Managing Older Adults' Chronic Pain: Lower-Risk Interventions

Abstract

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.

This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet—Information for Family Caregivers—and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

In Brief

This article—part of a series published in collaboration with the AARP Public Policy Institute—discusses evidence-based, lower-risk strategies to control pain and describes how nurses can engage family caregivers in using them.

Figure: A nurse reviews lower-risk pain treatment options with a family caregiver and an older adult. Photo courtesy of the AARP Public Policy Institute.

Pain management challenges family caregivers, who need education and coaching on safe, effective strategies to use with older adults. Caregivers also need guidance on lower-risk pain medication approaches, while reducing the use of higher-risk pain treatments like oral nonsteroidal antiinflammatory drugs (NSAIDs) and opioids. Nurses are in a key position to help caregivers develop, implement, and refine multimodal pain treatment plans that align with the older adult's values and preferences. This article discusses evidence-based, lower-risk strategies to control pain and describes how nurses can engage family caregivers in using them. (A subsequent article will discuss the use of higher-risk pain management strategies.)

BACKGROUND

Most older adults experience recurring or persistent pain, potentially increasing their dependence on family and health care resources.¹ Prolonged pain negatively affects one's body, mind, and relationships; untreated, it worsens mental clarity, overall health, and longevity.¹ Nurses and other health care providers can address pain-related disability and despair by promoting the safe use of multimodal pain therapies. Strengthening caregivers' self-efficacy and coping skills can also help them better handle the difficulties of caring for a person with pain.

The best practice of multimodal therapy entails using multiple lower-risk therapies to limit exposure to higher-risk treatments. A balanced, evidence-informed approach to pain management uses lower-risk pain treatments whether or not higher-risk therapies are needed. Mild or moderate pain treatment should start with simple lower-risk approaches, such as applying heat, cold, or topical creams, to improve pain tolerability and the older adult's functioning. Higher-risk treatments may need to be added to prevent the negative outcomes linked to undertreated pain.

In treating pain, using a shared decision-making model helps care recipients and caregivers understand that pain control is not about using one treatment to achieve one desired outcome; rather, it is an individualized dynamic process based on shared values and achievable goals. Goal setting should balance concerns about pain reduction, functional improvement, and avoiding harm. Exploring with patients and caregivers how pain or its treatment interferes with valued activities establishes a foundation for goal setting and treatment evaluation based on individualized risks, benefits, and trade-offs. Additionally, shared decision-making can help health care providers proactively address conflict-producing differences, inequities, mistrust, and dissatisfaction.

LOWER-RISK APPROACHES TO MANAGING PAIN

For older adults with chronic pain, the treatment plan should address general wellness practices and include lower-risk pain management approaches to offset the need for higher-risk options or higher medication doses. Though medications may be needed, they alone are insufficient to control pain and improve functioning and quality of life. Health care providers should establish an evidence-based multimodal treatment plan that, depending on the patient's needs, combines medication, restorative, interventional, behavioral, integrative, and/or self-management strategies.² Of these, those considered lower risk are discussed below.

Lower-risk medications. Nurses can encourage patients and caregivers to try topical NSAIDs, rubefacients, capsaicin, or local anesthetics for localized areas of pain.³

• Topical NSAIDs (such as diclofenac) have antiinflammatory effects on superficial musculoskeletal pain—similar to their oral counterparts—while being safer for older adult use.³ However, they may not penetrate to deep sources of pain and, although not evident in research, may worsen advanced kidney, liver, or gastrointestinal problems.³
• Topical rubefacients (such as Tiger Balm, Blue-Emu, Aspercreme, and Icy Hot) commonly contain salicylate or menthol, which desensitize nociceptors and increase circulation.³ Nurses should remind caregivers to monitor for application site discomfort or signs of salicylate toxicity if repeatedly applied to large areas.
• Topical capsaicin (such as Capzasin or Salonpas Hot) is derived from chili peppers and is available over the counter as a gel, cream, or patch. Nurses should reinforce with older adults and caregivers that a few weeks of daily use may be needed for capsaicin treatment to work and for postapplication burning to stop.³ If indicated, high-potency capsaicin (8%) is available only in clinical settings, applied by trained professionals.³
• Topical local anesthetics (such as lidocaine and xylocaine) are available in spray, cream, gel, or patch form and work for certain types of pain (neuropathic, procedural).³

