Developing the evidence and associated service models to improve pain management in older people living with frailty: a synopsis of the POPPY mixed method, co-design study

Background

Frailty increases vulnerability to adverse events (falls, illness) resulting in poorer health outcomes in later life. Persistent pain is common and impactful in older adults with frailty. Pain impact is potentially modifiable, and addressing it is important for supporting this population.

The Pain in Older People with Frailty study aimed to generate evidence and develop service models to improve pain management for older adults with frailty and inform service provision for this underserved population.

Objective(s)

• Phase 1: Map research evidence and synthesise findings from randomised controlled trials of multi-component pain management programmes and psychological therapies for community-dwelling older adults.
• Phase 2: In-depth qualitative interviews with community-dwelling older adults living with frailty and persistent pain, to explore pain experience and engagement with healthcare staff regarding pain.
• Phase 3: Service identification (four regions) including qualitative interviews with staff from pain service types (community, secondary care and specialist/tertiary) and generic community services to identify barriers and facilitators for older adults with pain and frailty to engage with pain management services.
• Phase 4: Co-design workshops with older adults, staff and commissioners to develop service guidance (supported by costing information) tailored to the needs of older adults with frailty and pain.

Design and methods

Mixed-method, co-design study.

Setting and participants

• Phase 2: Community-dwelling adults (≥ 75 years) with frailty and persistent pain.
• Phase 3: Staff from pain services and community services, and service commissioners.
• Phase 4: Older adults, staff and third sector representatives.

Data sources

Phase 1: Systematic review data; Phase 2: qualitative interview data (grounded theory); Phase 3: qualitative interview data (thematic analysis); Phase 4: workshop data.

Results

Phase 1: Across 31 randomised controlled trials, intervention mechanisms included enhancing self-efficacy, promoting positive psychological strategies, refocusing attention to manage pain and engaging in physical activity to improve well-being and reduce pain impact. Most interventions showed potential benefits for older adults.

Phase 2: Interviews with 26 older adults living with pain and frailty highlighted key themes: pain experience, pain acceptance, support seeking decisions and accessing support.

Phase 3: Forty-two staff shared their perspectives on supporting older adults with frailty and pain.

Phase 4: Findings were shared during workshops involving 47 stakeholders (older adults, general practices, staff and third sector representatives). Stakeholders proposed service recommendations.

A health economist calculated per-patient cost estimates for different service models.

Limitations

Limited representation from adults with severe frailty.

Conclusions

There is no need for a dedicated pain and frailty service. Integrating pain management into existing frailty and community services should better meet the needs of frail older adults. This should include training community staff about persistent pain, referral options and establishing pathways for reporting pain and routine enquiry. Service directories, including voluntary and community organisations, could provide resources for staff and older adults. Adapting content and delivery of existing pain services will better support older adults with frailty and unmanaged pain requiring additional support.

Future work

• How should general practices identify older adults with frailty and pain who would most benefit from referral to pain services?
• How can information and awareness of pain management services be improved for this population?

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR131319.