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
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
Chronic pain in the older population has a widespread impact on a variety of problems, including activity restrictions, sleep issues, and mood.
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.
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
Unfortunately, access to mental health care for older adults with pain is difficult at best, especially in rural areas. Szczerbinska et al found that in almost one-half of their sample of older adults in home care and institutional settings, mental health problems increased with age.16
Physical changes in older adults can influence the perception of pain. Recent research findings confirm that aging is associated with changes in the structure, function, and chemistry of the nervous system that directly impact the perception of pain. One example of change pointed out by Verdú et al, is that the density of unmyelinated fibers in the peripheral nervous system decreases with age.17 This reduction in density will result in a slowing of nerve conduction.
The changes we see with aging are a complex process that is not well understood. Recent evidence suggests that older adults also are unique regarding their perception of pain. As mentioned earlier, older adults tend to downplay symptoms as pain compared with symptoms of other chronic medical conditions. Keep in mind that many of the older patients (those born before 1945) are from a generation that experienced a world war and a major economic depression. In my opinion, those experiences had a profound influence on these individuals’ ability to cope with adversity; it was not socially accepted to talk about or admit you lived with pain. In addition, there is evidence to suggest that the acceptance of pain as “age normative” may act as a psychological buffer or protective mechanism to counteract the emotional reactivity associated with the pain experience.18
It is important for all health care providers to be aware of this behavior of older individuals to understate their pain. Given this, it is important for health care providers to consider multidisciplinary pain management for the older adult with recurrent pain.
As we age, we also rely more on medicine—both prescription medications and over the counter (OTC) formulations and supplements—to maintain a quality of life. Recent research indicates that older adults take between 5 to 8 medicines daily, with 12% to 39% taking more than 9 different medications daily.19 If this trend continues, the number of older patients taking multiple medications will grow as the baby boomers age.
The use of OTC preparations also has escalated in the older population. Adults older than 65 years of age represent about 12% of the population but use 40% of all OTC preparations.20 This trend in self-medicating can be potentially problematic for older adults coping with chronic pain. Adverse drug interactions with OTC medications (ie, acetaminophen, ibuprofen, naproxen) among the older population are on the rise, with some estimates reaching 20%.21,22
As we physically age, our ability to process medicines also changes. I will outline a few of these changes. According to Wooten, aging is associated with reduced drug absorption due to reduced gastrointestinal motility and blood flow.23 In addition, there are changes in muscle mass and an increase in body fat, poorer drug metabolism due to decreases in hepatic blood flow and liver mass, and reduced excretion due to declines in renal function. There also is evidence to suggest that molecular changes that occur with aging may be associated with receptor sensitivity to certain drug classes.24
For older adults who experience multiple health issues, including pain, the implications for negative health outcomes are considerable. Therefore, I always advise my older patients to work closely with their primary care physicians to regulate their medications, including the use of OTC preparations. I have found pharmacists to be very helpful in researching potential adverse drug interactions. For more information on this important topic, I would refer the reader to the American Geriatric Society Panel on the Pharmacological Management of Persistent Pain in Older Adults published in 2009.25
Behavioral therapy techniques are appropriate for older adults, provided they are not confused or that their memory is not compromised. In my practice, I have found that relaxation techniques can be effective if the patient is selected carefully. I also add temperature biofeedback to augment relaxation procedures.
One patient of mine, a 85 year-old male, was still actively farming despite coping with moderate levels of persistent pain and a significant sleep problem. It is important to note that he was a highly motivated individual, who was open to new experiences. He could not get enough relaxation therapy, always wanting more to achieve a deeper state of relaxation. He felt it gave him more control over his pain and improved his sleep, which were powerful reinforcements.
An additional factor to consider with older adults is a propensity to worry, which results in a higher level of psycho-physiologic arousal. If your patient is cold in the extremities, with possible color changes, temperature biofeedback may be indicated.
The role of social support to help patients cope with chronic pain is just as important for older adults as it is for younger ones. In older adults, social support is different in form and function because they report fewer friends and social supports compared with younger adults.26
In addition, older adults report feeling that emotional wellbeing is associated with having a few close friends rather than many friends or a broad social support network. This reduction in the size of one’s social support network may be due, in part, to the amount of energy expended in maintaining a large network of friends. In addition, as we age, we tend to be more selective in our friendships. In some cases, social support is critical for older adults who experience persistent pain. As we age, we rely on others to help with activities of daily living, transportation, and monitoring health issues, including medications.
The influence of memory loss or dementia is an important consideration when treating older adults who live with persistent pain. According to Corbett et al, 30% to 50% of older adults diagnosed with dementia experience persistent pain.27 When you combine dementia and pain, a number of behaviors can occur, including aggression, agitation, and confusion. In addition, a popular misconception that older adults with dementia feel and experience less pain may contribute to an underassessment and undertreatment of pain.28 The consensus of research suggests that older adults with dementia experience pain differently, but the perception of pain severity does not change.29
My own personal experience has shown me that the treatment of older adults in pain presents a special challenge for many reasons. Many older adults have experienced many hardships, including a world war and a major economic depression. These hardships have contributed to a mindset of stoicism (eg, being “brave in the face of pain”). This mindset presents a number of challenges:
If a primary care physician suspects that an older adult patient is understating his or her pain symptoms, they should refer the patient to a multidisciplinary pain program. The primary basis for this referral is that you need time and a variety of providers to fully evaluate the existence of a serious pain issue.
Understating pain may result in a number of related mental health issues, especially depression. Therefore, it is incumbent upon health care providers to assess for comorbid conditions. I realize there is much wisdom in the old adage of “letting sleeping dogs lie,” but do not overlook the older patient who is reaching out for help.