It is important to address safe use of topical medications, per package inserts, which includes heeding daily dose limits, handwashing after application, and not covering the medication (with tape, oils, perfumes) or exposing it to sunlight.

Acetaminophen is considered a safe, but not always effective, systemic analgesic.⁴ It can be harmful when used in patients who have certain diseases (kidney or liver), in cases of chronic alcohol consumption, with certain medications, or in high doses or for prolonged periods. A daily limit of 3,250 mg of acetaminophen from all sources is recommended for older adults.⁵

Cannabidiol (CBD) is a cannabis derivative that doesn't induce psychoactive effects and may be used for pain.⁶ CBD products containing less than 0.3% tetrahydrocannabinol, the psychoactive component of cannabis, were federally legalized in 2018.⁶ However, limited research and heterogeneous ingredients in CBD products make CBD's risk–benefit profile uncertain in older adults.^6-8

Restorative strategies. Many older adults already use topical heat and cold, electrical stimulation, or position aids (such as compression sleeves or orthotics) to improve comfort and function.² Caregivers should be instructed not to apply any of these items or devices to areas with altered sensation or if the person is unable to remove them. It is important to protect the skin from pressure and thermal injury and to examine any device cords for damage before each use.

Manual therapy (chiropractic care, physical therapy, osteopathy) and massage are skilled “hands-on” treatment approaches that can identify structural and functional anomalies in the musculoskeletal and soft tissues that may benefit from mobilization or manipulation. These treatments may not be tolerated in areas of hypersensitivity, and gentler forms may be preferred by some, yet ineffective for others.⁹ Deep pressure forms may be contraindicated or increase pain, and their use should be medically approved. Self-administered massage is possible with handheld devices, chairs and overlays, or even tennis balls. Meditative movement, such as yoga or tai chi, can alleviate musculoskeletal pain and also yield other physical and mental benefits.¹⁰

Therapeutic exercise can benefit individuals with pain and requires the health care provider's guidance to tailor the type, intensity, and duration of the exercise to the person's preexisting disuse-, deconditioning-, or morbidity-related limitations. Slow, deliberate progression of activity prevents overexertion or injuries that can sabotage the therapy. Devices like timers or Fitbits can help individuals pace their activities and motivate them to persevere through initial difficulty until noticeable functional improvements are realized.¹¹

Behavioral strategies. Psychological modalities can help reduce pain by addressing factors that make it worse, like high stress, strong emotions, and maladaptive biopsychosocial responses. Structured approaches such as cognitive behavioral therapy and mindfulness-based stress reduction may help people overcome cognitive and affective barriers to adaptive pain responses.¹² Nurses can coach patients and caregivers in the use of relaxation and distraction techniques. Nurses can also use the principles of cognitive behavioral therapy to teach patients to avoid unhelpful pain-amplifying thought patterns (such as catastrophizing) and instead use more adaptive approaches (acceptance, self-efficacy) to reduce pain.¹³ Caregivers can be referred to programs designed to help them use behavioral strategies to manage another's pain.¹³ Internet-based pain self-management programs have been developed, although some older adults may lack the digital literacy or dexterity needed to benefit fully.¹⁴ Other technological advances like virtual reality, voice assistants, and mobile apps can increase accessibility to a range of behavioral therapies.^{15, 16}

Integrative strategies. Complementary and wellness approaches may help reduce pain and aid in coping. Caregivers can help the care recipient engage with music, photos, books, videos, and hobbies to capture their attention and distract them from pain.¹⁷ Aromatherapy can soothe discomfort in older adults who have intact olfactory senses.¹⁸ These noninvasive, low-cost approaches can be used alone or in combination with other strategies.

