Chronic disease and elderly care
Chronic disease management [link]
The expert patient [link]
Normal ageing [link]
Elderly care and rehabilitation [link]
Prescribing for the elderly [link]
Falls amongst the elderly [link]
Assessment of pain [link]
Principles of pain control [link]
Pain-relieving drugs [link]
Morphine and other strong opioids [link]
Neuropathic pain [link]
Support for informal carers [link]
Pensions and benefits [link]
In other sections of this book, where management differs from the norm for elderly patients, the text is highlighted in a box marked with this symbol.
Chronic disease management
The predominant disease pattern in the developed world is one of chronic or long-term illness. In the UK, 17.5 million adults are currently living with a chronic disease. Long-term conditions frequently seen and managed in general practice include:
• Arthritis of all types
• Back pain
• Chronic lung disease
• Renal or liver failure
• Irritable bowel syndrome
• Inflammatory bowel disease
• Chronic neurological conditions, e.g. Parkinson’s disease, MS
• Cardiovascular disease, e.g. ↑ BP, heart disease, stroke
• Psychiatric illness, e.g. depression, psychosis.
Although details of chronic illness management depend on the illness, people with chronic diseases of all types have much in common with each other. They all:
• Have similar concerns and problems ( p.[link])
• Must deal not only with their disease(s) but also with the impact it has on their lives and emotions.
Common elements of effective chronic illness management
• Involvement of the whole family Chronic diseases affect not only the patient but everyone in a family.
• Collaboration between service providers and patients/carers Negotiate and agree a definition of the problem; agree targets and goals for management; develop an individualized self-management plan.
• Personalized written care plan Take into account patient’s/carers’ views and experience and the current evidence base.
• Tailored education in self-management A diabetic spends ~3h/y with a health professional—the other 8757h he/she manages his/her own condition. Helping patients with chronic disease understand and take responsibility for their conditions is imperative. User-led (i.e. led by someone who suffers from the condition) self-management education programmes are most effective.
• Planned follow-up Proactive follow-up according to the careplan—use of disease registers and call–recall systems is important.
• Monitoring of outcome and adherence to treatment Use of disease and treatment markers; monitoring of concordance, e.g. checking prescription frequency; medicine management programmes ( p.[link]).
• Tools and protocols for stepped care Provide a framework for using limited resources to greatest effect; step professional care in intensity—start with limited professional input and systematic monitoring, and then augment care for patients not achieving an acceptable outcome; initial and subsequent treatments are selected according to evidence-based guidelines in light of a patient’s progress ( p.[link]).
• Targeted use of specialist services for those patients who cannot be managed in primary care alone.
• Monitoring of process Continually monitor management through clinical governance mechanisms ( p.[link]).
National Service Frameworks (NSFs)
Models of how services should be provided. They were developed to improve patient care and address variations in service provision across the UK and are a key part of NHS quality initiatives. They cover all areas of service delivery, not just clinical practice. Relevant NSFs and related programmes include:
• Blood pressure
• Coronary heart disease
• Long-term (neurological) conditions
• Older people
• Mental health
• National stroke strategy
• End-of-life care programme.
Depression screening and chronic diseaseN
Depression is common among people with chronic disease. Use the NICE depression screening questions to detect depression:
• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?
A positive response to either of these questions should prompt further assessment. Depending on the severity of the depression consider additional support, e.g. with counselling or through disease-specific organizations and/or drug therapy with antidepressants.
The expert patient
Most doctors acknowledge that many of their patients with chronic conditions know their own condition best. Expert patient programmes (or patient self-management programmes) utilize this fact to improve patient care. The aim is to promote effective partnerships in management of chronic disease by combining the expertise of patient and doctor (Figure 9.2).
Chronic disease self-management programmes
have been developed over the last 20y. They are a system of patient education and empowerment. As well as using health professionals, they use trained lay people with chronic illness as tutors. The 5 core self-management skills are:
• Resource utilization
• Formation of a patient–professional partnership
• Taking action.
However, none of these is in itself the key to effective self-management. The key is the change in the individual’s confidence and belief that they can take control over their disease and their life.
Common patient concerns may include
• Finding and using health services.
• Finding and using other community resources.
• Knowing how to recognize and respond to changes in a chronic disease.
• Dealing with problems and emergencies.
• Making decisions about when to seek medical help.
• Using medicines and treatments effectively.
• Knowing how to manage the stress and depression that accompany a chronic illness.
• Coping with fatigue, pain, and sleep problems.
• Getting enough exercise.
• Maintaining good nutrition.
• Working with your doctor(s) and other care providers.
• Talking about your illness with family and friends.
• Managing work, family, and social activities.
The UK is home to 60.2 million people. Average age is 38.8y and rising. By 2004, women aged 65 could expect to live to the age of 85. Projections suggest that this will ↑ by another 3y by 2021. Over the past 35y, the population aged >65y has grown by 31% from 7.4 to 9.7 million. The largest percentage growth in population is in the >85y age group.
What is ageing?
Ageing is a gradual series of changes over time that lead to the loss of function of organs and cells, with the eventual outcome of death. Individuals vary greatly in the rate at which they age. Several factors seem to influence this:
• Genetic make-up
• Psychological health
• Lifestyle—diet, physical exercise, smoking.
