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12 Articles in Volume 17, Issue #1
A Brief History of the FDA’s Role in the Ongoing Effort to Ensure Safe Opioid Use
Distinguishing Neuropathic, Non-Neuropathic, and Mixed Pain
How Can Healthcare Providers Better Advocate for Patients With CRPS?
Ketamine for the Treatment of CRPS?
Letters to the Editor: Opioid Calculator; Metformin
Living With CDC Opioid Guidelines
Neurohormones in Pain and Headache Management: New and Emerging Concepts
Optimizing Neuropathic Pain Relief With Scrambler Therapy
Pain Management and the Elderly
Spinal Cord Stimulation: What Clinicians Need to Know
The Association Between Depressive Disorder and Chronic Pain
Updates in Management of Complex Regional Pain Syndrome

Pain Management and the Elderly

The elderly pain population presents many challenges for pain practitioners, including comorbid medical conditions, polypharmacy, and declining physical and mental function. Learn more about how to manage this challenging age group.

Pain and pain management are a growing concern among Americans age 65 and older.1 A recent analysis of data from a National Institutes of Health (NIH)-funded study found that more than half (53%) of the older adults surveyed reported having bothersome pain in the last month; three-quarters of them reported having pain in more than 1 location. Bothersome pain, particularly in multiple locations, also was associated with decreased physical capacity.2

The November issue of Practical Pain Management highlighted the positive benefits of incorporating an exercise program, even light exercise, into a pain management program for elderly patients.3,4 The benefits include improving physical function, reducing isolation and depression, and enhancing balance and mental acuity.

In this article, the authors present a variety of treatment options, ranging from medications, comorbid mental health issues, and comprehensive interdisciplinary pain management.

Medication Use in the Elderly

Treating pain in the elderly is complicated further by the fact that 75% of people age 65 and older have 2 or more chronic conditions—such as heart disease, diabetes, chronic lung disease, or arthritis.2 Despite the high prevalence of pain in the elderly, pain usually is undertreated. In 1 study, Maxwell et al found that pain is undertreated in about 21% of older adults in nursing homes.5 It should be noted that the undertreatment of pain in older adults is an especially significant problem for those who have severe dementia (Alzheimer’s disease).6 This is because they often have difficulty communicating their experience of pain due to major cognitive and linguistic impairments.

Each patient should be evaluated individually to identify the most effective strategies to use in hopes of achieving the best possible outcome with the least amount of side effects. This can be particularly problematic when working with the elderly population because they tend to face a unique set of challenges.7 Patients may face physical limitations that make traditional recommendations, such as exercise, stretching, or balance tasks, extremely difficult or unfeasible. In addition, Macfarlane et al found that elderly populations were more likely to be prescribed medications as their course of treatment rather than physical therapy, alternative treatments, or specialist referrals.7 In fact, an elderly person, on average, takes approximately 9 or more medications per day,5 increasing his or her risk of adverse reactions from drug-to-drug interactions.8 In 2008, elderly people over the age of 65 represented more than 31% of individuals who were hospitalized due to an adverse drug reaction.9

Elderly patients also are at a higher risk of adverse drug events (ADEs) due to natural physiological changes in the body that come with age, such as the slowing of the gastrointestinal tract that may inhibit the absorption rate of some drugs, or the dwindling liver oxidation rate that can lengthen drug half-life.10

Some commonly prescribed drugs in the elderly include nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvant drugs such as antidepressants, and opioids.10

Medication Risks And Contraindications In the Elderly

NSAIDs

NSAIDs are used commonly to treat musculoskeletal pain in the elderly, with some prescribers favoring NSAIDs over opioids for pain management.11 NSAID use is frequent among the elderly, but these agents pose considerable risks to this population. Although NSAIDs may be beneficial in some patients without heart or renal issues, they may interfere with certain necessary medications for blood disorders, heart problems, renal problems, or may be contraindicated with certain medications.12

Elderly patients are at increased risk for gastrointestinal toxicity associated with NSAIDs, specifically peptic ulcers.13 Gastro-protective drugs, such as misoprostol and proton pump inhibitors, could help those taking NSAIDs for long-term pain relief therapy,14 but only 40% of patients prescribed NSAIDs also are prescribed a gastro-protective medication.15

NSAIDs also are a common culprit in hospitalization due to drug-to-drug interactions because they interact negatively with commonly prescribed medications such as aspirin, selective serotonin receptor inhibitors (SSRIs), and antihypertensives.16 An elderly person who suffers from an ADE that requires hospitalization has a mortality rate of 9%.17 Prescribers should be attentive to the past medical history of each patient, regardless of age, to avoid potential adverse drug reactions  (ADR) or drug-to-drug interactions.

