Pain Management in the Elderly
As with any aspect of providing care for older adults, the management of pain can be far from straightforward. Although many people over the age of 65 perceive pain, report pain, and respond to interventions the same way that younger patients do, many others do not.
The purpose of this article is to highlight some areas of pain management that may be problematic in older populations and offer some suggestions for addressing them.
Epidemiology of Pain in Older Populations
Persistent pain is a common finding in older populations. Depending on the method used and population studied, the prevalence of pain has been reported to be from 18 to 88% among individuals over the age of 65 years.1,2Among those individuals with persistent pain, 45% to 80% report that it is undertreated.2
Regardless of its incidence, persistent pain can have important consequences for the patient. Outcomes of persistent, uncontrolled pain include loss of physical function, sleeplessness, disruption of attention, and depression.1 Patients lose function because of avoidance of activities that aggravate the painful area. However, chronic pain can also result in depressive symptoms which may lead to further loss of motivation and interest in activity. Inactivity and self-neglect can lead, in part, to a descending spiral into frailty and death.3 Consequently, it is critical to indentify persistent pain in older adults and make all reasonable efforts to control it.
Prescription Drug Abuse and Addiction
The diversion of prescription drugs for illicit purposes is often a consideration when managing patients with chronic pain. Although prescription drug abuse may be less common in older patients, it still occurs and may be more likely among those with multiple chronic medical conditions.4,5 Steps that are normally taken to ensure that opioids and other controlled substances are being used for their intended purposes should also be considered when managing patients over 65.
In addition to concerns that health professionals might have regarding prescription drug dependence or abuse, many older adults have similar concerns. As a result, some patients fail to request treatment or fail to use prescribed treatment because of a fear of drug dependence or addiction.5 Health professionals need to both use normal surveillance to detect controlled substance abuse as well as to identify situations where patients need reassurance to allay inappropriate fears regarding the risk of addiction.
Assessment of Pain
Readers of this journal are very likely to be familiar with pain assessment and probably assess older adults and their pain on a regular basis. However, it may be worth emphasizing a few things that have been discovered in studies of pain management of older adults. Elderly patients with persistent pain may deny experiencing pain.2,6,7 They may instead use such words as aching, discomfort, or hurting. Many older adults may neglect disclosing painful conditions because they believe that it is a normal result of aging or that nothing can be done to manage it. Given the high prevalence of pain in older populations, health professionals should regularly inquire about pain rather than waiting for the patient to mention it. Such an approach is consistent with the Joint Commission’s consideration of pain as a fifth vital sign.8 Pain should be assessed and monitored on a regular basis in all older patients.
As with other patients, it is critical that the pain must be assessed by its nature and potential cause. Is the pain musculoskeletal or visceral in nature? If so, then analgesics may be very effective. On the other hand, is the pain neuropathic in nature or does it have a neuropathic component? If so then, adjuvant therapy such as tricyclic antidepressants or anticonvulsants may be helpful.
Pain assessment is more complicated in patients with impaired cognition due to dementia and/or delirium. All patients, including those with dementia, should be first asked regarding their perception of pain before relying on caregiver input.9 Patients with mild to moderate dementia are usually able to communicate verbally and can describe their pain, particularly when the health worker focuses on the present. As dementia worsens, a patient’s recall of pain in the past hours or days becomes less reliable and input from a family member or professional caregiver may be necessary to complete a pain assessment. Patients with severe dementia or those with delirium may not be able to express themselves verbally so that other cues of pain need to be considered. Behaviors that may indicate the presence of pain in a patient unable to communicate verbally include: facial expressions, vocalizations, body movements, changes in interpersonal interactions (e.g. increased aggression), changes in routines (e.g. refusing food), and mental status changes.2 An important aspect of assessing pain in a patient who has limited ability to communicate is the institution of a trial of an analgesic (see Figure 1 for an algorithm for Pain assessment in older adults with severe cognitive impairment).
“Reduced liver and kidney function due to chronic diseases is common and result in altered drug pharmacodynamics and pharmacokinetics.”10
An important component of assessment includes an evaluation of the medication process in a patient being treated for pain. How are the analgesics being administered? Does the patient with persistent pain have separate orders for receiving an analgesic on a regular schedule in addition to as needed? How often is the patient receiving an as needed medication? Are the products being administered properly? Are there any problems with acquiring the products? Can the patient or their family afford the therapy that has been ordered? Most older adults have fixed incomes and many rely on a Medicare Part D prescription drug plan to assist with their medication-related expenses. Analgesics that are not available generically increase the patient’s out-of-pocket expenses as a result of higher co-pays. More costly products also accelerate a patient’s entry into their Medicare Part D plan’s coverage gap or “donut hole.”