• Socio-economic factors
Normal changes of ageing
Table 9.1 Normal changes of ageing
Cardiac enlargement/left ventricular hypertrophy
↓ cardiac output →↓ exercise capacity
↓ response of heart rate to exercise
Left ventricular failure
↓ FEV1/FVC and ↑ residual volume
↑ susceptibility to infection
↑ susceptibility to aspiration
↓ insulin sensitivity → impaired glucose regulation
↓ thyroid hormone production
↑ gastric acid production
↓ glomerular filtration rate not reflected by ↑ creatinine
Benign enlargement of the prostate (25–50% of men >65y) → prostatism
Slowing of sexual function; erectile dysfunction
Dry vagina and ↑ susceptibility to urinary infections (♀)
Sarcopoenia—↓ muscle strength/power, ↓ lean body mass (30–40%), ↑ fat body mass
↑ likelihood of falls
↑ osteoporosis/susceptibility to fractures
Slower thought processes/reaction times
General decline in performance
Dementia is not a normal change of ageing
Presbyopia (difficulty focusing on near objects), ↓ visual acuity, cataract, impaired dark adaptation
High-frequency hearing loss/presbyacusis—deafness affects 80% of 80y olds
Degenerative changes in the inner ear → impairment of balance, causing falls
Atrophy of the thymus
Reduced immune function resulting in ↑ infectious disease, reactivation of latent disease (e.g. TB, shingles), ↑ cancer, ↑ autoimmune disease
Dry skin, wrinkles, tendency to bruise easily, and slower healing
Greying of the hair
↓ sweating, heat generation, and heat conservation → heat stroke; hypothermia
↓ sensitivity to touch, pain and temperature discrimination → burns, pressure sores
Difficulties assessing the elderly
• Communication problems—hearing, cognition, speech.
• Multiplicity of cause—a single symptom may be caused by different concurrent processes, e.g. breathlessness as a result of COPD + heart failure.
• Non-specific symptoms/signs—confusion, falls or ‘off legs’ may be the only overt sign of underlying disease, e.g. UTI, MI, stroke.
• Symptoms may be absent despite disease, and signs harder to elicit.
• Polypharmacy ( p.[link]) may result in side effects and interactions.
• Laboratory tests may be unreliable, especially white cell counts and ESR (always check CRP).
The ageing process is compounded by overt disease. This may affect functional capacity, quality of life, and independence, cause frailty, ↓ well-being and independence, and result in ↑ care and mobility needs.
Effects of multiple conditions
Older people are more likely to have several ongoing chronic illnesses which can act in combination to cause disability greater than any one of those illnesses alone and/or result in:
• Direction of care at some problems, with relative neglect of others.
• Polypharmacy ( p.[link]).
• Involvement of multiple specialist teams which can cause inconvenience to the patient and family, and result in conflicting advice, and opposing opinions on cause/effect of symptoms.
Many elderly people are described as being ‘frail’. This term is used to describe individuals who are physically weak and fragile. It can occur on a background of natural ageing or be precipitated by a disease process. It is not a disease or disability in itself, but a vulnerability or inability to withstand physical/psychological stressors. Common features of frailty include:
• Unintentional weight loss (>5kg in a year)
• Feeling of exhaustion
• Weakness (measured by grip strength)
• Slow walking speed
• Low levels of physical activity.
Elderly care and rehabilitation
Use strengthens, disuse debilitates.
13–14% of the population have some disability. This is increasing as populations age and people survive longer with disability. Many more are just elderly and frail. 35% of people aged >80y cannot live an independent life. Most patients are best managed by a multidisciplinary team in their home environment (if practicable) with a problem-oriented approach. Good interdisciplinary communication and coordination is essential and many patients benefit from specialist rehabilitation services. Psychological and sociocultural aspects are as important as medical aspects.
Role of the GP
Maintain an open-door policy and encourage patients and carers to seek help for problems early. Try to become familiar with patients’ diseases, even if rare. It is impossible to plan care without knowledge of course and prognosis, and an easy way to lose a patient’s confidence is to appear ignorant of their condition.
The GP of any elderly patient or patient receiving rehabilitation in the community is a team member and is often the key worker who coordinates care. Information alone can improve outcome.
• Can physical symptoms be improved?
• Can psychological symptoms be improved? (including self-esteem)
• Can functioning within the home be improved? (aids and adaptations within the home, extra help)
• Can functioning in the community be improved? (mobility outside the home, work, social activities)
• Can the patient’s or carer’s financial state be improved?
• Does the carer need more support?
If progress is slower than expected, or stalls, consider other medical problems (e.g. anaemia, hypothyroidism, dementia), a neurological event, depression, or communication problems (e.g. poor vision/hearing).
Principles of rehabilitation and elderly care
• Use of assessments/measures Central to the management of frailty/disability. Use validated measures accepted by all team members (e.g. Barthel index p.[link]). Reassess regularly.
• Teamwork Good outcomes are associated with clinicians working as a team towards a common goal with patients and their families (or carers) included as team members.
• Goal-setting Goals must be meaningful and challenging, but achievable. Use short- and long-term goals. Involve the patient ± carer(s). Regularly renew, review, and adapt.
• Underlying approach to therapy All approaches focus on modification of impairment and improvement in function within everyday activities. Patients derive benefit from therapy focused on the management of frailty/disability.
• Intensity/duration of therapy How much therapy is needed? Is there a minimum threshold below which there is no benefit at all? Studies on well-organized services show it is rare for patients to receive >2h therapy/d. No-one knows what is ideal.
A multidisciplinary approach is ideal, e.g.
• DNs provide nursing care and equipment, advice on all aspects of nursing care and teach carers how to do everyday tasks (e.g. emptying catheter bags, lifting). They are sources of information on local services and provide support for carers of patients on their caseload.
• Community matrons provide specialist nursing support on all aspects of care for patients with chronic conditions who are high users of health services.
• Community physiotherapists are invaluable sources of help, advice, and equipment for practical problems relating to mobility.
• Occupational therapists can help patients and carers cope with difficulties in everyday living caused by disability by providing aids and appliances and arranging alterations.
• Speech therapists can help with communication problems.
• Medical opinion for clarification of diagnosis (e.g. if diagnosis is in doubt or patient has symptoms/signs incongruous with diagnosis).
• Specialist rehabilitation services New or deterioration in existing impairment, disability, or handicap, or advances in management that warrant referral for specialist care.
• Social services for assessment of the home for modification, assessment to allow application for mobility aids or services to help the disabled person and/or carer to cope.
• Voluntary organizations and self-help groups Useful sources of support for patients and carers.