Adjuvant Analgesics

Another common type of medication used in the elderly is adjuvant analgesics. These are medications whose primary focus is not to treat pain, but whose side effects have been found to assist in pain management, specifically in the management of neuropathic pain.18 Antidepressants are the most commonly prescribed form of adjuvant medication, and, overall, physicians prefer SSRIs over tricyclic antidepressants (TCAs). Elderly patients, however, are 73% more likely to be prescribed TCAs than SSRIs.19

The high number of TCAs prescribed to elderly patients exposes them to an increased risk of ADRs, including loss of equilibrium, which can contribute to an increase of falls and injuries; sudden decreases in blood pressure; sleep disturbances; and arrhythmias.20 A study by Ray et al found that although a low dose (<100 mg) of TCAs did not increase the risk of cardiac death, a high dose (>100 mg) was associated with a greater number of cardiac deaths.21

Opioids

The World Health Organization 3-Step Analgesic Ladder for pain management recommends that opioids be used in Step 2 and 3, after the use of NSAIDs or adjuvant medications (Step 1) have failed to provide pain relief.22 Opioids, such as morphine, oxycodone, fentanyl, and methadone, commonly are prescribed to treat both acute and chronic pain in adults. However, opioid medications have an addictive nature and are among the most abused substances in the United States.23

In a study of 10,372 nursing home residents reported to have persistent pain, 38.4% were on an opioid-based treatment plan.12 As with other analgesics, the risks versus benefits associated with opioid-based treatment should be discussed prior to prescribing, especially in this vulnerable population.

Some of the risks the elderly may experience when taking opioids are constipation, nausea, gastrointestinal complications, respiratory depression, increased falls, and sleep disturbances.7 Many of these ADRs are treated pharmacologically, which further increases the number of drugs the patient consumes each day.

Elderly patients also should be counseled to avoid consuming alcohol while taking opioid medications, as well as to avoid sedatives such as benzodiazepines that can increase the risk of respiratory depression.24,25 Opioids have been associated with unhealthy body composition changes, including decreases in muscle, fat, and bone mass, potentially leading to an increased risk of overdose.26

The risk of opioid addiction and misuse also is a concerning factor when prescribing opioids for pain management—even in an elderly population. A strong determinant as to whether a patient will misuse his or her opioid medication is an existing history of substance abuse.27 If a patient has a high risk of addiction, nonopioid modalities should be used.

Practical Pain Management recently published a guideline, titled Opioid Prescribing and Monitoring: How to Combat Opioid Abuse and Misuse Responsibly, which we recommend to readers.28 In addition, Arbruck has provided an excellent overview of what clinicians should know about the use of opioids and NSAIDs in managing pain.29

Consideration of Mental Health Disorders In the Elderly  

Alzheimer’s Disease

According to the National Institute on Aging, Alzheimer’s disease is characterized as an irreversible brain disorder that slowly destroys an individual’s memory and thinking ability.30 Overall, it is estimated that more than 5 million Americans suffer from Alzheimer’s disease,31 and an estimated 57% of Alzheimer’s patients report having pain.32

Pain treatment and assessment become more difficult when they are  coupled with a cognitive disorder.33 As a result, patients with a cognitive disorder are prescribed fewer medications for pain than their counterparts without any cognitive disorder. In fact, there is debate in the literature about whether patients with Alzheimer’s disease experience more or less pain than neurologically normal adults.

Scherder and Bouma examined the pain experience in patients with mid-to-late-stage Alzheimer’s disease.34 They hypothesized that, as the disease progressed, individuals would report more acute than chronic pain. To test this hypothesis, the researchers developed a questionnaire that included 10 pairs of painful situations, with each pair consisting of 1 acute and 1 chronic affective pain situation. Results of the study confirmed that patients suffer more from acute pain situations than from chronic ones. Additionally, as Alzheimer’s disease progresses, patients reported acute pain as their most common burden.34

In contrast, Pickering et al postulated that there is decreased pain in individuals with Alzheimer’s disease compared to other neurological disorders.33 In their study comparing the consumption of prescribed analgesics for acute pain among individuals with Alzheimer’s disease and controls, they found that Alzheimer’s disease patients used a significantly lower rate of prescribed analgesics. The researchers suggested that these findings indicated a possible dissociation between sensory-discriminative and motivational-affective characteristics of pain in patients with Alzheimer’s disease.33 More studies are needed to sort out these 2 hypotheses.

