Guidelines for a Palliative Approach in Residential Aged Care

examined the addition of paracetamol for people with advanced cancer who were already
receiving a oral morphine regimen [153] . The authors’ concluded that paracetamol improved pain
and well-being for the majority of the participants without the incidence of significant adverse
reactions [153] (Level II). Further studies with older people are required to determine that this
finding is appropriate for people without a diagnosis of cancer.
NSAIDs
NSAIDs are often used when other non-opioid analgesics are not sufficient for pain
management; for example with older persons who have rheumatoid arthritis or osteoarthritis
[154,155]
(Level I; Level I). A recent systematic review of the use of NSAIDs in combination
with an opioid was found to be effective in managing cancer pain, with side effects equivalent
to placebo [156] (Level I). A systematic review of paracetamol versus NSAIDs for rheumatoid
arthritis found that the participants preferred NSAIDs more than paracetamol for pain
management [155] (Level I). However, NSAIDs have the potential for more adverse side effects
than paracetamol does, such as gastrointestinal events, headaches, and renal, cardiac and hepatic
impairment. [155] These agents are associated with greater toxicity for older people. Therefore,
the benefits and harms of NSAIDs should be given careful consideration when determining
whether NSAIDs or paracetamol are more appropriate for each resident [154] (Level I). Further
RCTs are required to determine which NSAIDs are appropriate for use with older people and
which NSAID is the safest and most appropriate.
Misconceptions regarding opioid use
Pargeon and Hailey (1999) [157] outline the many misconceptions regarding the use of opioids
in the minds of doctors, nurses, family members and others. According to the WHO guidelines
on pain management, opioids are the medications of choice for the management of moderate
to severe pain. [148] This group of medications is effective and easily titrated, and has risks
that are easily managed. For most people receiving a palliative approach, morphine is the
opioid analgesic of choice[ 158] (Level EO). However, a number of myths abound regarding
use of opioids, particularly their use with older persons. This results in limits to effective pain
management. Examples of some of these myths and their counter evidence are provided in the
following table.
82 Guidelines for a Palliative Approach in Residential Aged Care