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10 Articles in Volume 15, Issue #1
Psoriatic Arthritis: Current Strategies for Diagnosis and Treatment
Traumatic Brain Injury: Evaluation, Treatment, and Rehabilitation
Pain Management in the Elderly: Treatment Considerations
9 Best Practices in Evaluating and Treating Pain in Primary Care
Rationale for Medical Management
New York State Enacts New Law to Prevent Drug Diversion
Editor's Memo: Acknowledging the Failure of Standard Pain Treatment
PPM Editorial Board Discusses Epidural Steroid Injections and Blindness
Ask the Expert: False Positive Amphetamine Urine Screens
Letters to the Editor: Pregnenolone, Acute Porphyria, Opioid Calculator, Arachnoiditis

Pain Management in the Elderly: Treatment Considerations

Using a multidisciplinary treatment plan that follows the biopsychosocial model, pain practitioners can treat pain in the elderly safely and effectively.

The elderly community is at high risk for developing chronic pain conditions. The Institute of Medicine report, Relieving Pain in America, highlighted the increasing prevalence of pain among all age groups but noted that it is consistently greatest among elderly Americans.1 It is estimated that approximately 30% of the elderly population suffers from chronic pain.2 Typically, elderly patients are more likely to report pain in multiple locations, and elderly women are more likely than elderly men to report pain.3 Moreover, these older Americans have the highest rate of long-term consumption of medications for pain.1

Despite being fairly common in the elderly, persistent pain is not an inevitable part of aging. Believing that pain is an expected consequence of aging is one of several common misconceptions that can lead to biased and ineffective management of pain in the elderly. A multitude of other factors pose barriers to effective treatment—these include factors related to patients themselves, to medical professionals, to the health system, and to medications and interventions (Table 1).4

In addition, treatment for pain in the elderly can be complicated by comorbid factors such as cognitive or functional impairments (eg, delirium, dementia, speech impairment, paralysis, etc),5 many of which were discussed in Part 1 of this 2-part series.6 Understanding the special needs of an aging population is an important aspect of pain management for the elderly.

Biopsychosocial Model

Treatment for chronic pain should follow the biopsychosocial model, a well-known model that encompasses biological, psychological, and social factors that contribute to a person’s illness.7,8 Through this model, practitioners take into account not only a person’s physiologic makeup and genetic history, but also their perceptions about this physiology and the resulting emotional responses, as well as social factors, such as what the culture views as an appropriate response to the illness. This helps clinicians assess illness severity and find the best path to recovery for that person.9

Pain in the elderly is a specialized illness. To properly address treatment, guidelines have been created by many different associations and societies.10-15 These groups recommend a multidisciplinary approach for optimal pain management. Treatment modalities typically are categorized by the following 4 areas of treatment: pharmacotherapy, psychosocial treatment, physical rehabilitation, and interventional modalities.16,17

Pharmacotherapy

Pharmacotherapy is the first, and most widely used, treatment modality recommended for geriatric pain. For many patients, pharmacologic therapy is necessary, either for a short time or chronically. There are a number of caveats to remember when using medication to treat pain in this population. Older patients frequently take multiple medications for concomitant medical problems, increasing the risks for adverse effects (AEs) and even mortality from pharmacologic agents. In addition, there are some key dynamics of pharmacotherapy that need to be understood and compensated for as decisions about medication management are undertaken.18 These include the following:

  • Older adults have a higher increased body fat and decreased water and muscle mass. This means that water-soluble drugs become more concentrated and have higher initial concentrations, whereas fat-soluble drugs have longer half-lives due to slower release from the body’s fat stores.
  • The livers of older patients frequently are smaller and have less blood flow, resulting in a decrease in the number of functioning hepatocytes. This, along with medication effects on the cytochrome P450 system, lead to changes in drug metabolism that need to be carefully monitored and adjusted for in each patient.
  • An increase in the incidence of renal disease impacts decisions about medications affected by renal clearance or known to increase the risk for renal damage. Even in the absence of known renal disease, renal clearance can decline significantly in older patients, impacting the AE profile of a number of medications used without problems in younger patients.

Despite the complexity of treating chronic pain in older individuals, the benefits of addressing and treating pain are clear. Chronic pain decreases function, increases the incidence of depression, creates kinesiophobia (fear of movement), and may worsen other chronic diseases that require ongoing management for maximal control, such as diabetes, hypertension, and heart disease.

