Reducing Distress by Managing Pain, Delirium and Unmet Health Needs in Older People’s Services
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In older people’s services, distress is frequently labelled as “agitation”, “refusal” or “challenging behaviour”. In reality, the root cause is often clinical: pain, infection, constipation, dehydration, medication side effects, delirium, sensory impairment, or sleep disruption. When these drivers are missed, staff may unintentionally respond with control-based approaches that increase distress and risk. Commissioners and CQC expect providers to recognise the health drivers of distress, escalate appropriately, and evidence safe, person-centred responses. This article builds on our Quality & Governance and Safeguarding, Capacity & Human Rights content, focusing on operational practice for spotting and responding to unmet health needs.
Why health needs are missed in “behaviour” presentations
Older people may not be able to describe pain or discomfort clearly due to dementia, aphasia, delirium, sensory loss, or fear. Staff may also normalise distress as “part of ageing” or assume it is solely psychological. Busy routines, agency staffing, and limited clinical confidence can mean red flags are not escalated early. The result is avoidable deterioration, increased incidents, and sometimes safeguarding referrals that could have been prevented with better clinical awareness.
Common health drivers of distress in later life
- Pain: arthritis, neuropathic pain, pressure damage, dental pain, fractures, or poorly managed long-term conditions.
- Infection: UTIs, chest infections, skin infections — often presenting as confusion or agitation rather than fever.
- Delirium: acute confusion triggered by infection, dehydration, constipation, medication changes, or hospital discharge.
- Constipation and dehydration: frequently overlooked, strongly linked to agitation and sleep disturbance.
- Medication effects: sedation, akathisia, dizziness, or rebound agitation related to changes in medicines.
- Sensory impairment: untreated hearing/vision loss causing fear, misinterpretation, and social withdrawal.
Practical approaches: what “good” looks like day to day
1) Baseline knowledge and “what’s normal for this person”
Effective services document a clear baseline: appetite, sleep, mood, mobility, communication, continence, engagement, and typical triggers. This makes deterioration easier to identify and supports more confident escalation.
2) Simple early-warning tools (used consistently)
Staff should use consistent checklists or prompts during daily notes and handovers, especially after hospital discharge or medication changes. The goal is not clinical diagnosis, but reliable detection of “something is different”.
3) Pain recognition in people with communication difficulties
Where verbal reporting is limited, teams should use structured pain observation approaches: facial expression, guarding, changes in gait, vocalisation, withdrawal, disrupted sleep, or new refusal of care. Evidence must show staff know how to interpret and respond.
4) Clear escalation routes and accountability
Services should be able to evidence: who is contacted (GP, district nursing, NHS 111, community mental health, out-of-hours), what information is shared, and how follow-up is tracked. Escalation must be recorded and reviewed.
Operational examples (minimum 3)
Example 1: Distress driven by constipation and dehydration
Context: A person becomes restless and verbally aggressive most evenings, particularly after meals. Staff initially attempt repeated reassurance and prompts to sit down, which escalates conflict. Support approach: The team treats distress as a potential physical discomfort signal. Day-to-day delivery detail: Bowel charts are reviewed, fluid intake is monitored, and staff introduce routine offering of warm drinks and preferred fluids mid-afternoon. A GP review is requested and laxative plan is adjusted. Staff stop issuing repeated commands and instead offer short walks and calm engagement while monitoring discomfort indicators. Evidencing change: Incident frequency reduces, bowel movements normalise, and evening distress is documented as shorter and less intense.
Example 2: Delirium following infection and medication change
Context: After a hospital discharge, a person shows sudden confusion, hallucinations, and attempts to leave the service, becoming distressed when redirected. Support approach: Staff recognise a delirium pattern rather than “absconding behaviour”. Day-to-day delivery detail: The team escalates to GP urgently, shares baseline changes, and requests physical checks. Environmental stress is reduced (quiet room, familiar objects, consistent staffing). Staff provide short orientation cues, avoid confrontation, and document triggers and times of day. Evidencing change: Medical assessment confirms infection; treatment is commenced. Distress reduces over 48–72 hours and records show improved sleep, reduced exit-seeking, and stabilised cognition.
Example 3: Pain presenting as refusal of care
Context: A person repeatedly refuses bathing and personal care and becomes distressed when staff persist, leading to near-restrictive responses (blocking exits, raised voices). Support approach: The service treats refusal as a possible pain signal. Day-to-day delivery detail: Staff observe grimacing on shoulder movement and note reduced range of motion. Pain relief is reviewed with GP, moving and handling plan is updated, and personal care is adapted (shorter sessions, warm room, preferred staff, clear consent prompts). Staff are instructed to pause immediately at distress cues and re-offer later. Evidencing change: Refusal reduces, care is completed with consent, and distress incidents in personal care drop significantly.
Commissioner and regulator expectations
Commissioner expectation: Providers should evidence timely identification and escalation of clinical drivers of distress, with clear documentation, partner working, and demonstrable reductions in incidents and avoidable deterioration.
Regulator / Inspector expectation (CQC): Inspectors expect staff to understand the health causes of distress, take appropriate action, record decision-making, and avoid inappropriate control or restriction where distress is clinically driven.
Governance and assurance: making it auditable
To make practice defensible, services should evidence:
- Patterns and trend analysis: recurring times, triggers, health changes, medication adjustments.
- Audit of escalation: timeliness, quality of information shared, outcomes and follow-up actions.
- Supervision and reflective practice: learning from episodes of distress and refining approaches.
- Multi-disciplinary communication: evidence of collaboration with GP, community nursing, pharmacy, and other partners.
Outcomes: what “better” looks like
When clinical drivers are identified early, services typically see fewer incidents, lower staff stress, reduced use of restrictive responses, fewer emergency admissions, and stronger family confidence. Most importantly, people experience care that is safe, responsive, and respectful — where distress is treated as a meaningful signal, not a behaviour to suppress.
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