• Citizen’s Advice Bureau for independent advice on benefits and services.
• Disabled Living Foundation for independent advice on equipment and appliances.
Common neurological rehabilitation problems
Equipment and adaptations
Table 9.6 Adaptations and equipment for elderly and disabled people All purchases related to disability are VAT exempt
How to apply
Anyone requiring a wheelchair(s) for >3mo
Short-term loan of equipment is often available via the Red Cross
Referral by GP or specialist to the wheelchair service centre
Directory of service centres is available at www.wheelchairmanagers.nhs.uk
Provision of suitable wheelchair
Vouchers enable disabled patients to purchase their chairs privately
Occupational therapy (OT) assessment
All elderly or disabled people
Request a needs assessment by an occupational therapist via local social services department
Enables provision of equipment and adaptations necessary to maintain an independent lifestyle
Disabled Living Centres
Disability Living Foundation
All elderly or disabled people
49 Disabled Living Centres in the UK—list available from www.assist-uk.org
Disabled Living Foundation www.dlf.org.uk
Disabled Living Centres look at and try out equipment with OTs on hand to advise
Disabled Living Foundation information on aids and adaptations
People who have physical difficulty using the telephone or communication problems
British Telecom produce a booklet Communication Solutions obtainable from 0800 800150 or www.bt.com
If difficulty using a telephone directory register to use directory enquiries free 0800 5870195
Gadgets and services that make it easier for disabled or elderly people to use the telephone
Any disabled or elderly person who is alone at times, at risk, and mentally capable of using an alarm system
Arrange via local social services or housing department. Alternatively, charities for the elderly have schemes e.g.
Age Concern—Aid-Call 0800 772266
Enables a call for help when the phone cannot be reached
Patient information and support
Prescribing for the elderly
Use of medicines ↑ as people get older. 1 in 3 NHS prescriptions are issued to patients >65y. 90% of these prescriptions are for repeat medications. Adverse drug events are common reasons for hospital admission in the >75y age group. Many are avoidable. Regular review is essential.
Problems commonly encountered
Elderly people often have multiple problems—it is easy to keep adding drugs for each new problem → polypharmacy. This ↑ confusion about drug regimes, and results in poor concordance and multiple interactions/side effects.
• Before prescribing a new drug, consider whether it is necessary—avoid treating normal changes of ageing; use non-pharmacological therapies wherever possible; avoid ‘a pill for every ill’ approach and try to treat the underlying condition, not the symptoms
• Balance the potential risks of the drug against the benefits. Drug trials of efficacy of medication often exclude older participants—the applicability of evidence to elderly patients cannot be assumed. For prophylactic medication (e.g. warfarin, statins), consider the likelihood of concordance and benefits in the context of the whole person (including other comorbidities).
• Review medication regularly. Stop ineffective/redundant drugs and consider whether the overall drug regime can be simplified.
Form of the medicine
Swallowing tablets can be difficult for elderly people. Consider using liquid preparations/giving explicit advice to take medication with plenty of water and sitting upright.
Up to half of all patients are inadvertently prescribed the wrong medication after hospital discharge.
Especially if recent changes in medication. It is common for elderly people to have a back stock of drugs and continue taking their old drugs alongside new ones. A written list may be helpful. Many elderly people also self-medicate extensively with OTC preparations. If necessary, do a home visit to sort out the drugs.
↑ susceptibility to side effects
Common due to altered:
• Pharmacodynamics—↑ susceptibility to GI side effects (e.g. constipation with opioids; gastric irritation with NSAIDs) and ↑ sensitivity to effects of CNS drugs (e.g. benzodiazepines, opioids—use with care).
• Pharmacokinetics—↓ renal function is particularly important. Always assume any elderly person has moderate impairment if renal function is not known.
Beer’s list is a list of agents to be avoided/used with extreme caution in elderly patients. It can be accessed via: www.dcri.duke.edu/ccge/curtis/beers.html
Gallagher P et al. STOPP (Screening Tool of Older Persons Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation Int J Clin Pharmacol Ther (2008) 46, 72–83.
Find This Resource
Falls amongst the elderly
Falls are a major cause of disability and the leading cause of mortality due to injury in people aged >75y. Tendency to fall ↑ with age. Assessment of a patient who has fallen is a common primary care emergency.
Risk factors for falls
Recurrence ↑ with number of risk factors:
• ♀:♂ ≈ 2:1 in the over 75s
• ↑ age
• Multiple previous falls
• Disorders of gait or balance
• Visual impairment
• Cognitive impairment
• Low morale/depression
• High level of dependence
• ↓ mobility
• Foot problems
• Lower limb weakness or arthritis
• History of stroke or PD
• Use of psychotropic drugs, sedatives, diuretics, or β-blockers
• Environmental factors, e.g. loose rugs, poor lighting, ice, high winds
• Infection, e.g. pneumonia, UTI.
Deal with the injuries first—ask about pain, loss of function, headache. Ask carers about behaviour.
Check for bruising, ↓ function, confusion, BP, pulse, neurology, and fundi. Consider hypothermia if on the floor for any duration.
Investigate the cause of the fall
• Physical problems Neurological problems (e.g. stroke); visual loss; cardiac abnormalities (e.g. arrhythmia, postural hypotension); muscular abnormalities (e.g. steroid-induced myopathy); skeletal problems (e.g. osteoarthritis); infection (pneumonia, UTI).
• Environmental problems Climbing ladders to do routine maintenance; loose/holed carpets; slippery floor or bath; chair or bed too low.
• Treat acute injury (20%). Exclude fracture (mainly Colles’/neck of femur). Subdural haematoma may take days/weeks to reveal itself.
• Even if uninjured, older people might not be able to get up off the floor without help. The result may be a prolonged period of lying on the floor until help arrives. Apart from the indignity/helplessness this causes, 2° problems (e.g. pneumonia, pressure sores, hypothermia, UTI, and dehydration) may follow.
