Kong and Spain.

A range of settings was used, including palliative care/inpatient hospice, acute post-operative ward, veteran rehabilitation unit, long-term nursing home, outpatient tertiary pain management service. The majority were community settings. Most studies used a cross-sectional design of associations between pain, physical functioning, and demographic, social and psychological factors. Two studies used a longitudinal design.

The most common self-report assessment tools for pain included: Multidimensional Pain Inventory (MPI), Pain & Impairment Relationship Scale (PAIRS), McGill Pain Questionnaire (MPQ), PRI, Brief Pain Inventory (BPI) (and in some cases: interRAI, Long term care facility (LTCF), STEP, Oswestry Disability Index (ODI), and items from Short Form (SF-36). The self-report assessment tools for mood most commonly used were: Geriatric Depression Scale (GDS), Centre for Epidemiologic Studies (CES-D), Disability Rating Scale (DRS), Depression Anxiety Stress Scale (DASS) (and in some cases: Postural Assessment Scale (PASS), Hospital Anxiety & Depression Scale (HADS), Addiction Severity Index (ASI), CAMDEX, PVS, and selected items from Kessler (K6), Movement Disorder Society (MDS), SF-36). Physician recorded diagnosis, structured interviews, body map diagrams, simple checklists, multiple choice questions and Likert scales designed specifically for the research were also used to assess pain and mood.

Strong associations were seen between pain and depressed mood with each being a risk factor for the other. Additionally, loneliness/social isolation were associated with an increased risk of pain. Older adults who experienced communication difficulty coupled with depression, also reported higher pain scores.

Clinicians should be cognicent that social isolation and or depressive signs and symptoms may be indicators of pre-existing pain or a predictor of future pain onset. Additionally, clinicians need to be aware of the added effects of communication difficulty on pain report in those who also experience symptoms of depression.

The levels of evidence for the included studies are shown in Table .

14. Pain assessment in cognitive impairment
Patricia Schofield
The literature search identified 164 papers, of which 54 were duplicates and 32 were relevant. Forty nine papers were reviewed in total. The majority of papers were from the US ( n = 27), the remainder were from Germany, France, Australia, Austria, UK, Canada, New Zealand and Norway. Fifteen of the papers were systematic reviews which were aimed at consolidating the state of the science. All but five of the studies involved the testing of pain scales. Four studies were intervention studies and three studies [ 69- 71] involved surveys of the staff and perceived barriers to pain assessment implementation. Rainfray et al. [ 71] surveyed 221 hospital staff in France regarding the use of the Doloplus scale. Whilst Keane et al. [ 70] surveyed 58 consultant geriatricians in Ireland regarding the use of a number of scales (Numerical Rating Scale (NRS), Visual Analogue Scale (VAS), Verbal Rating Scale (VRS), NRS, Faces Rating Scale (FRS)). A range of settings were used including: nursing home, acute, dental.

The intervention studies varied between: measuring the impact of education upon pain assessment practice ([ 72]; Level II++), to the use of pressure or aversive stimuli used to inflict pain which is then subsequently measured using a behavioural scale or facial expression.

In terms of behavioural pain assessment scales, we identified a total of 12 scales (Abbey, PAINAD, Pain Assessment Scale for Seniors with Severe Dementia (Pacslac), Disability Distress Scale (DisDat), Pade, Universal Pain Assessment Tool (Paine), Doloplus, NoPain, Checklist of Nonverbal pain indicators (CNPI), Assessment of discomfort in Dementia (ADD), Mobilization-Observation-Behavior-Intensity-Dementia Pain Scale (Mobid) & COOP). The recent review undertaken for these guidelines has identified sixteen scales, an increase of four scales. In 2007, we recommended the use of the Abbey, PAINAD or Doloplus scales based upon the best evidence at the time. We also recommended that more work needed to be done in terms of validating scales as opposed to developing any new scales. There has been no further work in terms of validating the Abbey scale, yet it still remains popular in the UK. The Bolton Pain Assessment Tool (BPAT) continues to be evaluated in clinical practice in different settings [73].