Acupuncture can safely and effectively treat pain and discomfort while improving ability to function and well-being.¹⁹ Adequate access to trained professionals, limited Medicare coverage, and fear of needles are common barriers to acupuncture that nurses can help address.^20-22

Self-management strategies. Sleep hygiene, maintaining a healthy weight and diet, and using dietary supplements may alleviate musculoskeletal pain with little risk.^{23, 24} Supplements, however, can be expensive, have adverse effects, or interact with systemic medications or certain disease states. Nurses, pharmacists, and registered dietitians can help evaluate the costs, benefits, and relative risks of supplement use.²³ Often, patients don't disclose the use of supplements because their provider doesn't ask or discourages supplement use. Inquiring in a nonjudgmental tone can encourage disclosure.

ENGAGING CAREGIVERS AND PATIENTS IN TREATMENT PLANNING

Family caregivers' involvement in pain treatment planning is important, and varies according to their relationship to the care recipient (partner, child, other) and prior involvement with the recipient's health concerns.²⁵ Health care providers should approach treatment planning by engaging the care recipient and caregiver empathetically and using active listening to facilitate sharing of insights, advocacy, and direct communication.²⁶ Through one-on-one and group conversations, nurses can serve as trusted confidantes to both caregivers and care recipients, helping to identify and resolve issues that may affect treatment planning.

Addressing the caregiver's needs. Caregivers may be living with their own pain or with physical, mental, or financial limitations,²⁷ which could affect their ability to provide care. Women, minoritized individuals, and those challenged by socioeconomic factors face particular caregiving burdens.²⁸ Nurses should assess for caregiver role strain, which may manifest as physical, emotional, communication, or relationship changes. Empathizing with the caregiver and providing stress-relieving interventions and informational support can strengthen caregiver self-efficacy, resilience, and therapeutic engagement.

Promoting pain management and coping skills. Nurses should ask caregivers and care recipients to review what has helped to relieve pain in the past and identify additional methods they are willing to try. See Common Self- or Caregiver-Initiated Pain Management Approaches for a list of options; have them select at least one method per category to master in order to build their coping skills and help them better manage pain and function.

Box 1: Common Self- or Caregiver-Initiated Pain Management Approaches

Coping styles can be classified as problem focused or emotion focused.²⁹ Problem-focused coping identifies and modifies factors that worsen pain, disability, or distress.³⁰ For instance, if an older adult knows that standing for long periods to cook exacerbates pain, they can alternate sitting with standing or ask for support while cooking. For issues outside the person's control, using emotion-focused coping strategies like acceptance, humor, or prayer may be more helpful than trying to change the situation.³⁰ Nurses can facilitate the use of adaptive problem-solving or emotion-focused coping depending on whether the problem can or cannot be controlled.²⁹ They can also respectfully challenge and reframe inflexible, false, or unhelpful perceptions. Harmful coping strategies, such as substance use or disengagement, should be addressed.³⁰

Reviewing treatment options. In developing a treatment plan, providers should review both lower- and higher-risk options with the care recipient and caregiver. Determining the most effective way to capitalize on lower-risk methods can minimize the use of higher-risk treatments without denying access to potentially helpful therapy. Nurses can improve outcomes by learning about any fears or misconceptions the care recipient and caregiver may have, which if ignored, could undermine treatment adherence.³¹ Aligning the treatment plan with the values and beliefs of the care recipient and caregiver, and realistically appraising its risks and benefits, enhances the caregiver's self-efficacy to improve therapeutic outcomes.¹³