Dementia

Alzheimer’s disease is the most common form of dementia, which is not a specific disease but a vast array of cognitive impairments, the risk of which increases with age. It is difficult to assess and treat acute and chronic pain in individuals with dementia, and the inability to communicate pain is a substantial barrier to treatment.6 Unfortunately, the longer pain is untreated, the more debilitating it is in older adults.35

Cunningham et al examined the role of pain management in patients with dementia in a hospital setting and found that pain management needs to begin with a patient’s admission into the hospital—this establishes a baseline; then healthcare professionals can determine when certain behaviors do not “make sense” and may indicate a change in pain status.36    

Among the pain treatments evaluated in people with dementia, opioids have been the most studied. In general, opioid use among older adults is common. Over 7 million people age 65 or older have filled at least 1 opioid prescription.37 Despite any benefits in the reduction of pain, prolonged opioid use has negative side effects on cognition. Researchers have indicated that opioid use may cause neuropathologic issues, which may lead to a decline in cognition.37

Due to this possible connection, Dublin et al examined the role of opioid use as a risk factor for developing dementia.37 Overall, they analyzed more than 2,500 adults over the age of 65 without a diagnosis of dementia. They continued to study this population over 10 years to assess the effects of opioid and NSAID use in older adults. The results of the study indicate that prolonged use of these prescription drugs could lead to the development of Alzheimer’s disease and dementia. For cumulative opioid use, the hazard ratios for dementia were 1.06 (95% CI = 0.88-1.26) for 11 to 30 total standardized doses (TSDs), 0.88 (95% CI = 0.70-1.09) for 31 to 90 TSDs, and 1.29 (95% CI = 1.02-1.62) for 91 or more TSDs, versus 0 to 10 TSDs. A similar pattern was seen for NSAID use, but heavier NSAID use was not associated with more rapid cognitive decline. Overall, these older adults had a slightly higher risk of developing a cognitive impairment.37

Assessing Pain

Despite the difficulty of communicating pain in patients with dementia, it is critical to be able to assess levels of pain. Tsai and Chang examined measurement instruments for assessing pain in older adults with dementia.38 Pain assessments included self-report, proxy report, and observation. When a patient is unable to communicate pain, a healthcare provider can complete a proxy report. However, the researchers found that proxy reports often underestimate pain in patients.38 Observation methodology, although effective, may be difficult for health professionals responsible for reporting pain. Overall, each measurement tool has its strengths and weaknesses in communicating the experience of pain.

Administering Medications

The administration of medications can be an issue for healthcare professionals handling patients with severe dementia. In addition to oral medications, injections can be used when pain relief is needed quickly, when oral consumption is not an option due to injury or unconsciousness, and when patients have mental health disorders that make them unwilling to take oral medications.39

Topical agents also are an alternative to oral medication. Topical agents may not be effective, depending on the location and source of the pain; if the pain is too deep, the topical agent may not be able to penetrate the body. In addition, topical substrates often need reapplication throughout the day and may wear off during long downtimes such as overnight, causing further disruption to the patient’s sleep cycle, and, thus exacerbating the vicious cycle of pain and stress.

A mechanism to combat many of the aforementioned “downsides” is to deliver the medication via transdermal patch, which seems to be most effective in targeting specific areas plagued by arthritis, although some patients still may not achieve the necessary penetration to affect deep tissue or bones.12

Complementary Integrative Approaches to Pain Management

Pain management is becoming more diverse as the clinical research validates and acknowledges that chronic pain is a multidimensional phenomenon, involving biological, psychological, and sociological components.40 According to the National Institute on Aging, 41% of older adults (ages 60 to 69) are frequent users of complementary and alternative medicine (CAM), including vitamins and herbal supplements, chiropractic manipulation, acupuncture, meditation, and massage.41

Before recommending a complementary approach to your elderly patients, please speak with the corresponding practitioners—chiropractor, physical therapist, yoga instructor—about the possible limitations and adjustments that need to be made for this delicate population. Many elderly pain patients may be too fragile to undergo traditional manipulation and massage therapy, and even yoga may be too strenuous. Therefore, all treatments need to be tailored and personalized for individual patients. Also, transportation may be an issue for this age group, so coordinating with a relative or caregiver may be essential.