Persistent pain, especially musculoskeletal pain, can be treated with non-opioids, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs). However, acetaminophen is not appropriate when the patient has liver failure or chronic alcohol abuse or dependence, and patients taking NSAIDs should be monitored for hypertension and other AEs such as gastrointestinal (eg, dyspepsia, mucosal erosions, ulcers, perforations, bleeding) or renal (fluid retention, hyperkalemia, decreased renal blood flow, acute renal failure) effects.

Topical Agents

In older patients, it is important to look at topical agents as the safest approach for those who may be on multiple other oral medications or who have comorbidities that may increase the risk for medication AEs or drug interactions.Topical agents can include topical lidocaine, capsaicin cream, topical analgesic agents, or NSAIDs (Table 2).19,20

Lidocaine ointment is an inexpensive option and can be used for patients with neuropathic and arthritic pain. It is easier for many patients to use lidocaine patches, which only need to be applied once per day, compared with the 4-times-daily dosing of lidocaine ointment. Formulary concerns can limit the ability to prescribe patches for some patients. Although the only FDA-approved indication for lidocaine patches is postherpetic neuralgia, recent studies have indicated that lidocaine patches are effective in the treatment of other neuropathic conditions, back pain, and arthritis pain.19,21

Other topical agents, such as capsaicin cream and topical menthol creams, might provide significant pain improvement with minimal risk if there is no allergy to the agents.

NSAIDs

Many patients benefit from intermittent NSAID use. Older patients are more sensitive to the nephrotoxic effects of NSAIDs and must be advised to use them only when needed and to remain well hydrated. All NSAIDs worsen hypertension, congestive heart failure (CHF), and renal impairment. NSAIDs are contraindicated in patients with renal disease, those on anticoagulation therapy, and those with CHF. Because many patients take NSAIDs over-the-counter (OTC) (Table 3), every patient needs to be questioned about their OTC medication use.

The cyclooxygenase (COX)-1 NSAIDs have GI and coagulation AEs, but the various NSAIDs have some differences with respect to these AEs. Of the COX-1 NSAIDSs, ibuprofen (Advil, Motrin, others) has the least GI toxicity, but it interferes with the cardioprotective effect of aspirin. Naproxen has an intermediate risk for GI toxicity, but it does not interfere with aspirin. Piroxicam (Feldane, others) and ketorolac (Sprix, others) have the highest risk for GI toxicity. Low doses of the COX-2 NSAID celecoxib (Celebrex), and meloxicam (Mobic, others), which has COX-1 properties at higher doses, have the lowest risk for GI toxicity, but concerns have been raised about cardiotoxicity, especially in higher doses.

Acetaminophen

Acetaminophen (Tylenol, others), when used in low doses, can be a safe and effective option for patients, especially when combined with other modalities. There is no GI toxicity or effect on platelets. However, there are some warnings that need to be followed when using this agent. It is important to monitor the international normalized ratio carefully when acetaminophen is used with warfarin (Coumadin, Jantoven, others). In addition, acetaminophen is found in many OTC medications, and patients need to be questioned about his or her OTC medication use. The FDA has requested that makers of prescription combination products containing acetaminophen limit individual doses to 325 mg because of concerns about liver toxicity with higher doses. Recently, an acetaminophen manufacturer has suggested an upper limit of 3 g per day in divided doses, also because of concerns about liver toxicity. The dose of acetaminophen in patients with renal disease or liver disease also should be lowered to 2 g per day.22

Anticonvulsants

Gabapentin (Neurontin, others) and pregabalin (Lyrica) have labeled indications for specific neuropathic pain disorders. Lower toxicity and fewer drug–drug interactions increase the usefulness of these drugs in older patients. Like other medications with a risk for increased sleepiness, these anticonvulsants should be given in low starting doses and titrated upward slowly.23,24

Antidepressants

Dual-acting antidepressants have been shown to improve chronic pain even in patients who do not have a diagnosis of depression. Duloxetine (Cymbalta, others), a selective serotonin-norepinephrine reuptake inhibitor (SNRI), has approved labeling for certain painful conditions and appears to be a better tolerated by older adults. The SNRI venlafaxine (Effexor, others) requires slow titration to the usual therapeutic dose of 150 mg. It also has a significant discontinuation syndrome when abruptly stopped. The immediate-release formulation of venlafaxine can result in significant GI toxicity and hypertension at doses higher than 75 mg.25,26