• Perform/refer to a specialist falls service for a falls assessment.
• Undertake measures to ↓ risk of falls or damage from falling.
Refer to A&E if
• Significant head injury ( p.[link])
• Any suspicion of fracture
• Any other significant injury (e.g. lacerations).
Admit to the acute medical team or elderly care team if
• Cause of the fall was an acute medical problem (e.g. stroke).
• The patient is unable to cope at home.
Prevention of falls
Falls are one of the biggest risk factors for fracture. All elderly people should have risk of falls assessed regularly.
Any fall may seriously undermine an elderly person’s confidence and cause worry about the possibility of recurrence. As a result, there may be restriction of activities →↓ fitness and ↑ dependency on others.
Is a falls assessment needed?
Ask if patients fall—they may not volunteer the information spontaneously.
The Get up and Go test—People who can get up from a chair without using their arms, walk several paces, and return with no difficulty or unsteadiness are at low risk of falling. People who have difficulty with the Get Up and Go test, have to stop walking whilst talking, present following a fall, or have recurrent falls need a falls assessment.
If available, refer to a specialist falls service. Record:
• Frequency and history of circumstances around any previous falls.
• Drug therapy—polypharmacy, hypnotics, sedatives, diuretics, antihypertensives may all cause falls.
• Assessment of vision.
• Examination of gait and balance, including abnormalities due to foot problems or arthritis, and motor disorders (e.g. stroke, PD).
• Examination of basic neurological function, including mental status (impaired cognition and depression), muscle strength, lower extremity peripheral nerves, proprioception, and reflexes.
• Assessment of basic cardiovascular status including BP (exclude postural hypotension), heart rate, and rhythm.
• Assessment of environmental risk factors, e.g. poor lighting particularly on the stairs, loose carpets or rugs, badly fitting footwear or clothing, lack of safety equipment such as grab rails, steep stairs, slippery floors, or inaccessible lights or windows.
Measures to ↓ risk of falls and damage from falling
• Assess and correct vision, if possible.
• Correct postural hypotension—alter medication; consider compression stockings, but many elderly people cannot apply stockings tight enough to be of any use themselves.
• Treat other medical conditions, e.g. refer to cardiology if arrhythmia.
• Review medication and discontinue/alter inappropriate medication.
• Remove environmental hazards—arrange bath at a day centre, refer to OT to identify and correct hazards in the home (e.g. remove loose carpets, wheeled trolley for use indoors, commode or urine bottle for night-time use, moving the bed downstairs, etc.).
• Liaise with other members of the PHCT and social services to provide additional support if needed; refer to local council for ‘carephone’ or alarm system to call for help if any further falls.
• Refer to rehabilitation/physiotherapy to improve confidence after falls and for weight-bearing exercise (focusing on strength and flexibility) and balance training (↓ risk of falls). Use of hip protectors ↓ fracture risk in patients at high risk, but compliance is a problemC.
Osteoporosis and prevention of fracture
Assessment of pain
Take a history to ascertain:
• what the patient means when he/she complains of pain
• the cause of the pain
• the severity of the pain.
Don’t jump to conclusions or make assumptions about a patient’s pain.
There are many approaches to assessing pain. The specifics of each scheme are not crucial, but it is important that the scheme used has a logical outline which works for the individual clinician. A simple mnemonic approach is detailed in Figure 9.3.
Elderly patients and patients with difficulty communicating
High prevalence of pain in the elderly population is now well recognized. 40–80% of elderly people in institutions are in pain. The reason for this lies in the difficulty in assessing those with communication difficulties. Additionally, the elderly often minimize their pain, making it even more difficult to evaluate.
Methods of evaluation
Unusual behaviour and its return to normal with adequate analgesia may be the only confirmation of pain in patients with communication difficulties. Examples include:
• Crying when touched
• Becoming very quiet
• Talking without making sense.
• Jumping on touch
• Hand pointing to body area
• Increasing confusion
• Not eating
• Staying in bed/chair
• Grumpy mood.
• Closing eyes
• Worried expression
• Withdrawn/no expression.
Pain assessment tools
Sometimes it is helpful to use pain scales to assess the degree of pain that a patient is in, particularly if communication is difficult. The most commonly used tool is a simple visual analogue pain scale—this consists of a line marked in graduations from 0 to 10. Ask patients to point to the place on the line which represents how much pain they are in, where 10 is the most possible pain and 0 is no pain.
Examine the patient
The cause of the problem may be clear to you from history alone, but examine the patient to confirm/refute your proposed diagnosis.
Beware of emergency requests for opioids from patients unknown to you or your practice.
Principles of pain control
Symptom of injured/diseased tissue. Subsides as the injury heals. Can be worsened by fear. Treat the underlying cause.
Defined as pain persisting for >3–6mo. Affects ~7% of adults in the UK. Cause is often multidimensional, with physical, social, and psychological factors all contributing to the overall feeling of pain.
Goals of chronic pain management
• Set realistic targets. Abolition of pain may be impossible—70% have pain despite analgesia.
• If analgesia is not helping—stop it.
• The aim is often rehabilitation with ↓ in distress/disability.
Strategies for pain management
A multidisciplinary approach is essential. Consider:
• Prevention, e.g. wrist splints for carpal tunnel syndrome, analgesia prior to minor surgery.
• Removal of cause Treat medical causes of pain, e.g. infection, ↓ blood sugar (diabetic neuropathy). Refer surgical causes for surgery if appropriate, e.g. hip osteoarthritis—joint replacement.
• Pain-relieving drugs Start with a single drug at low dose and step up dose or add another drug as needed. Especially in situations of acute pain, step down if pain diminishes.
• Physical therapies Acupuncture, physiotherapy, or TENS.
• Nerve blocks Consider referral for epidural (low back pain), local nerve block, or sympathectomy (e.g. vascular rest pain).
• Modification of emotional response Psychotropic drugs, e.g. anxiolytics, antidepressants.