Following is a review of the effectiveness of these therapies in pain management.

Acupuncture  

Acupuncture is a well-known alternative form of treatment for pain. Results of numerous studies show that acupuncture may ease certain types of chronic pain, such as chronic low back pain (CLBP), neck pain, knee pain, osteoarthritis, and migraine headaches.42 Yuan et al conducted a meta-analysis which revealed that real acupuncture treatments for low back pain were no more effective than sham acupuncture treatments, but real and sham acupuncture treatments were more effective than no acupuncture treatment for low back pain.43

The effects of acupuncture on the brain and body, and how these effects can be measured, are only starting to be understood. Evidence suggests that many variables, such as expectations and beliefs, that are unrelated to acupuncture needling, could play crucial roles in the beneficial effects of acupuncture on pain.42 Medicare does not cover acupuncture therapy; for private insurance, patients should check with their providers.      

Chiropractic Care

Chiropractic care is another popular alternative method of managing CLBP. According to the latest National Health Interview Survey, chiropractic care was the fourth most commonly used CAM, increasing from 7.5% of the population in 2002 to 8.4% (more than 18 million adults) in 2012.44 Meade et al examined chiropractic care’s effectiveness for CLBP, compared to hospital outpatient treatment.45 Chiropractic treatment was more effective than hospital outpatient treatment for improving pain disability and flexibility tests of leg straightening and lumbar flexion in patients with CLBP.

Medicare Part B will cover 80% (after the deductible is met) of spinal manipulation provided by a chiropractor or another qualified healthcare professional if it is medically necessary to correct a subluxation.46

According to the NIH, side effects from spinal manipulation include temporary discomfort in the area that was treated, headache, and tiredness. There have been rare reports of serious complications such as stroke, although it’s not clear whether spinal manipulation actually caused the complications.47

Hypnosis

Hypnosis continues to gain acceptance as an effective method to help manage chronic pain,48 and it may be a particularly attractive alternative for older pain patients.49 Hypnosis is defined as an altered state of consciousness characterized by increased responsiveness to suggestion. According to NIH literature, “This hypnotic state is attained by first relaxing the body, then shifting attention toward a narrow range of objects or ideas as suggested by the hypnotist or hypnotherapist.”47

Studies conducted using fMRI and PET scan technology have discovered that a number of brain structures involved in the pain perception (eg, somatosensory cortex, anterior cingulate cortex, insula) can be affected through hypnotic suggestion.50-52

Hypnotic suggestion is more complex for chronic pain than for acute pain, due to the layers of psychosocial issues that commonly are associated with chronic pain conditions.53 Stoelb et al reviewed almost 20 studies involving hypnosis for headaches, low back pain, fibromyalgia, disability, and cancer-related pain, as well as mixed chronic pain problems, and found that hypnosis generally resulted in significant reductions in a number of key pain-related outcomes, such as pain intensity, duration, frequency, and opioid use.48

An extensive number of randomized controlled clinical studies of hypnotic analgesia provide evidence of its efficacy, giving practitioners empirical data to consider hypnosis as treatment for pain management. These positive results of hypnotic therapy make hypnosis a viable treatment option for some patients.  

The American Society of Clinical Hypnosis recommends working with a healthcare professional who is properly trained and has credentials, including graduate training; a valid license in medicine, dentistry, social work, nursing, psychology, or psychiatry; and supervised experience providing their professional service to patients or clients.54

The cost of hypnosis treatment differs among healthcare professionals, as well as by the severity of the problem, duration of treatment, and location. Most insurance companies will cover 50% to 80% of individual therapy if it is administered by a licensed professional, but it is recommended that patients contact their insurance provider in advance to determine coverage.54

With regards to government insurance, Medicare Part B covers counseling for smoking cessation55 and weight management56 for individuals with a body mass index > 30, if the counseling includes hypnosis therapy and is recommended by a doctor.

