Background & Aims

Pain is a common symptom reported by inpatients either as a result of long-standing disorder or due to an acute injury. Opioids are often the mainstay treatment used for the management of severe acute pain. In recent times we have observed a significant increase in the age profile of medical inpatient’s in St. John’s Hospital. The management of pain in this group of patients is challenging owing to the increased risk of delirium if pain or medications to relieve the pain are poorly managed.
The aim of this audit is to determine if current practice is in keeping with national and international recommendations regarding opioid prescribing and stewardship in patients 65yrs old and over.
The objectives are to examine opioid prescribing practices, to assess the incidence severity of pain in this cohort, and to provide insight into the current care delivery to the management of acute pain.

Methods

A snap shot audit using point prevalence was undertaken. All inpatient medical patients were assessed by the Clinical Nurse Specialist in Pain Medicine on a given day using the Pain Assessment and Documentation Tool.
Inclusion Criteria: all medical inpatients within St. John’s Hospital aged 65yrs and older capable of self-report of their pain and other symptoms.
Exclusion criteria: Patients unable to provide self-report of their pain and other symptoms

Results

•89% (n = 48) fulfilled the inclusion criteria and were included in this audit
•35% (n =17) of the patients reported their worst pain as severe
•23% felt their physical function had declined since admission due to pain and 12.5% reported pain interference with sleep
•A total of 46% of the patients were prescribed opioids
•Of these, 55% received long-acting opioids and 45% short acting opioids

Conclusions

This audit has identified crucial areas for improvement in the process of pain assessment and management in St. John’s Hospital, namely, the criteria warranting a prescription of strong opioid medication, and the judicious use of PRN opioids. Appropriateness of therapy was outside of the scope of this preliminary audit, however due to the high prevalence rates observed, this will be the subject of further investigation and audit in the coming quarter to increase our knowledge and understanding.
Given the findings from this audit the need for guidance on the topic of acute pain management in this patient cohort is evident, thus the development of a guideline on this topic will be prioritised in order to increase knowledge and ensure a consistent approach to pain management across the organisation in keeping with HSE guidelines.
As well as helping to improve the quality of pain management and opioid stewardship in patients >65years of age presenting with acute pain.

References

1.Fischer T, Hosie A, Luckett T, Agar M, Phillips J (2019) Strategies for pain assessment in adult patients with delirium: a scoping review. Journal of Pain and Symptom Management. 58(3):487-502.
2.Hasseini F, Mullins S, Gibson W, Thake M (2022) Acute pain management for older adults. Clinical Medicine. 22(4): 302-306.
3.Kelley A, Siegler EL, Carrington Reid M (2008) Pitfalls and recommendations regarding the management of acute pain amongst hospitalized patients with dementia. Pain Medicine. 9(5): 581-586.
4.Robinson S, Collmer C, Jirka H, Rich C, Midiri C, Bisby D (2008) Aging and delirium: too much or too little pain medication? Pain Management Nursing. 9(2): 66-72.
5.Mehta SS, Siegler EL, Henderson CR, Carrington Reid M (2010) Acute pain management in hospitalized patients with cognitive impairment : a study of provider practices and treatment outcomes. Pain Medicine. 11: 1516-1524.
6.Sampson EL, West E, Fischer T (2020) Pain and delirium: mechanisms, assessment, and management. European Geriatric Medicine. https://doi.org/10.1007/s41999-019-00281-2.
7.HSE Guidance for opioid prescribing for acute non-cancer, post-operative, and post procedural pain (2021).
8.Barry M (2022) appropriate prescribing of opioids in the management of chronic non-cancer pain. Medicines Management Programme. (MMP).
9.Scottish Intercollegiate Guidance Networks (SIGN) (2022) Guidance of chronic pain (primary and secondary) in over 16s: assessment and management of chronic pain. NICE Guideline. www.nice.org.uk/guidance/ng193. Accessed on 10th of May 2024.
10.Passik SD, Kirsh KL, Whitcomb L, Portenoy RK, Katz NP, Kleinman L, Dodd SL, Schein JR (2004) A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy. Clin. Ther. 26(4): 552-61.
.1 Fischer T, Hosie A, Luckett T

Presenting Author

Patricia Molyneau

Poster Authors

Patricia Molyneau

MSc in pain management

Cardiff University

Lead Author

Topics

  • Pain in Special Populations: Elderly