• Modification of behavioural response, e.g. back pain—consider referral to a back rehabilitation scheme.
The analgesic ladder
Use a step-by-step approach (Figure 9.4).
Step 1. Non-opioid
Start treatment with paracetamol. Stress the need for REGULAR dosage. Adult dose is 1g every 4–6 h (maximum daily dose 4g). If this is not adequate in 24h, either try a NSAID, e.g. ibuprofen 400mg tds (if appropriate) alone or in combination with paracetamol, or proceed to step 2.
Step 2. Weak opioid + non-opioid
Start treatment with a combined preparation of paracetamol + codeine/dihydrocodeine. Combining 2 analgesics with different mechanisms of action enables better pain control than using either alone. Combinations have ↓ dose-related side effects but the range of side effects is ↑ (additive effects of 2 drugs). Combinations using 30mg of codeine are more effective than paracetamol alone, but it is cheaper and more flexible if constituents are prescribed separately. Advise patients to take tablets regularly and not to assess efficacy after only a couple of doses.
There is no proven additional analgesic benefit for preparations containing paracetamol + 8mg of codeine compared with paracetamol alone.
Step 3. Strong opioid + non-opioid
• Use immediate release morphine tablets or morphine solution. 2 tablets of co-codamol (30/500) contain 60mg of codeine which is equi-analgesic to ~6mg of oral morphine. If changing to morphine, use a minimum dose of 5mg (6mg is hard to prescribe).
• Chronic pain may be only partially opioid sensitive. Give for a 2wk trial and only continue if of proven benefit. Worries of tolerance/addiction are unfounded for patients with true opioid-sensitive pain. If the pain seems responsive to opioids and there are no undue side effects, ↑ the dose upwards by 30–50% every 24h until pain is controlled ( p.[link]).
Take care if the patient is elderly or in renal failure—consider starting with a ↓ dose of morphine.
Addition of co-analgesics and adjuvant drugs
In combination with analgesics, can enhance pain control. Examples include:
• Antidepressants in low dose for nerve pain and sleep disturbance associated with pain; in larger doses for secondary depression.
• Anticonvulsants for neuropathic pain.
• Corticosteroids for pain due to oedema.
• Muscle relaxants for muscle cramp pain.
• Antispasmodics for bowel colic.
• Antibiotics for infection pain.
• Night sedative when lack of sleep is lowering pain threshold.
• Anxiolytic when anxiety is making pain worse (relaxation exercises may also help in these circumstances).
If unable to remove cause and unable to achieve adequate pain relief consider referral to a specialist pain control clinic or palliative care (depending on the context of the pain).
Be aware of 2° gain from pain if symptoms seem out of proportion (outstanding compensation claims are a significant negative factor in success of pain management).
(BNF 4.7.1) As effective a painkiller as ibuprofen. No anti-inflammatory effect but potent antipyretic. Drug of choice in osteoarthritis where inflammation is absent. Side effects are rare. Dose 1g qds. Overdose (>4g/24h) can be fatal, causing hepatic damage which is sometimes not apparent for 4–6d. Inadvertent overdosage is easy because of presence of paracetamol in most OTC cold preparations—refer to A&E.
Non-steroidal anti-inflammatories (NSAIDs)
(BNF 10.1.1; Table 9.2) Anti-inflammatory, analgesic, antipyretic. Start at the lowest recommended dose and do not use >1 NSAID concurrently. 60% respond to any NSAID—for those who don’t, another may work.
Table 9.2 Commonly used NSAIDs (BNF 10.1.1)
1.2–1.6g/d in 3–4 divided doses
Fewer side effects than other NSAIDs. Anti-inflammatory properties are weaker. Do not use if inflammation is prominent, e.g. gout
0.5–1g/d in 1–2 divided doses
Good efficacy with a low incidence of side effects.
75–150mg/d in 2–3 divided doses
Selective COX2 inhibitors. As effective as non-selective NSAIDs and share side effects but risk of serious upper GI events is lower. Only use if at low risk of cerebro- or cardiovascular disease and high risk of GI side effects
200mg od or bd
GI side effects
Common (50%), including GI bleeds (¼ GI bleeds in UK). ↑ with age. Risks are dose related and vary between drugs. For the elderly, and those on steroids or with past history of GI ulceration or indigestion, protect the stomach with misoprostol or a proton pump inhibitor (PPI). Selective inhibitors of cyclo-oxygenase-2 (COX2) are equally effective but should not be given to any patient with pre-existing or high risk of cardio- or cerebrovascular disease.
Other side effects
Hypersensitivity reactions—5–10% asthmatics develop bronchospasm; fluid retention—relative contraindication in patients with ↑BP/cardiac failure; renal failure—rare, more common in patients with pre-existing renal disease; hepatic impairment—particularly diclofenac.
• have NO effect on platelet aggregation
• have no benefit if used in patients on continuous low-dose aspirin, and
• combining a COX2 inhibitor with PPI/misoprostol does NOT give extra stomach protection.
(BNF 4.7.2) Most commonly used weak opioid in the UK. Dose is 30–60mg every 4h to a maximum of 240mg/24h. Analgesic effect is ↑ by regular ingestion.
Equipotence with morphine
60mg codeine 4×/d equals 240mg codeine in 24h. 10mg of codeine is equipotent to 1mg of morphine, so the equivalent morphine dose would be 24mg/24h.
The most common side effects are nausea, vomiting, constipation, and drowsiness ( p.[link]). Codeine is effective for the relief of mild to moderate pain but is too constipating for long-term use. Always consider prescribing a laxative (e.g. bisacodyl 1–2 tablets nocte) with codeine to prevent constipation.
Reasons for decreased effectiveness
• 5–10% of Caucasians have CYP2D6 genotype. They lack the hepatic enzyme necessary to convert codeine to morphine and will obtain less analgesia when taking codeine-containing analgesics.