Opioid Therapy

The worsening rates of overdoses and AEs related to prescription opioids is at epidemic proportions and creates a complex public health crisis.27 The Centers for Disease Control and Prevention recommends that healthcare providers only use opioids in carefully screened and monitored patients when non-opioid treatments are insufficient to manage pain.20 This is especially important in the elderly, in whom added risks associated with recognized opioid-related AEs might be magnified. These AEs include constipation, cognitive decline, increased risks for falling, overdose, hip fracture, and exacerbation of sleep apnea. Recent articles include age greater than 65 years as a risk factor for overdose, heart disease, and GI bleeding when opioids are used (Table 4).28,29

Despite the risks, opioids may be helpful in selected patients when they are used with caution and when full patient education about the risks and benefits is provided. Many providers do not think that opioid agreements are needed in older patients, but it is important to observe “universal precautions” in all patients, including those older than 65 years. This includes the use of an opioid agreement and urine drug screening in all patients. In addition, each patient should have a diagnosis with an appropriate differential, a full assessment of psychiatric and substance abuse risk factors, and a pre- and post-intervention assessment of the level of pain and functioning, with proper documentation. Documentation should include assessment of analgesia, activity level, AEs, and any evidence of aberrant behavior.30

An opioid agreement serves a number of purposes and is as important in older patients as it is in younger ones. The opioid agreement fosters an open and honest discussion with patients, discussing how opioids may be helpful, but it is critical to pay attention to the warnings while using them. This is an opportunity to review AEs and what to do if they occur. It also is an opportunity to review office policies and procedures about opioid prescribing that must be adhered to during treatment.

If possible, it is helpful to have a family member sign the agreement as well, but it is mandatory to have a responsible family member understand what is being discussed if the patient has someone else managing his or her medications. Urine drug screens also can be quite informative in older patients, and they should be mandatory before the first opioid prescription and repeated as appropriate.

High-risk behaviors can occur in older as well as younger patients, and they need to be discussed and reviewed regularly. Behaviors important to note in older patients are the following:

  • Sharing medications can be felt to be a normal part of life by many patients. The medical community has been remiss in pointing out the dangers of mixing many medications with opioids, and the need to reinforce this is very clear as we look at AEs associated with opioid usage.
  • As patients retire, there are some situations in which alcohol use may increase, and previous use of illicit substances such as marijuana may resume. These drugs represent significant drug interactions with even more problematic outcomes in older patients, and this needs to be reviewed and discussed with all older patients on or off opioid therapy, especially when they have chronic pain symptoms.
  • As financial burdens increase, there have been a number of older patients who have supplemented their retirement incomes with the sale of opioids, which remains a crime in all 50 states.
  • Unused opioids can be found by family members and diverted.
  • Caregivers other than family members may take opioids from the patient and substitute non-opioid medications in their place without the patient’s knowledge.

When using opioids in the elderly, the caveat to start low and go slow remains crucial. Opioids tied into fixed acetaminophen dosing such as hydro-codone/acetaminophen (Vicodin, others) should be avoided, and it may be best to start with low-dose morphine (MS Contin, Kadian, others) or oxycodone (OxyContin, Roxicodone, others). The use of buprenorphine in the elderly has been extensively written about and may represent an option for providers familiar with its use, because it has been associated with less respiratory depression and cognitive impairment than other opioid analgesics. It is available as a patch (Butrans), improving ease of use for many patients.31

Methadone presents even greater risks for the elderly and should be used with extreme caution. It has greater efficacy for neuropathic pain than other opioids, but it has a number of drawbacks. It has a long and variable half-life, making serum levels difficult to predict. Methadone also is associated with drug-drug interactions. Such interactions can be exacerbated further by age-related changes in drug metabolism. In addition, methadone can cause fatal ventricular arrhythmias in patients with prolonged QTc intervals due to a torsades de pointes. In general, a QTc interval greater than 500 msec is an absolute contraindication to methadone therapy; if the QTc interval is between 450 and 500 msec, extreme caution needs to be exercised if methadone is used.32

Low-doses (25-50 mg) of tramadol (Ultram, others) can be helpful, posing an intermediate risk in patients compared with other opioids. Older patients taking tramadol have been shown to have a lower incidence of falls and hip fractures. Tramadol needs to be used cautiously in patients taking antidepressants, but it can be used in low doses even in that setting. Tramadol may increase the risk for both seizure activity and serotonin syndrome in patients taking selective serotonin reuptake inhibitors and SNRIs.33,34 There is significant synergy with respect to pain control when tramadol is mixed with acetaminophen.

