Relieving Pain during Dressing Changes in the Elderly

   Sensory processing of painful stimuli does not change as we age. The widespread belief among clinicians is that pain tolerance decreases with age and that the elderly tend to increase their complaints over minor painful experiences. In fact, older people may experience more pain than younger people though they may be less likely to complain about it. As a result, the elderly receive poor pain management. Cultural mores and personal values also affect pain treatment. The beliefs that pain relief is not possible and that medications are addictive prevent optimal intervention.

   Unrelieved pain interferes with healing. The goals of the clinician should be to listen to the patient and to address his/her pain. Pain control goals should be discussed with the patient; a pain scale can help the clinician and patient define these goals.

   Understanding the physiology of aging assists in administering and implementing pain relief measures. When treating an elderly patient, keep the following in mind.
  - In the elderly, blood flow to organs is reduced. The kidney and liver become smaller and filtration is reduced.
  - Reduced creatine clearance results in poor drug distribution and excretion.
  - Protein binding capacity is reduced.
  - Body composition changes and fat distribution decreases. Functional tissue turns into fat. Injections are absorbed poorly due to decreased muscle mass.
  - Reduced stomach acidity interferes with absorption of oral pain medication. Decreased saliva may hamper swallowing.
  - Depression is common. Poorly controlled depression negatively impacts pain perception and control. Patients with chronic wounds should always be assessed for depression.

   Some practical measures can reduce pain during dressing changes, making the experience tolerable for patients.
  - Wounds that are immobilized hurt less. Dressings that adhere well to healthy tissue without adhering to the wound reduce pain and trauma. Avoid all sticking, pulling, bleeding, and tearing of the wound bed. Trauma not only increases pain, but it also keeps the wound in the inflammatory phase and causes increased drainage.
  - All dressings should be moist when they are removed from the patient. The wound bed should be kept moist. The drying of exposed nerve endings and air flowing against nerve endings is very painful. Removing adherent dressings requires soaking until the dressing is saturated. Lotion on the caregiver's hands as the edges of the dressing are gently removed helps break the adhesive-type dressing. Painful dressings should be replaced by the newer silicone and polymer-type dressings. The attachment breaks when in contact with water, resulting in reduced pain.
  - Exudating wounds require absorptive dressings and timely dressing changes. Exudate that remains in and on the wound bed increases cellular pressure, causes pain, and erodes the periwound surface.
  - The periwound surface must be protected throughout the healing process. Trauma, excoriation, erythema, maceration, and dermatitis of intact skin delay epithelial activity and increase pain. All re-epithelialization is orchestrated from the edges. Special attention to the periwound should be part of all dressing changes. Using fillers to collect exudate is helpful. The frequency of dressing changes should be based on the amount of drainage. Many absorptive foams cue the clinician when dressing saturation is 70% to 75%.
  - When cleaning wounds, use warm solution and only noncytotoxic materials. Avoid using cleansers or products that produce burning, stinging, or bleeding. Any trauma to the wound is damaging to the cellular matrix.
  - Pressure relief always must be part of the treatment regimen. Wounds must be offloaded, loosely packed, and protected from pressure. This can be achieved by using appliances, foams, specialty mattresses/cushions, and positioning devices. Patient education in the use of these products is necessary for success. If the device is not comfortable, the patient will not use it consistently. Follow up with the patient and ask how the device is working.
  - Allow patients to assist and participate in dressing changes. Suggest that patients call time-outs if they are feeling uncomfortable. As patients know their own tolerance level, they may want to remove the dressings themselves or assist in cleaning the wound.
  - Prepare the patient for the dressing change. Explain what is taking place during the dressing change. Instruct patients in deep breathing techniques. Utilize calming imagery. Constantly check with the patient throughout the procedure.
  - If analgesics are needed, administer them at a time that will provide relief to the patient during the dressing change.

   Consider the patient holistically. Failure to treat pain effectively is no longer acceptable and should be considered a prime indicator of poor quality medical care.

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