• Effects of codeine are reduced by concurrent use of:
• Anti-psychotics, e.g. chlorpromazine, haloperidol
• Tricyclic antidepressants, e.g. amitriptyline.
has analgesic efficacy and side effect profile similar to that of codeine. The dose of dihydrocodeine by mouth is 30–60mg every 4h. A 40mg tablet is now also available.
is a synthetic analogue of codeine. It is not a controlled drug. Dose range 50mg bd, increasing to a maximum of 400mg/24h. Produces analgesia by two mechanisms:
• An opioid effect, and
• An enhancement of serotonergic and adrenergic pathways.
Advantages over codeine and dihydrocodeine
• Rapid absorption of oral doses—analgesia in <1h, peaks at 1–2h.
• Metabolized in the liver—safer for the elderly/those with renal failure.
• Fewer typical opioid side effects (notably, ↓ respiratory depression, constipation, and addiction potential).
• May have a significant effect on neuropathic pain.
Morphine and other strong opioids
• Recommendations for the appropriate use of opioids for persistent non-cancer pain (2005)
• A practical guide to the provision of chronic pain services for adults in primary care (2004)
Morphine and other strong opioids
Morphine is the strong opioid of first choice for moderate to severe pain in both malignant and non-malignant conditions.
Starting a patient on oral morphine
Start with 4 hourly immediate release morphine. Give clear instructions. Initial dosage:
• Adults not pain controlled with regular weak opioids (e.g. co-codamol 500/30 2 tablets qds)—5–10mg every 4h.
• Elderly, cachectic, or not taking regular weak opioids 2.5–5mg every 4h (2.5mg if very elderly/frail).
Once pain is controlled, consider a long-acting preparation of equivalent dose (e.g MST® bd, MXL® od). Calculate total daily dose of morphine by adding together the 4h doses.
Pain of rapid onset, and moderate/severe intensity despite background analgesia. Management:
• Prescribe immediate release morphine for breakthrough pain—give the equivalent 4 hourly dose as an additional dose.
• If pain starts to occur regularly before the next dose of analgesia is due, ↑ the regular background dose.
Common side effects of opioid drugs
• Nausea and vomiting affects >1:3 patients for the first 2wk of opioid use. Prescribe a regular antiemetic for 2wk (e.g. haloperidol 1.5mg nocte). If nausea/vomiting continues, consider an alternative opioid.
• Constipation. Consider prescribing prophylactic laxatives (e.g. bisacodyl 1–2 tablets nocte). Fentanyl causes less constipation than morphine.
• Drowsiness/cognitive impairment usually wears off in <1wk. Advise not to drive, perform other skilled tasks, or work with dangerous machinery for ≥1wk after starting morphine (longer if drowsiness persists), or after ↑ in dose. If not improving, consider an alternative opioid or refer for specialist advice.
Conversion to injectable morphine and other opioids
Table 9.3 Quick conversions of oral morphine
Oral morphine (total dose) e.g. 10mg morphine 4 hourly = 60mg oral morphine in 24h
+ by 3
60+3=20mg diamorphine by syringe driver over 24h
+ by 2
60+2=30mg morphine by syringe driver over 24h
+ by 2
60+2=30mg oral oxycodone in divided doses over 24h
+ by 7.5
60+7.5=(60×2)+15=8mg hydromorphone in divided doses over 24h
If total 24h dose is equivalent to 360mg morphine or more—get specialist advice
Reasons to chose/switch to an alternative strong opioid
Unacceptable side effects; renal failure (fentanyl is licensed for use; oxycodone is safe in mild–moderate renal failure); patient unable to take oral medication regularly (consider fentanyl or buprenorphine patch, or syringe driver); choice (morphine is unacceptable for some patients).
Alternative strong opioids
Diamorphine; oxycodone; fentanyl; buprenorphine; hydromorphone; pethidine (not suitable for severe continuing pain—used for acute pain relief/obstetric pain).
Never attempt dose titration for unstable pain using a fentanyl patch—convert from oral morphine once a stable dose is attained.
Intentional or unintentional overdose produces:
• Drowsiness or coma
• Pinpoint pupils
• Confusion—including auditory and/or visual hallucinations
• Respiratory depression:
• If respiratory rate ≥ 8/min and the patient is easily rousable and not cyanosed adopt a policy of ‘wait and see’. Consider reducing or omitting the next regular dose of opioid. Stop syringe drivers temporarily to allow plasma levels to ↓; then restart at lower dose.
• If respiratory rate < 8/min and the patient is barely rousable/unconscious and/or cyanosed dilute naloxone 400 micrograms to 10mL with sodium chloride 0.9%. Administer 0.5–1mL IV every minute until respiratory status is satisfactory. If respiratory function still does not improve, question diagnosis. Further doses may be needed later as naloxone is shorter acting than morphine.
• Muscle rigidity/myoclonus—consider renal failure (can produce myoclonus alone). Treat by rehydration, stopping other medication which may exacerbate myoclonus, switching opioid, or with clonazepam 2–4mg/24h depending on circumstances.
Slowly progressive somnolence and respiratory depression—common in patients with renal failure. Withhold morphine for 1–2 doses and then reintroduce at 25% lower dose.
DTB Opioid analgesics for cancer pain in primary care (2005).
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Neuropathic pain occurs as a result of damage to neural tissue. Examples include post-herpetic neuralgia, complex regional pain syndrome (reflex sympathetic dystrophy), peripheral neuropathy (e.g. due to DM), compression neuropathy, and phantom limb pain.
Pain typically occurs in association with altered sensation, e.g. burning, stabbing or numbness. Pain may also be provoked by non-noxious stimuli (allodynia) e.g. gentle heat or cold. Neuropathic pain is generally managed with tricyclic antidepressants or antiepileptic drugs.
is prescribed most frequently (unlicensed indication). Start at a dose of 25 mg nocte—10mg nocte if elderly. ↑ dose by 10–25mg nocte every 5–7d to a maximum of 75mg nocte as needed (higher doses under specialist supervision). Some patients do not derive benefit for 4–6 wk.