Older patients are more sensitive to the effects of opioids, especially in the presence of renal or hepatic dysfunction. The most serious risk, however, is respiratory depression, which occurs less frequently when opioids are dosed and titrated cautiously. Patients are at the highest risk for respiratory depression during the first day of opioid therapy and during periods of dose escalation. Patients with chronic obstructive pulmonary disease, obesity, kyphoscoliosis, or sleep apnea are at the greatest risk for developing respiratory depression during opioid therapy.

Although use of long-acting opioids decreases the risk for end-of-dose failure (breakthrough pain) and treatment failure, it is important to understand the therapeutic response of patients to each formulation. Given the impaired metabolism and excretion that occurs in older patients, the shorter-acting agents may, in fact, remain effective for more prolonged periods in older patients than in younger ones.35 It is, therefore, important to ask patients about pain exacerbations and their relationships to dosing to determine if end-of-dose worsening of pain indicates the need for a longer-acting formulation.

Constipation is the most common side effect of opioids in the elderly, and patients do not develop a tolerance to this side effect with prolonged opioid therapy. Treatment with a stool softener, increased dietary fiber, and occasional use of cathartics, such as lactulose or polyethylene glycol, frequently are necessary. In severe cases, there are a number of prescription medications approved for the management of opioid-induced constipation, including methylnaltrexone (Relistor), naloxegol (Movantik), and lubiprostone (Amitiza).36

Opioids also can increase the risk for falling due to cognitive problems and/or peripheral vasodilation. In addition, opioid-induced immune suppression can lead to an increased risk for infection in susceptible individuals.

Psychosocial Support

The next component of multidisciplinary treatment is psychosocial support. There are a number of techniques that patients can use to cope with their pain. Cognitive-behavioral therapy (CBT) is a widely used form of therapy employed in people of all ages. However, it must be adjusted when dealing with older patients.37 Therapists must take into account that each generation has had specific events that have shaped its views and values, so these need to be considered when beginning CBT with an older adult. For instance, many of the current elderly lived through the Great Depression, and this hardship became a defining factor in their lives.

Another challenge to be addressed when treating an older patient is that the elderly may be “set in their ways,” which means that the change proposed by CBT may be difficult to adopt. In addition, the mentality that a patient has toward aging also will impact how the patient reacts to therapy. If a patient has a negative view of growing older, this can exacerbate maladies such as depression, which can, in turn, increase their pain.

In addition, cognitive ability will play a large role in a patient’s response to CBT. As a patient ages, their cognitive abilities have a natural tendency to slow and decrease. This may require the therapist to slow down the treatment pace to allow the patient to successfully retain CBT benefits.37

CBT offers a wide range of techniques for patients to use to cope with their illness. Some CBT techniques specific to pain include “self-instructions (eg, distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (eg, minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting.38 CBT also can help address comorbid conditions such as depression and anxiety, which are common in both elderly and pain populations.

Finally, patients who have a solid support system will find that a positive socioenvironmental situation will help improve their ability to cope with their pain. It has been determined that social support positively influences quality of life and that social isolation and inadequate support are clear negative quality-of-life indicators.39 Patients who feel that they do not have enough social support are at least 2 times more likely to be in poorer health than elderly patients who feel they have adequate support.39

Physical Rehabilitation

Physical rehabilitation is another important aspect of pain management in the elderly because it is necessary for patients to adapt to any loss of physical, psychological, or social skills.40 Physical rehabilitation has several aims to aid in pain management. The first is to stabilize the primary disorder that is causing pain, while also preventing any secondary injuries to the patient. By promoting adaptations to their disability, patients will learn to become more independent, thus allowing for better treatment. They will also increase their perception of control over the situation, which can help them recover.

Adaptations may be seen in the use of canes or walkers, the installation of grab bars in the restroom, a seat in the shower, or the use of a hearing aid. Not only does the use of adaptations improve treatment, but it also improves quality of life to such an extent that seniors who live independently with adaptations experience well being equal to that of seniors who live independently without any type of assistance.41 Physical rehabilitation has been shown to improve physical performance significantly in elderly patients who are considered “frail,” and it might even delay the onset of disabilities in mobility.42

Multidisciplinary Treatment

Successful multidisciplinary treatment of pain requires use of the full biopsychosocial model, with integration of physical rehabilitation, medication management, and CBT. Multidisciplinary treatment might alleviate the need for heavy medication use, thereby reducing concerns about AEs. By using a multidisciplinary approach, healthcare professionals can provide optimal care for geriatric pain patients.43

It is important to note that pain thresholds will change as patients age, causing more sensitivity to somatosensory types of stimuli.44,45 Elderly patients will be able to withstand exposure to stimuli such as warmth, cold, and vibrations, yet their ability to withstand pressure will decrease. These changes are important to keep in mind when attempting homeopathic pain management techniques such as ice, heat, or massage.