There have been a number of studies which have further explored the Doloplus scale ([ 74]; Level I+, Holen et al. [ 75]; Level II+, Rainfray et al. [ 71]; Level II, Hutchison et al. [ 76]; Level II+, Pickering [ 77]; Level II+). Furthermore, this scale has now been translated into many languages including English for use across Europe, yet it remains unpopular in the UK.

More work has been carried out using Pacslac ([ 78]; Level II+, Schiepers et al. [ 79]; Level II, Zwakhalen et al. [ 80]; Level II, Lints-Martindale et al. [ 81]; Level II+) and PAINAD ([ 82]; Level III, Jordan et al. [ 83]; Level III, Lane et al. [ 84]; Level III, DeWaters et al. [ 85]; Level III). The Pacslac scale has good inter-rater reliability ([ 78]; Level II+), is the scale most valued by nurses ([ 80]; Level III), but does need a short form and more testing in larger scale studies. PAINAD is a sensitive tool for detecting pain in adults with dementia, but does have a high false positive rate ([ 83]; Level III). The scale has not been evaluated in adults with mild to moderate dementia, but we do know that adults with mild to moderate dementia can appropriately use self-report measures and scales such as numerical rating scale and verbal descriptors. Nevertheless, PAINAD has a high sensitivity (92%) but low specificity for pain (62%). It is easy and simple to use. More research is needed using larger sample sizes and Black & Minority Ethnic groups.

15. Pain assessment guidelines for older adults
Gary Bellamy and Aza Abdulla
We conducted a review which aimed to identify existing guidelines (national and international) relating specifically to pain assessment in older adults in order to set in context this revision of the 2007 guidelines. Pain assessment is a fundamental process in effective pain management. For more detailed information please see Turk D, Melzack R [ 86] Handbook on Pain Assessment.

Search strategy: A three phase process was adopted. Based on the assumption that existing guidelines might not be available or published solely via academic journals, two additional searches were also conducted (see 2 and 3 below).

1. A literature review of key databases was conducted, including: Academic Search Premier, MEDLINE, Psychology and Behavioural Sciences Collection, PsycINFO, CINAHL Plus with Full Text, MEDLINE, EMBASE of journal articles published between 1997 and 2013. The search was limited to English Language papers only. Key search terms included: guidelines; pain assessment; older people. In addition, citations and references in selected journal articles were screened to supplement the search strategy.

73 papers were identified

47 once duplicates were removed

43 papers were considered relevant to the aim of the review. These were read to identify existing guidelines for pain assessment in older people (see attached document for articles reviewed).

The 43 papers were reviewed to identify and review pain guidelines relating specifically to older people

2. A list of world countries was also identified via the website: http://www.nationsonline.org/oneworld/countries_of_the_world.htm

Using the search engine Google scholar and the same search terms, each country on that list was added to the initial search terms. This was done so as not to miss any guidelines which may have been published elsewhere but may not have featured in academic journal articles.

3. To ascertain additional pain assessment guidelines not identified via the above searches, an advanced search of the websites: The National Guideline Clearinghouse http://www.guideline.gov and NICE http://www.nice.org.uk/ were conducted. The site aims to provide physicians and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others, with an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines, and to further the dissemination, implementation, and use of these guidelines.

The advanced search filters used were:

Search strategy key words: 'Pain'

Age of target population: Aged 65-79 and 80 years plus

Clinical speciality: Geriatrics

For the most part, guidelines relating to pain assessment in older adults are manifest in the USA, Australia and the UK. To a lesser extent, work has also been conducted in Spain, Belgium and Switzerland. The work of the latter three countries has been mentioned briefly in this document.