Evaluating relationships. Nurses should evaluate the care recipient–caregiver relationship during treatment planning. Role reversal—when the caregiver takes on tasks once handled by the care recipient—may strengthen the relationship or trigger conflict.²⁶ Spouses may be burdened with greater psychological distress than offspring, who are more likely to feel obliged to provide for their parents' basic needs.³²

Other factors. Consider race, ethnicity, the care environment, and accessible resources when developing a realistic, culturally congruent treatment plan. These factors shape the meaning of pain, behavioral responses, treatment expectations, and engagement in therapy. Acknowledge the impact of pain and potential for bias, stigma, and structural inequalities. Nurses should inquire in a compassionate way about the individual's perceived meaning of pain and the best way to treat it. This invitation to express concerns shows consideration for differing values while building trust and rapport.

Mutually aligned goals. Shared goals among the caregiver, care recipient, and health care team provide a sense of respect, control, and order that facilitates communication and better outcomes.³³ Nurses can work with the caregiver and care recipient to create long-term and short-term SMART (specific, measurable, achievable, realistic, timely) goals, which should be periodically reviewed and revised to refine treatment.³⁴ For example, an older adult's long-term goal may be to “walk one mile with my granddaughter by next June.” The related short-term goal (to be revised weekly) is to “control my pain enough to walk 100 feet by next Monday.” Despite the desire to expediently eradicate pain and functional limitations, realistic expectations should be based on incremental improvements that may take weeks or months to achieve.

IMPLEMENTING AND EVALUATING THE TREATMENT PLAN

Nurses should delineate the caregiver's role in implementing the treatment plan and evaluating its effectiveness. The value of the caregiver's cautious optimism, plan adherence, and monitoring of desired and undesired treatment effects shouldn't be overlooked. Some lower-risk treatment options require a commitment of weeks or months of unclear efficacy until the full benefits are realized. Even when a good plan is established, continued monitoring of pain, activity, and treatment effects is necessary, as pain, patterns of daily living, and health conditions may change, requiring revisiting the goals of care and treatment strategy. Given their synergistic effect, lower-risk treatments should be continued even if higher-risk treatments are needed. Establishing wellness and lower-risk pain control routines is important in case higher-risk treatments require multiple trials over several months to find the most effective plan.

Caregiver insight can help health care providers consider treatment goals and evaluation through the lens of the care recipient's culture and values.³⁵ This insight can reveal how pain or its treatment affects the person's daily activities, cognitive and emotional state, and quality of life, which are central to refining the plan.

Nurses can encourage caregivers to use written or digital treatment response logs to record daily observations on pain symptoms, activity, rest, and responses to therapy. These logs provide valuable insight that can guide treatment adjustment, sustain motivation, or indicate functional decline. When updating treatment plans, nurses should review the logs with the caregiver and care recipient, discussing progress on SMART goals and refining them as needed using shared decision-making.

It is also important to attend to caregivers' personal concerns and promote self-efficacy by using strategies such as skill practice, modeling helpful responses, sharing relatable experiences, and conveying confidence in their ability to meet the care recipient's needs. Overestimating the caregiver's or care recipient's responsibilities in pain management can lead to excessive burden, nonadherence, and negative effects on the caregiver's physical and mental health. As the treatment plan is refined, it may be necessary to shift roles and responsibilities and secure additional support from available resources.

RESOURCES FOR CLINICIANS AND CAREGIVERS

For a detailed overview of the pain management interventions described in this article—including benefits, risks, and tips for using them—see https://geriatricpain.org/low-risk-pain-treatments. Additionally, nurses can refer family caregivers to the tear sheet, Information for Family Caregivers, for guidance on using lower-risk strategies to manage pain.

Box 2: Information for Family Caregivers

Resources for Nurses

• Lower-Risk Treatments for Managing Pain
• https://links.lww.com/AJN/A242

Note: Family caregivers can access these videos, as well as additional information and resources, on AARP's Home Alone Alliance web page: www.aarp.org/nolongeralone.