Pain and Aging
How does age influences the perception of the pain experience? In this article, the author will focus on the end of the age continuum—older adults—and will examine the role of age as it relates to social and physiological development, cognitive processing, and coping skills.
(Editor’s Note: For a more in-depth guide to pharmacotherapy in the elderly, please see "Pain Management in the Elderly." Dr. Olson’s previous article, Pain and Children, was featured in the May issue of Practical Pain Management.)1
Pain in Older Adults
The assessment and treatment of recurrent pain in older adults (>65 years of age) present special challenges for health care providers. Over the course of my 30 years of practice, I have assessed and treated a fair number of older pain patients. Now, I am in the category of an “older adult” who lives with recurrent pain on a daily basis. This experience does not give me any special insight, but I do “practice what I preach.” My experience as a pain psychologist has taught me not to over-generalize or place older adults into the same group just because of their similar ages. On the contrary, I have found considerable variation across the older pain patient population. Each older patient presents with unique coping skills, history, and intellectual skills that need to be considered when they are evaluated and treated for recurrent pain.
The growth of research studies focusing on the older adult has increased considerably over the past 2 decades. This growth can be explained, in part, by the growing numbers of adults over 65 years of age, who currently make up approximately 10% of the total US population.2 According to the US Census Bureau, older adults are the fastest growing segment of the population, with an average of 10,000 individuals turning 65 years of age every day.3 By 2030, older adults will represent 20% of the total population, or 72 million people.4
Longer lifespans also contribute to more chronic conditions. According to the Centers for Disease Control and Prevention, over two-thirds of older Americans suffer from multiple chronic conditions and treatment for these conditions comprise 66% of the total health care budget.4
In addition, it is estimated that 60% to 75% of people over 65 years of age report having persistent pain (see Table 1).5 Tsang found that the prevalence of pain increases with age and that women are more likely than men to report persistent pain.5 In a European survey, Langley found that most older adults describe their pain as moderate (60%) whereas 25% describe it as severe.6
Pain’s Impact on Older Adults
Chronic pain in the older population has a widespread impact on a variety of problems, including activity restrictions, sleep issues, and mood.
Activity and Exercise
Limiting activity due to pain is a natural instinctual response, but in the case of persistent pain, it becomes a counterproductive strategy that can lead to more pain.7 In my practice, finding an appropriate activity for every patient is a primary goal in the treatment plan.
It often is challenging to find activities older patients feel comfortable performing. Usually, the largest hurdle to overcome is the fear of falling. In addition, as older patients reduce their activity level, they will gain weight, which further compromises their agility level, which, in turn, compounds the fear of falling.8 Weight gain will place more stress on the knees, hips, and back, and often can result in more pain.9
Besides walking, the one activity I strongly recommend to my patients is warm water exercise. This form of activity removes the fear of falling and reduces the stress on joints, which is especially important if the patient is overweight. I generally recommend that patients start by walking in the pool in waist-deep water and work up to deeper levels, which increases resistance and builds strength. Once they achieve a level of comfort and increased strength, they can graduate to wearing a flotation belt, which allows them to walk or jog in deeper water. Eventually, they can work up to a water exercise class designed for older adults, which provides the additional benefit of group support.
The class I attend spends at least 10 minutes before and after the class devoted to stretching in the water. The chief advantage of warm water is that it relaxes the muscles, which in turn promotes a greater stretch. The pool I use maintains a water temperature around 90°F, which I find perfect. For the more severely impaired patients, physical therapy in a warm pool is advised, and it usually is covered under most insurance plans with a physician’s order.
Pain and Sleep
Pain and sleep often are intertwined, but older patients present additional challenges. Older patients with persistent pain are twice as likely to report sleep problems that include a delay in sleep onset and excessive time in bed.10 According to Valentine et al, 42% of middle-aged and older patients with persistent pain experience chronic sleep deprivation that contributes to subsequent daytime fatigue and more inactivity.11
In addition, older adults produce less melatonin, which influences the regulation of sleep cycles.12 Sleep medicine specialists generally believe that lower melatonin levels in older adults is a cause of reduced sleep in adults over 70 years of age.
I always consult with the patient’s referring physician before recommending adjunctive melatonin as a sleep aid. Keep in mind that melatonin has a relatively short half-life; therefore, it only will be effective in helping patients initiate sleep. There are extended-release formulations available in both pill and sublingual preparations.
A majority of patients with chronic pain are at risk for depression. The incidence of severe depression in older adults with persistent pain ranges from 19% to 28%.13 Although this association appears significant, not all older pain patients are depressed. Corran et al reported that 75% of older adults being treated in a multidisciplinary pain clinic reported reasonable levels of pain control and low levels of depression.14
I have found in my own practice that many older patients, both men and women, generally understate their symptoms. This stoic presentation should be considered in the assessment of older patients with pain because it is easy to overlook a major mood issue. When I discuss pain and depression with my older patients, I will use the metaphor of a horse and buggy—what one does, the other will follow. Chou discussed this reciprocal relationship between pain and depression in older adults, with pain predicting increases in depression and depression predicting increases in pain.15