USA

In 1998 the American Geriatrics Society (AGS) provided the first clinical practice guideline on the management of chronic pain in older people [ 87]. This was updated in 2002 [ 88]. Both versions concentrated on the assessment of pain and its pharmacological management.

The guidelines put forward by the AGS [88] are divided into four sections. These include: the assessment of persistent pain, pharmacologic treatment, non-pharmacologic strategies, and recommendations for health systems that care for older persons. For each section, general principles are followed by the panel's specific recommendations for improving the clinical assessment and management of persistent pain in older persons. These recommendations are meant to serve as a guide to practice and should not be used in lieu of critical thinking, sound judgment, and clinical experience.

The guidelines produced in 2002 by the AGS were subsequently revised in 2009 by an expert panel assembled under the auspices of the American Geriatrics Society, with recommendations for pharmacologic management of pain in older adults [ 89]. It was determined that the sections of the 2002 guideline dealing with assessment and non-pharmacologic treatment did not need updating and were still relevant to today's practicing clinicians. However, another guideline was developed describing medications to avoid and dosing modifications for older adults with poor renal clearance [ 90]. The American Society for Pain Management Nursing Task Force on Pain Assessment in the Nonverbal Patient (including individuals with dementia) also recommended a comprehensive, hierarchical approach that integrates self-report and observations of pain behaviours [ 91].

Guidelines created by an expert group convened by the American Pain Society and the American Academy of Pain Medicine evaluated the current evidence on safe practices for the use of opioids to treat non-cancer pain [ 92]. Notably, comprehensive approaches were recommended to address psychosocial factors and functional impairment as well as pain. Specific recommendations for older patients include low-dose initiation and slow titration of opioid therapy, constipation prophylaxis and frequent monitoring of patient responses to therapy. These guidelines provide some of the landmark principles for pain treatment decisions and care of older adults today. Current guidelines in relation to general principles of pharmacological pain management for older people [ 89] state:

Use the least invasive route for medication

Where possible, choose sustained release formulations

Introduce one agent at a time, at a low dose, followed by slow dose-titration

Allow a sufficiently large interval between introducing drugs to allow assessment of the effect

Treatment should be constantly monitored and adjusted if required to improve efficacy and limit adverse events

It may be necessary to switch opioids.

Australia

The Australian Pain Society addresses the issue of pain in its first ever publication focused exclusively on older adults; it is entitled Pain in Residential Aged Care Facilities: Management Strategies [ 93]. It presents strategies and guidance to assist in identifying and assessing residents' pain effectively across a range of areas that includes managing pain using a combination of pharmacological and non-pharmacological treatment options. It also examines issues of quality management and organisational structure related to pain management. An additional document, the Pain Management Guidelines (PMG) Kit for Aged Care [ 94] has been designed to be used with the Australian Pain Society's document [ 93] to assist in the implementation of best practice for pain management in aged care facilities.

The APS document [93] draws upon relevant international best practice approaches, expert opinion and published research evidence up to 2004 - particularly from the American Geriatric Society and the American Medical Directors and Health Care Associations. The document is evidence based and should be used to guide decision making about changes to current practice. The pain management guidelines are a summary only and should not be used in isolation to guide practice.

United Kingdom (UK)

In 2007 the Royal College of Physicians, British Pain Society and British Geriatric Society published their guidelines on the assessment of pain in older adults [95]. The emphasis of the document is on chronic pain management and it is a comprehensive guide to the methods of assessment and the tools available. The guidelines recommend that for older adults with mild to moderate dementia, the numerical rating scale and the verbal rating scales can be applied. However, as the level of cognitive impairment becomes more severe, specific behavioural scales should be used, of which there are 11, to measure pain intensity. The guidelines suggest that the Abbey Pain Scale appears to be the most user-friendly. They are designed to allow clinicians to make rapid, informed decisions based wherever possible on synthesis of the best available evidence and expert consensus gathered from practising clinicians and service users. A key feature of the series is to provide both recommendations for best practice, and where possible practical tools with which to implement it.