Mindfulness, Meditation, and Cognitive Behavioral Therapy

The psychological dimension of pain can be treated using a variety of therapeutic modalities, such as behavioral, cognitive-behavioral, interpersonal, family, embodiment, and mindfulness therapies.57 For example, there is extensive research on the treatment effectiveness of CBT for both acute and chronic pain patients.40 CBT therapy, however, requires a committed routine, so keep this in mind when recommending it to a patient with mobility issues or transportation concerns. Alternative options may be Skype sessions and online platforms.

In terms of mindfulness training, a study conducted by Feuille and Pargament58 examined the efficacy of mindfulness—defined as having increased awareness of the present moment59—to manage pain in migraine sufferers. They found that trained mindfulness techniques—using breathing methods, guided imagery, and other practices to relax the body and mind—had a moderate effect on decreasing reported stress in migraine sufferers during a cold-presser task (placing one’s arm in freezing water) as compared to patients who practiced just the relaxation technique.58

In a study conducted by Kwok et al,60 psychological flexibility—a person’s ability to fully interact with the present moment and regulate one’s own values-based behaviors based on social and contextual needs61—accounted for the variance observed between self-discrepancy—the self-regulatory process in which a person strives to attain one’s goals or needs62—and pain outcomes in chronic pain patients.60

Myofascial Release

Although technically not under the umbrella of CAM, myofascial release techniques (MFRT) can be performed by a number of certified healthcare providers, including chiropractors, acupuncturists, occupational and physical therapists, and pain specialists. In MFRT, release of myofascial tension is accomplished by applying force (a massage-style technique) on myofascial trigger points—sensitive areas in discrete, tight bands of hardened muscle that result in symptoms of pain, stiffness, and tightness.63,64

There is evidence showing that MFRT is promising as a treatment for chronic pain and psychosocial symptoms associated with chronic pain management. For example, Castro-Sanchez et al found that fibromyalgia patients receiving MFRT over a 20-week period had significant improvements in 18 assessed trigger points of myofascial tension; lower self-reported pain; an increase in reported physical functioning; and a decrease in pain severity.65 In addition, Castro-Sanchez et al found that MFRT significantly improved scores on pain anxiety, depression, sleep quality, and quality of life.66

MFRT generally involves slow, sustained pressure (120–300 s) applied to restricted fascial layers, either directly or indirectly.67 MFRT can be self-administered with a device that applies pressure. A therapist can show an elderly patient how to practice MFRT alone or at home, using foam rollers, a tennis ball, Myo-Release Ball, baseball, and/or massage sticks.68 A general search online for certified myofascial release therapists will help clinicians and patients find one closest to their current location.

Some types of massage may not be appropriate for elderly people with certain health conditions. For example, deep-tissue massage could cause bleeding in people who have bleeding disorders or those who are taking anticoagulant medications (blood thinners).

Multidisciplinary Team  

Another alternative method to manage chronic pain that encompasses a multidimensional approach is Functional Restoration (FR). FR includes a physician/nurse team specializing in spine management; a psychologist to help patients manage stress and develop coping skills; an occupational therapist to help patients enhance everyday function toward predetermined goals; a physical therapist to improve body mechanics with joint movement, stretching, body awareness, and education; an exercise and health educator to help patients maintain a healthy lifestyle; and a rehabilitation counselor concentrating on occupational concerns.69

Such FR programs involve an intensive training component, using multiple modalities to increase flexibility, force, and cardiovascular and muscular endurance; occupational therapy; and psychological counseling to help patients manage pain.40,70 Roche et al found that such FR programs significantly improve CLBP patients’ trunk flexibility, back flexor and extensor endurance, cardiovascular endurance, pain intensity, quality of life, anxiety, depression, social interest, work and leisure activities, and self-reported improvement.70

FR programs have been found to be effective for chronic pain management in older adults.71 FR facilities are not as easy as other alternative methods of treatment to locate in a general internet search, but they can be found. The medicare.gov site does not have any information about coverage of FR specifically, but coverage of the components involved in an FR program (ie, physical therapy, occupational therapy, counseling) are provided by Medicare Part B plans.  

With such well-documented and replicated results showing the success of FR programs for chronic pain patients, it is crucial that the biopsychosocial model of health and interdisciplinary pain management approaches be adopted as a conventional form of treatment to help patients receive the best evidence-based methods that can be provided for chronic pain management.

Last updated on: May 6, 2019
Continue Reading:
The Association Between Depressive Disorder and Chronic Pain

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