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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

Pain Management in the Elderly

A series of clinical vignettes provides insight into assessment and management of pain in the geriatric patient population.
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With the elderly segment of the population quickly becoming the fastest growing in the world, and aging baby-boomers increasing the healthcare burden in the United States, pain clinicians are encouraged to familiarize themselves with relevant pain issues affecting the aging and to be ready to face the challenges ahead. This review enumerates some of the physical and mental changes that occur in those age 65 and over through clinical examples and offers recommendations for assessment and management of comorbid pain conditions in this population. For the purposes of this article, pathophysiologic and pharmacologic modalities will not be discussed.

Source: 123RFAssessing and treating pain the elderly, or geriatric, patient population requires unique considerations.

Pain Assessment and Evaluation

Geriatric pain assessment is different from that conducted in other age groups. Several factors are responsible for this distinction, including biology, culture, religion, ethnic background, cognitive function, and attitudinal barriers.1 Multiple studies and literature reviews have addressed these aspects. Biologically, elderly patients are frail, have poorer circulation, have multiple comorbidities and more coexisting pain types, such as somatic pain and neuropathic pain at the same time, and recover slower than other age groups. Culturally, assessment of pain in the elderly is influenced by psychologic, physiologic, spiritual, social, behavioral, and physical factors. Elderly tend to be more religious and spiritual than other age groups as they near the end of their journey and seek a “pain free” remainder of their lives.

Elderly individuals, for instance, may have biased pain perception and modified threshold. Many may feel they have to “just deal with the pain,” that reporting pain is a sign of “weakness,” or presume that pain medications will lead to addiction.1 In older age groups, pain may be masked by an inability to communicate or dementia. Evidence shows that pain is under-recognized, underestimated and undertreated in patients 65 or older. However, in the authors’ clinical experience, the older the patient, the more common these trends tend to be.

 

As shown in Table I, several reliable methods exist for assessing pain in the elderly. A recent literature review found that, in cognitively normal patients, the Numeric Rating Scale, Visual Analog Scale (VAS), Face Pain Scale, and Verbal Descriptor Scale are valid for assessment.2 In older patients with cognitive impairment, however, the Abbey Pain Scale, Doloplus-2, Pain Assessment in Advanced Dementia Scale, Pain Assessment Checklist for Seniors with Limited Ability to Communicate, Checklist of Nonverbal Pain Indicators, Pain Assessment for the Dementing Elderly rating tool, and the Clinical Utility of the Certified Nursing Assistant Pain Assessment Tool (CPAT) may be more appropriate. Many of these tests may be administered by a family member or a caregiver.

Pharmacokinetic and Pharmacodynamic Changes in this Population

Clinicians may need to adjust medication selection and dosage for elderly patients compared to younger patients, and should be mindful of changes in homeostasis as well as underlying conditions. For example, renal drug excretion typically declines at age 65 and over, and out of caution, the elderly should be considered renally insufficient. Therefore, pain providers should pay special attention to all medications the elderly are taking, whether prescribed or over-the-counter. Many of these medications may linger in the body for many days and affect multiple vital systems including the heart, kidneys, circulation, cognition, coherence, balance, and even breathing patterns with possible respiratory depression. Medications that have high hepatic extraction (ie, blood flow-limited metabolism) usually have reduced metabolic clearance.

However, the metabolism of medications with low hepatic extraction (ie, capacity-limited metabolism) is not usually affected.3 Elderly individuals often have decreased water content and muscle mass, and increased fat content. Therefore, the distribution volume of hydrophilic drugs may be reduced whereas lipophilic drugs increase.3

Decreased serum albumin in this population may increase the amount of free drug availability, especially in chronic disease states and if malnutrition is present. A drug’s half-life is increased for many medications if there are coexisting kidney and liver diseases.4 Age alters hepatic Phase I reactions that involve hydrolysis, reduction, and oxidation more so than Phase II conjugation, such as acetylation, glucuronidation, sulfation, and glycine conjugation.4 In addition, Cytochrome P-450 function declines with age and, along with polypharmacy, may lead to potential drug toxicity and side effects in this population.4 Table II reviews some of these changes.

 

CLINICAL VIGNETTES

 

Case #1: 69-Year-Old Male Veteran with Chronic, Low Back Pain, Kidney Disease, and Vitamin D Deficiency

A 69-year-old African American veteran was referred to the pain clinic with chronic recurrent low back pain with left leg paresthesia. His past medical history (PMH) is significant for DM-II, hypertension, hyperlipidemia, CAD s/p 3 stent placements about 3 months ago, chronic kidney disease, GERD, and Vitamin D deficiency. His medications include Metformin, Januvia, Lisinopril, Metoprolol, Plavix, Aspirin 325 mg qd, Gabapentin 100 mg tid, Oxycodone 5 mg 2 tablets qid prn, Lipitor, and Omeprazole. His surgical history is significant for right inguinal hernia repair and appendectomy. He is widowed, has three adult children who live in a different state. He lives alone. He is a former smoker and drinks vodka on a nightly basis to “relax.”

His low back pain is located across the posterior lower lumbar spine and radiates to his buttocks and down to the posterolateral left leg, all the way to his left ankle. He has tried chiropractic care but did not complete more than 6 sessions of physical therapy as they “hurt.” The patient has not tried injections for the back pain. Upon further discussion, he was found to be a kind, soft-spoken man, who did not talk or complain much. He seemed to under-estimate his complaints and repeated the phrase “not a big deal” frequently. His vital signs were all normal except for a BP of 171/76 and heart rate of 101. He rated his pain score at “3/10” but it was unclear if he understood the rankings.

Last updated on: November 7, 2018
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Medication Management in the Aging
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