More than half of older adults experience some moderate or intense pain on a monthly basis – a fact that has been recorded across the world.

Although older adults are very different – which is why ageism is so hurtful – there is a sizeable number of older adults who are unwell and in pain. Pain is not a normal part of ageing, but most people in older age groups experience long-term pain.

It is surprising to most people, especially nowadays when drugs (both medications and recreational drugs) are so accessible and easy to obtain, that people are still in pain. In the US, where we ingest more medicine than any other country (but not recreational drugs), nearly eight out of every 10 hospital deaths occur without any pain management.

More than four out of every five older adults in long-term care facilities experienced untreated or under-treated pain at the time of death. While seven out of 10 older people on government health care in the US, who are about to die within the next two years, regardless of their age or location, received an inadequate amount of pain management.

There is a problem with controlling pain, especially for older adults and specifically at the end of life for most older adults. With the opioid crisis in the US – where pain-numbing drugs that mimic heroin are increasingly killing people in that country and Canada – there is a growing awareness that controlling pain is not simply dulling the experience of it.

Drug overdoses, mostly due to opioids, are now the leading cause of death for those aged under 50. Every year three times the population of Birkirkara – the largest city in Malta – dies of overdoses in the US (64,000). Drug overdoses have lowered the number of years people are expected to live. Only wars have the same effect on life expectancy.

However dramatic these figures are, there is a larger threat. A threat that is undefined and undisclosed: pain management and deaths in assisted living facilities and nursing homes.

More than four out of every five older adults in long-term care facilities experienced untreated or under-treated pain at the time of death

One of the characteristic features of Maltese society is the attraction of nursing homes for older adults. Although nursing homes have a very important role to play in geriatric care, there is a fear that they can be used to warehouse dying people.

In the US the use of nursing homes by older adults has been on the decrease, especially due to the emergence of assisted living options. Assisted living facilities are homes where older adults can receive some assistance with their daily tasks. Most of these are private, run by a husband-and-wife team, and with an average of 10 to 15 beds. Although they are a cheaper alternative to nursing homes, assisted living facilities are by no means an alternative, since they are not supposed to help with medical needs, but they do.

With fewer restrictions, less oversight and greater coverage, assisted living facilities are an unknown world for older adults. We can expect lower quality of care in these facilities than in nursing homes, although we do not know. Even death is sometimes hidden since they call for an ambulance and the patient is recorded as having died in hospital.

A recent 2018 General Accounting Office (GAO) report, a special ‘parliamentary’ investigative branch, found that half of all states could not tell if there were any cases of abuse, neglect or exploitation in any of the facilities. There was no oversight. Considering that more than a third of a million older adults use these facilities, there is a lack of concern about their well-being. When there is monitoring, as with nursing homes, the picture that emerges is one of stark lack of quality care.

Although nursing homes have a very important role to play in geriatric care, there is a fear that they can be used to warehouse dying people. Photos: Shutterstock.com

The GAO cited one in five of the nation’s 17,000 nursing homes for violations involving serious physical injury and in some cases death of older residents. Lack of concern for the patients can be seen before their death.

A report by the Italian researcher Roberto Bernabei and his colleagues found that for 13,625 older cancer patients living in nursing homes in the US, nearly a third reported still being in pain, with only a quarter receiving pain relief medication. The authors conclude that older patients and minority patients were less likely to have their pain treated, especially if they are dying. Given that the main fear we have is not of dying, but of dying in pain, this lack of concern for pain management is worrisome on a personal basis.

Pain is complex. Pain is a way for our body to communicate danger. We cannot just dull the message because the body will simply increase the volume of the message. When older adults are in pain, medications are useful and necessary. But when it is long term, there are other avenues, such as physiotherapy, exercise and diet that might help.

But with older adults, they are less likely to receive such treatment, especially in a nursing home or assisted living facility.

Mario Garrett was born in Malta and is currently a professor of gerontology at San Diego State University in California, US.