Due to their sensitivity to pressure, geriatric chronic pain patients should seek specialized massage therapists who understand their specific condition. Techniques such as acupuncture might modulate the nervous system and have been shown to relieve both acute and chronic pain in the elderly.46-48 Although it is difficult to make specific recommendations regarding long-term use of complementary and alternative therapies such as as these listed above, physicians should be careful about discouraging those benign therapies to avoid inadvertently inciting hopelessness in their patients.49

Advice to Caregivers/Children

It is important that caregivers be prepared to manage the complex needs of an elderly friend or family member. This includes being able to recognize and differentiate symptoms and manage them appropriately.50 When caregivers are unprepared, there is a higher risk of errors, duplication of services (like giving the same medication twice), or inappropriate care, which may be detrimental to the patient. However, when a caregiver is prepared, they can improve patient outcomes and reduce the number of readmissions to the hospital.51 Therefore, it is important to assess caregivers’ abilities, and train them appropriately. Using the Informal Caregivers of Older Adults at Home: Let’s PREPARE! survey, which assesses caregivers in multiple areas, may be helpful. Table 5 shows the dimensions of preparedness, which make up the acronym PREPARE.52

In addition to making sure the caregiver is able to take care of the elderly patient adequately, it is also important for caregivers to take time for themselves. Being a caregiver can be extremely stressful, and participating in long-term home care can result in depression, grief, fatigue, financial hardship, and changes in social relationships.53 Caregivers also can experience their own health problems.54 Therefore, it is important to understand the levels of strain the caregiver is under by assessing whether sleep is disturbed, and, if caregiving is inconvenient, whether it presents a physical strain or feels confining. In addition, family, financial, and emotional adjustments in response to caregiving may be quite stressful—it often is difficult to discover that a loved one has changed so much that they require extra care. Lastly, difficulties with memory or incontinence may be particularly hard to deal with emotionally.55

It often is difficult to have conversations with an elderly patient about their pain, especially if he or she has dementia. In these cases, it is recommended that the caregiver pay more attention to their behavior (Table 6): ask simple direct questions that only require a yes/no response; use short simple sentences; avoid slang; model the behavior with gestures; limit choices when asking questions; avoid guessing when unsure of what the patient is trying to say; and assess for unmet needs. For instance, are they hungry, thirsty, in pain, or do they need to go to the bathroom?56

In addition, it is important to be alert for signs of elder abuse, exploitation, neglect, and abandonment. It is estimated that only 1 in 10 such cases are reported. Signs of abuse include bruising, fractures, and lacerations. Signs of neglect include malnutrition, urine burns, diarrhea, poor hygiene, and inappropriate medication use (either over- or underuse). Exploitation could include misuse of money, caregiver demands for goods in exchange of services, and the inability to account for money or property. Abandonment also includes leaving the elderly patient alone in an unsafe environment or withdrawing care without making alternate arrangements.56

Among all the problems, however, is a point of light: caregivers can help their charges increase their function and mobility. According to the American Academy of Nursing’s Expert Panel on Acute and Critical Care, loved ones will recover sooner if they are encouraged to be active during hospitalization (working in conjunction with hospital staff, of course) and use all appropriate assistive devices, such as hearing aids, glasses, and walkers/canes.57 When the elderly patient begins to move independently again, ensure that he or she is wearing appropriate footwear and provide handrails, uncluttered hallways, door levers, elevated toilet seats, and other physical aids that may be of helpful. It is important to remember that safety should be promoted alongside independence, in a way that helps patients maintain their dignity.

Summary

There are many natural physical changes that take place during the aging process that can influence pain processing. These include the body’s changing composition of fat deposits, muscle mass, and bone density, as well as decreases in sensory systems, and kidney and cardiovascular functioning. These changes do not mean that acute or chronic pain is a natural part of aging or that they should be written off as “acceptable losses.” Understanding the special needs of an aging population—including comorbid factors, such as anxiety, depression, insomnia, and dementia, that can increase pain—is an important aspect of pain management for the elderly.

Last updated on: June 15, 2015
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