How can I improve pain management for my elderly mother?

[Thriftygal]

My mum is 92 years old with dementia, She moved into a care home 18 months ago after a fall resulting in a broken hip that effected her mobility. A long hospital stay had resulted in steep cognative decline and her weight plummeted to 5 1/2 stone.

The care home where amazing, they supported her in regaining some mobility with a zimmer frame and got her weight increased to a safe level.

She has numerous medical conditions including osteoarthritis and osteoporosis with previous fractures to her lower spine causing ongoing pain all of the time. Id say she hasnt been totally painfree for years.

Last week she had a fall and was admitted to hospital with a small pelvis fracture. Since then she has refused to any and all atempts at mobility and is screaming in pain if any attempt is made to move or mobilise her in any way. They put her through a CT scan to double check if anything had been missed but it hadnt.

The hospital have her on regular oramorph but because of her frailty and now very low weight they are mindful of dosage guidelines (she also has aortic stenosis so doctors are hesitant of prescribing anything stronger even though it is clear her pain is currently unmanaged). She is back to severly underweight as she is barely eating. She is drinking water a lot and saying she is thirsty and she is sleeping a lot.

Doctors have declared her medically fit for discharge as she no longer requires acute medical treatment. Her care home came to review her and she refused to mobilise so they said they would be unable to meet her care needs. They are going to attemp another assesment tomorrow before formally declaring that she cant return to them.

I went up to the hospital this afternoon to try again to encourage her to at get up, I begged and pleaded and she refused point blank. She then soiled the bed and still refused to move so the nurses had no option but to move her against her will, they took the opportunity to sit her in a chair while making her bed. The gave her some oramorph before moving her but despite this she screamed and cried out repetedly in distress and pain. At one point she even pretended to be asleep to try to stop them moving her. It was pretty horrific to witness.

Does anyone have any suggestions on how to approach her pain managment with doctors that are cautious to give her anything stronger? Id rather her be comfortable for a short time than suffer daily for months on end. She has zero quality of life at this point.

With love. That sounds awful for both of you. She clearly needs significant nursing care.

Scans don't always show everything-a few doctors have warned me about scans for my condition, saying some people who look like they should have more pain from scans have none, and vice versa.
I am so sorry for both of you. In your situation, I begged them to give as many drugs as possible.

I think the significant pain is from her lower back that she fractured 16 years ago, they had to do 3 Xrays before the CT on her admission to hospital to rule out a back fracture, her lower spinal area was quite compressed so it was difficult to see clearly. They said there was no new injury to that area after the scan. Thanks so much for the replies.

My dm had a buprenorphine pain patch, she was 44kgs and on dialysis, with spine and pelvis fractures. Still needed regular paracetamol as well. They also tried amitriptyline but it didn’t help her.

Pregabalin worked wonders for my mum

I think I would put my size 5 down very very hard about a discharge prior to them getting her pain under control.

She definitely needs a pain management plan putting in place as the oramorph and paracetamol doesnt seem to be even knocking the edges off her discomfort. Realistically there is nowhere to discharge her to at the moment. After what I witnessed today it is likely her care home will be unable to meet her needs anymore and will have to refuse her return.

Oromorph is a shit painkiller! Please ask them to reassess her pain management and refuse to allow them to discharge her anywhere until her pain is better controlled.
if she’s got one fracture in her pelvis, it’s highly likely there will be at least one more.

A low-dose fentanyl patch might help, given your mum must already be opioid-tolerant. They'd be likely to resist due to the dangers of toxic build-up in elderly patients and low body weights.

Assuming it doesn't contradict any advance directive she may have made, it's probably worth stressing that comfort's worth more than longevity at this point. Doctors can't make this decision for her or you, but they will listen.

This is horrible for you both. I'm sorry, and wish you a viable solution

Bloody ridiculous they’re reluctant to give anything stronger to a 92 year with dementia in agony in case it is them unwell. The nhs is a joke.

The hospital should have a pain management team to provide specialist input for inpatients with difficult to manage pain/ complex medical histories making choice of medication more challenging etc. I would suggest that you ask the ward staff whether she has been referred to this team, and if not ask that she be referred to them for a review as soon as possible. I’m sorry to hear that your mum is going through this.

I'm sorry to hear about your mother, that must be so difficult to witness.

I wonder if all her behaviours are exclusively due to pain. It is very hard to know what is going on when someone has dementia and cannot tell you.

I'm just asking because my mother had dementia and while she did have some pain, part of her objection to being moved was fear and confusion. She fiercely resisted being moved or in any way 'tampered with' in hospital by nurses she did not know. But when in the familiar environment of the care home with carers she knew, she would tolerate it quite well with just some slight moaning. They tried various pain relief including opioid patches but she ended up on co-codamol.

I'm surprised the care home cannot manage her if she is not mobile. My mother was immobile for the last 2 years and had to be hoisted and moved by wheelchair from bed to chair. Her dementia care home had no issue with that. Like your mother, she had no quality of life but at least she was able to remain in a familiar environment.

Ask her to be seen by the ‘pain team’. I’m guessing it’s a pubic rami fracture? If so these are very painful when weight bearing for the first 2 weeks. There is a huge risk of deconditioning. Make sure the physios are involved.

In my trust the palliative care team are often called in to give specialist advice on pain relief. I would be asking very loudly for a review by the palliative care consultant.