Gabapentin and pregabalin
Both licensed for treatment of neuropathic pain. Dose regimes:
• Gabapentin 300 mg on day 1; 300 mg bd on day 2; 300 mg tds on day 3; then increase dose according to response in steps of 300 mg daily (in 3 divided doses) to a maximum of 1.8 g/d.
• Pregabalin Initially 150 mg/d in 2–3 divided doses; increased if necessary after 3–7d to 300 mg daily in 2–3 divided doses; increased further if necessary after 7 d to a maximum of 600 mg daily in 2–3 divided doses.
Traditionally the drug of choice for neuropathic pain but it is unlicensed and often poorly tolerated. Start with 100–200mg 1–2×/d (less if elderly or frail). Build up dose slowly to minimize adverse effects to the usual dose of 0.8–1.2g daily in divided doses. Oxcarbazepine is an alternative for trigeminal neuralgia.
Sometimes effective for neuropathic pain either because there is mixed nociceptive pain or because they ↓ inflammatory sensitization of nerves. There is considerable variation in individual patient tolerance and response ( p.[link]).
Neuropathic pain often responds only partially to opioid analgesics. Oxycodone, tramadol, and methadone are probably the most effective of the opioids—consider when other measures fail.
Other drug treatments
may help relieve pressure in compression neuropathy and, indirectly, pain. Start with a high initial dose to achieve rapid results (dexamethasone 8mg/d works in 1–3d); then rapidly ↓ dose to the minimum that maintains benefit.
is a topical treatment licensed for neuropathic pain. Apply a small amount 3–4×/d. Acts by counter-irritation, but intense burning during initial treatment limits use. Advise patients to wash hands after application and avoid application after a hot shower/bath (↑ burning sensation).
• Patients with chronic neuropathic pain often require a multidisciplinary approach including physiotherapy and psychological support.
• TENS and/or acupuncture help in some cases.
• Nerve blocks and/or central electrical stimulation may help in some cases—refer for specialist advice.
If unable to achieve adequate pain relief, consider referral to a specialist pain control clinic (or palliative care team if more appropriate).
Support for informal carers
In the UK there are 6 million informal carers who are vitally important to the well-being of disabled people in the community. Most are relatives or friends of the person being cared for. Many are elderly with health problems themselves. There is good evidence their health suffers as a result of caring - 52% report treatment for a stress-related illness since becoming a carer and 51% report being physically injured as a result of caring. Young carers (<18y) are at particular risk of social, educational, and mental health problems.
Record whether patients are carers in their notes. GPs and their primary care teams are often the 1st point of access for any help needed and 88% of carers have seen their GP in the past 12 mo. Carers see the GP as the professional most able to improve their lives but few GPs have had any training about their problems and 71% carers believe their GPs are unaware of their needs.
• Practical advice on nursing skills Ask DNs to review problems.
• Advice on management Specialist nurses (e.g. respiratory nurses, cancer care nurses, Macmillan nurses, etc.) provide special expertise.
• Additional help Social services can provide home care. Voluntary organisations provide sitting services e.g. Crossroads schemes.
• Home modification Local authorities can arrange modifications. DNs have access to equipment needed for nursing. The Red Cross loans commodes, wheelchairs, etc.
• Respite Hospitals, charity organizations, and local authorities provide day care (to give regular breaks each week) and respite care (for a week or more at a time).
• Carer centres Provide practical advice, may provide counselling, and give carers an opportunity to share experiences with people in similar situations.
• Always ask carers how they are when visiting, even if they are not your patients themselves.
• If the patient and/or carer have a religion, the clergy will often provide ongoing support
• Maintain good lines of communication Make sure that you inform both carer and patient fully. Make appointments for review. Don’t be short with a carer, patronising, or impossible to contact.
Many patients who have carers are entitled to Attendance Allowance or Disability Living Allowance ( p.[link]). If the patients are not expected to live >6mo, they are entitled to claim under Special Rules. This benefit is not means tested. Other benefits:
• Low income p.[link]
• Given up work to look after the patient May be eligible for carers allowance ( p.[link])
• Substantial modification to home Council tax may be payable at lower rate (consult local council).
Table 9.4 Benefits for disability and illness
How to apply
Statutory Sick Pay
Notify employer of illness: self-certification first 7d (SC2); Med 3 after that time ( p.[link])
Some employers have more generous arrangements. Paid through normal pay mechanisms
Employment and Support Allowance (ESA)
2 types of ESA
Claim from www.jobcentreplus.gov.uk or 0800 055 6688 (textphone: 0800 023 4888)
First 3d—no payment
Assessment phase (>3d but <14wk)
Main phase (≥ 14wk)
Figures are for a single person. Additional payments may be available for dependents if receiving income-related ESA
Disability Living Allowance
Mobility component Help needed to get about outdoors
Care component Help needed with personal care
0800 882200 (0800 220674 in Northern Ireland) or
Leaflet DLA A5DCS available from Post Offices or
Using claim packs available at Citizen’s Advice Bureau and social security offices or
Attendance Allowance (AA)†
0800 882200 (0800 220674 in Northern Ireland) or
Leaflet AA A5DCS available from Post Offices or
Lower rate £70.35
Higher rate £47.10 (for people who need day and night care or are terminally ill)
Community Care Grant
Receiving Income Support, income-related ESA, pension credit, or income-based Jobseeker’s Allowance and:
Form SF300 from local social security offices or www.direct.gov.uk
Minimum payment £30
No maximum amount
Disabled Facilities Grant
For work essential to help a disabled person live an independent life; means tested
Apply via local housing department
Any reasonable application for funds is considered
Complete form in leaflet CAA5DCS available from local social security offices or
plus additions for dependants
( no new claims for dependant children have been accepted since April 2003)
† No need to receive help to apply. Not means tested.
