I believe better care starts with better understanding. That’s why I am part of an amazing team Liz Blacklock Stella Shaw and Daniel Cook building @Care Boodle – a simple, smart app to help carers spot and manage delirium, a common and often missed condition in older adults living with frailty.
One of the major drivers of delirium is untreated pain – and recognising pain, especially in those with dementia or frailty, is not always straightforward. That’s why this article explores how pain presents, how to assess it, and how tools like the PINCH ME checklist can help carers find the root cause of sudden confusion or behaviour change.
Stay tuned as @Care Boodle launches soon – putting carer-friendly tools like the PINCH ME screen, delirium checklists, and symptom trackers at your fingertips.
Pain in the Elderly: Silent Suffering and What We Can Do About It
Pain is not a normal part of ageing – yet many older adults live with chronic pain every day. What’s worse, their pain is often under-reported, under-assessed, and under-treated.
The Hidden Impact of Pain
Persistent pain can lead to reduced mobility, social withdrawal, sleep disturbances, depression, and even cognitive decline. For older adults living with frailty, pain can tip the balance from independence to dependency.
How Do People with Dementia Express Pain?
Pain may look different in someone with dementia. They may not be able to tell you where or how much it hurts, but there are common signs:
- Grimacing or frowning
- Moaning, groaning, or calling out
- Resistance to care or sudden aggression
- Withdrawal or becoming unusually quiet
- Increased confusion or restlessness
- Guarding a body part or not using it normally
- Changes in appetite or sleep
As dementia progresses, pain may be expressed more through behaviour than words. That’s why observation is key.
Pain Assessment Tools for Carers
1. Abbey Pain Scale For people unable to verbalise pain – looks at facial expression, vocalisation, body language, and more.
2. PAINAD (Pain Assessment in Advanced Dementia) Scores five items – breathing, vocalisation, facial expression, body language, and consolability.
3. Doloplus-2 Used in residential settings – tracks physical, psychomotor and psychosocial indicators.
4. Wong-Baker FACES or Verbal 0–10 Scales Helpful in those still able to self-report with prompts.
Delirium and the PINCH ME Screen
Delirium is a sudden change in awareness, alertness (more sleepy than usual) or behaviour (more agitated or restless than usual). It’s common in frailty, and pain is a key cause. The PINCH ME acronym helps carers look for treatable causes of delirium:
- P – Pain
- I – Infection
- N – Nutrition (poor intake or dehydration)
- C – Constipation
- H – Hydration
- M – Medications (new or stopped)
- E – Environment (change, overstimulation, sensory impairment)
The @CareBoodle app will soon offer carers a digital PINCH ME screen – making it easy to track changes and identify if a client might be experiencing pain-driven delirium.
Treating Pain in Older Adults Living With Frailty
Pain in frailty is often complex and multifactorial – but many types are treatable with a mix of medication, physical measures, and careful observation.
Here’s a practical, carer-friendly approach:
✅ 1. Ask Regularly
- Don’t assume no complaint = no pain
- Ask simple, direct questions like “Do you feel sore or stiff today?”
- Use visual pain scales if needed (e.g., Wong-Baker FACES)
✅ 2. Observe Behaviour
- Look for facial expressions, guarding, flinching, restlessness, or agitation
- Use tools like the Abbey Pain Scale or PAINAD for people with dementia
✅ 3. Trial Simple Measures First
- Identify and treat cause – e.g. Osteoarthritis, infection, urinary retention, constipation, cancer, fractures, uncomfortable position, dentition, ear ache, emotional pain
- Regular paracetamol (up to 4g per day, spaced doses) – low side-effect profile
- Warmth (heat pads, warm bath)
- Gentle massage or movement
- Repositioning (especially for pressure areas)
- Encourage hydration – dehydration worsens pain and increases confusion
✅ 4. Involve Families and Follow Up Often
- Families know the person’s baseline and notice subtle changes
- Check regularly if the pain has improved or changed
- Keep a written record if possible, especially if multiple carers are involved
🧓 Pain Relief in Older Adults with Frailty – Choosing the Right Painkiller for the Right Pain 👩⚕️
Pain in older adults is often complex – and choosing the right medication matters. Here’s a quick carer-friendly guide to types of painkillers, what they’re used for, and how they’re given:
🔹 Paracetamol Best for: Musculoskeletal pain (e.g. arthritis, chronic stiffness), mild general pain Forms: Tablets, liquid, suppository 💡 Safe, effective, and well tolerated – often given regularly rather than as needed
🔹 NSAIDs (e.g. ibuprofen, naproxen) Best for: Inflammatory pain (e.g. osteoarthritis flares) Forms: Tablets, gels, creams ⚠️ Use with caution in frailty – risks include stomach ulcers and kidney injury. Avoid in dehydration or with heart failure.
🔹 Codeine and other Weak Opioids Best for: Moderate pain not controlled by paracetamol alone – e.g. post-surgical pain Forms: Tablets, liquid, combination products (e.g. co-codamol) ⚠️ Can cause constipation, drowsiness, or confusion – always co-prescribe a laxative.
🔹 Stronger Opioids (e.g. morphine, oxycodone, fentanyl, buprenorphine) Best for: Severe pain – cancer pain, advanced arthritis, palliative care Forms: Tablets, liquids, patches, oro-dispersible tablets 💡 Patches (e.g. fentanyl, buprenorphine) are useful in swallowing difficulties or when regular oral doses are hard to manage ⚠️ Requires careful titration and review – monitor closely for side effects
🔹 Nefopam Best for: Moderate to severe pain where opioids are unsuitable (e.g. in renal impairment) Forms: Tablets 💡 Doesn’t affect the gut like opioids – useful when constipation is a major concern ⚠️ Can cause confusion or dizziness in older adults – use with caution
🔹 Amitriptyline, Gabapentin, Pregabalin (Neuropathic agents) Best for: Nerve pain – e.g. post-stroke, diabetic neuropathy, shingles Forms: Tablets or capsules 💡 Start low and go slow – these can help with sleep and pain but may cause sedation or dizziness
🔹 Topical Analgesics (e.g. lidocaine patches, capsaicin cream) Best for: Localised musculoskeletal or neuropathic pain Forms: Gels, creams, patches 💡 Good option when oral meds are risky – e.g. in polypharmacy or frailty
✅ Always consider non-drug options too: Treating the cause (e.g. constipation, urinary retention, hip replacement), warmth, repositioning, massage, physio, walking aids, and hydration all help.
Let’s treat pain properly – the right med, at the right dose, for the right kind of pain.
When to Refer for Medical Review:
- Sudden onset or new pain
- Pain that interferes with sleep or mobility
- Suspected fracture, infection, or internal cause
- Pain that’s worsening despite regular treatment
- Signs of delirium (confusion, new aggression, drowsiness)
By taking small, consistent steps to ask, observe, and act – carers can make a powerful difference. Pain is treatable. And in frailty, treating it well means preserving independence, dignity, and quality of life.
Final Thoughts
Having a comprehensive older adult health assessment can help clients and their loved ones recognise signs of infection sooner for prompt treatment.
https://homevisithealthcare.co.uk/comprehensive_geriatric_assessments/
Call us to learn more:
Dementia, Delirium or Mild Cognitive Impairment – The Bitesize Guide