The concise guidelines for pain management in older adults include the following:

Where pain is present, a detailed clinical assessment of the multidimensional aspects of pain should be undertaken including:

Sensory dimension: the nature, location and intensity of pain

Affective dimension: the emotional component and response to pain

Impact: on functioning at the level of activities and participation.

An attempt to locate pain should be made by asking the patient to point to the area on themselves, and by using pain maps to define the location and the extent of pain.

Pain assessment should routinely include the use of a standardised intensity rating scale, preferably a simple verbal descriptor scale or a numeric rating scale if the person is able to use these.

Once a suitable scale has been identified, serial assessment should be undertaken using the same instrument to evaluate the effects of treatment [95].

Another guidance document was produced in 2013 which reviews the epidemiology and management of pain in older people via a literature review of published research. This document informs health professionals in any care setting who work with older adults regarding best practice for pain management [96]. The document is separated into sections addressing pharmacology, interventional therapies, psychological interventions, physical activity and assistive devices and complementary therapies.

Spanish geriatricians typically rely on the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons guideline [ 88] and the recommendations of the Assessing Care of Vulnerable Elders (ACOVE) project (Rand Health 2000). A regional guideline for the management of chronic pain in older adults in nursing homes was released in Valencia, but no geriatricians contributed and it is rarely used. The Sociedad Española de Geriatría y Gerontología (SEGG) has published two booklets with recommendations on pain management in older people [ 95, 97, 98], but these are not used widely either.

There are no official clinical guidelines or standards for the management of chronic pain that focus exclusively on older patients. However, there is a pocket guide concerning the treatment of pain in older people written by Belgian pain specialists and geriatricians [99]. Many hospitals and nursing homes have developed their own tools and standards. These are mostly locally available and not widely known.

According to Pautex et al. [ 100] the management of chronic pain in older patients has received some attention in Switzerland recently. In collaboration with the division of clinical pharmacology and toxicology, guidelines have been developed in Geneva University Hospitals for the use of opioids in the older population, in particular for those with renal impairment. Some other local tools might be available in the German or Italian part of Switzerland [ 100].

The importance of pain assessment is clearly acknowledged and specific tools and strategies are promoted in older patients, especially for those with impaired communication abilities. Furthermore, pain management has received increased attention, in stationary and ambulatory settings, and for different types of pain. It has been stressed that chronic pain in older people does require taking into account both the somatic co-morbidities and the psychosocial dimensions. Indeed, chronic pain and associated functional limitations may be an indicator of distress and of a need for help. The therapeutic response will then address and highlight the patient's functional capacities, aiming to re-mobilise the patient's resources; pain management will focus on restoring self-esteem and increasing quality of life. Treating a concomitant depression requires a true commitment from the therapist; its benefits are clearly documented in older patients. However, no specific standards have yet been devised for the management of chronic pain in older patients [101].

16. Acknowledgements

The Guideline Development Group (GDG) would like to thank Joanna Gough, scientific officer at the British Geriatric Society for providing administrative support. The GDG would also like to thank Leigh Rooney and Prof Denis Martin for leading and undertaking the systematic search of the literature. The GDG are grateful to the British Pain Society and the British Geriatrics Society for the provision of facilities for meetings, and to the peer reviewers who took the time to provide valuable and considered feedback. The British Geriatrics Society and the British Pain Society had no role in the writing of this manuscript.

17. Matrices

Available in Age and Ageing online.

18.References

19. Appendices

Available in Age and Ageing online.

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Assessment of Pain in Older People: UK National Guidelines | Age and Ageing | Oxford Academic

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We are facing a huge increase in the older population over the next 30 years. This brings an anticipated increase in the prevalence of chronic pain and with this comes the challenge of assessment of pain in many varied settings. Our first iteration of this document was published in 2007.

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Gabapentin patient information