* Terminal illness (not expected to live >6mo)—claim under Special Rules. Claims are processed much faster and the highest care rate is automatically awarded. GP or hospital specialist fills in form DS1500 to provide clinical information to support application (fee can be claimed).
• Consider appointing a carers lead to champion the needs of carers within the practice.
• Try to identify carers e.g. notice in reception, question on registration form, scanning discharge summaries for patients with long-term conditions likely to need carers, opportunistically.
• Provide appointments for carers at times when they can attend. Consider offering home visits for the carer if unable to get to the sugery as a result of caring duties.
• Offer carers an annual influenza vaccination.
• Include carers as partners in care.
• Consider asking the cared-for for written consent to share medical information about them with their carers.
The RCGP and Princess Royal Trust for Carers have developed a self-assessment checklist and action guide for GP practices to help them to support carers. Supporting carers: an action guide for general practitioners and their teams is available from www.carers.org
Social services assessment
Every carer has a right to ask for a full assessment of their needs by the social services. Emergency planning is part of the carer’s assessment.
Advise carers to make an emergency plan. Emergency plans are lodged on a database and the carer is provided with a card to carry with the emergency contact number printed on it.
• If carers have an unexpected crisis and cannot provide care, they can ring the emergency line with the knowledge that short-term replacement care will be available.
• Carers are advised to carry the cards with them in an obvious place (e.g. wallet or purse). In the event of mishap, this will alert that the person is a carer and allow the emergency plan to be activated.
Support organizations for carers
Benefits Enquiry Line 0800 882200; 0800 243355 (minicom facility); 0800 441144 (for help with form completion)
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Support organizations for the patient’s condition
Find This Resource
A carer skills course has been developed by Caring with Confidence. Further information is available at www.caringwithconfidence.net
Pensions and benefits
A state retirement pension is currently payable to women aged ≥60y and men aged ≥65y, even if still working. Entitlement age will rise to 65y for women between 2010 and 2020 (affects those born April 1950 to April 1955). Claim forms should be received automatically—if not, request one through the local Jobseeker Plus office. Pensions are taxable.
Flat rate amount—different for single people and married couples. If not enough National Insurance (NI) contributions have been paid, amounts may ↓. >80y a higher rate is payable which is not dependent on NI contributions.
Increase for dependants
• The claimant’s spouse is <60y and earns under a set amount/does not receive certain other benefits.
• The claimant has children (if claim made before April 2003).
State second pension (replaced SERPS). Based on NI contributions and earnings. Workers can opt out of the additional pension scheme, pay into a private or company scheme instead, and pay lower NI.
Some people may be entitled to a graduated pension. This is based on earnings between 1961 and 1975.
Apply on form PC1 0800 991 234
≥60y and income below the ‘appropriate amount’. Appropriate amount varies according to circumstances. Capital (excluding value of own home) >£6000 is deemed to count as income at the rate of £1/wk/£500 capital. Confers automatic eligibility for housing benefit, community tax benefit, and social fund payments.
Other benefits just for pensioners
• Free colour TV licence All pensioners >75y.
• Winter fuel payment Annual payment to all pensioners >60y.
Home Responsibilities Protection (HRP)
Scheme which protects basic state pension for people who don’t work or have low income and are caring for someone. www.thepensionservice.gov.uk
One-off payment made to people receiving a retirement pension or income support a few weeks before Christmas.
Cold weather payment
Help with mobility
Table 9.5 Mobility for elderly and disabled people Local public transport schemes also exist
How to apply
Blue Badge Scheme
Age >2y and ≥1 of the following:
Apply through local social services department.
In most circumstances the disabled person does not have to be the driver. The badge should not be used if the disabled person is not in the car
0207 944 2914
Entitles holder to park:
Driver may be someone else
Application guide available at www.motability.co.uk
Mobility payments can be used to lease or hire-purchase a car, powered scooter, or wheelchair
Grants may also be available for advance payments, adaptations, or driving lessons
Road Tax Exemption
Usually received automatically
If not and claiming DLA
If claiming War Pension 0800 1692277
Exemption from Road Tax
Certain medical conditions, e.g. colostomy
Medical practitioner must complete exemption certificate
Exemption from wearing seatbelt
For people injured whilst serving in the armed forces and their dependants (if injury caused or hastened death). Administered by the Veterans Agency, Ministry of Defence. No time limit for claims.
War pensions scheme
for ex-service personnel whose injuries, wounds, and illnesses arose prior to 6 April 2005.
War Disablement Pension
• Basic benefits: based on percentage disablement:
• if <20% disabled—lump sum
• if >20% disabled—weekly sum (pension).
• Other benefits Allowances if severely disabled, e.g.
• War Pensioners Mobility Supplement for walking difficulty. Holders can apply for the motability scheme and road tax exemption.
• Constant Attendance Allowance for high levels of care.
Some services and appliances may be paid for by the Veterans’ Agency (includes prescription charges, nursing home fees).
War widows’ and widowers’ pensions
for spouses/civil partners of service/ex-service personnel:
• where death was a result of service or
• if the deceased was in receipt of a War Pensions Constant Attendance Allowance
• if the deceased was in receipt of a War Disablement Pension at the rate of ≥80% and was getting unemployability supplement.
Armed Forces Compensation Scheme (AFCS)
provides benefits for illness, injury, or death caused by service on or after 6 April 2005. Time limit is 5y from the event, from the time when medical advice was first sought, or after retirement, whichever is soonest. There is an exceptions list for late onset conditions. Provides:
• Lump sum for significant illnesses/injuries—15 levels of award.
• Tax-free Guaranteed Income Payment (GIP) for life for injuries at the higher tariff levels (1–11) to compensate for loss of earnings capacity.
• Guaranteed Income Payment for Survivors (SGIP) where an attributable death occurs.
• People who need someone’s help to get out of the house are entitled to free prescriptions ( p.[link]).
• Severe Disablement Allowance is still paid to those who applied prior to April 2001.