Pain in the older patient (over 65 years of age) is often undertreated and misunderstood.1 Undertreatment can lead to decreased quality of life, depression, and diminished socialization.1,2
In a study of 65 nurses practicing in a midwestern retirement community, a standard nursing knowledge and attitudes survey was conducted prior to a pain management education program. Posttests were completed immediately after the educational session and again 4 weeks later. Study findings indicated that the nurses had knowledge deficits in opiate pharmacology, use of meperidine, preferred routes for medication administration, cancer pain management, treating unrelieved pain, risks of addiction, and risks of respiratory depression.3 Nurse practitioners who care for older patients may have some of the same issues, knowledge deficits in pharmacology, fears of addicting patients, or adverse events.4
There is no definitive evidence that older patients physically experience pain differently than their younger counterparts.5 Treating pain in the older patient can be challenging, especially in the presence of comorbidities and polypharmacy.
Prevalence of Pain
By 2030, an estimated 20% of the population will be over age 65.6 Today's older patients can expect to live longer and have a more active retirement because of advances in medical science. If pain prohibits activity and limits functionality, it can cause decreased social interactions, sleep disturbances, depression, anxiety, and increased healthcare utilization and costs.1
Pain is very common in patients over 65.1,2,5,7 In long-term care facilities, about 80% of the patients report chronic daily pain.2 The incidence of pain is lower for older adults living in a community but still affects approximately one-quarter to one-half of the population.2 Cancer is the second leading cause of death in older adults,6 and cancer pain is present in approximately 14% to 100% of these patients.8 When cancer is first diagnosed, 20% to 75% of all patients report pain.8
Minority patients are at higher risk of experiencing severe pain with fewer resources for management. In one study, 28% of minority patients living in communities reported daily pain.9 In ethnically diverse populations, predictors for severe pain include1:
- Medicaid recipient
- two or more comorbidities
- a low level of education
- psychological distress.
Barriers to Treatment
Undertreatment may be related to healthcare providers' age bias or knowledge deficits, as well as patient characteristics. Healthcare providers may not prescribe opioid medications for pain in older patients for fear of oversedation or other side effects. Patients may also fear addiction to opioids and constipation.
In a recent survey, one in five older patients reported taking pain medication only occasionally during a 1-week period.1,10 Reluctance to take pain medications, financial constraints, and prescriber reluctance contributed to this cycle of undertreatment. The imbalance between pain and medication use suggests a disconnect in healthcare for older adults.
Pain can be adequately treated in older patients. They can remain productive and functional despite chronic pain conditions such as diabetic neuropathy or arthritis. Using a multimodal management strategy, careful prescribing, frequent reevaluation, and patient education can help provide a safe environment for treating pain in this patient population.
Let's look at a typical older patient who is experiencing pain.
Samantha Stone is your 75-year-old neighbor. She has done her own housework and gardening for years and really enjoys being in her yard. She has a son and two daughters who do not live locally. They visit every few months or so. Her main source of income is Social Security and a small pension from the local nursing home where she worked as a nurse's aide for many years. Recently, Samantha's yard has started to look unkempt. You don't see her very often and you notice she is using a cane to walk. One day you meet her at her mailbox and ask her about her health. She responds, “I've been having a lot more pain from my arthritis and diabetes lately. It seems like my feet are numb and burn all the time. My knees and back hurt from my arthritis. When I ask the doctor about the pain, he says it's just part of growing old. He wants me to take Tylenol only and use a heating pad for the arthritis. He doesn't want to give me anything stronger because I live alone and he's afraid I'll fall and break my hip if I get confused or lose my balance from the stronger medicine. My children agree. They don't want me to get “hooked” on pain killers. To tell the truth, I'm a little reluctant to take anything stronger because I don't want to get constipated or fuzzy-headed. Sometimes I just sit in my living room and cry. It's so sad. I thought I would have a lot of years to enjoy my family, house, and garden after I retired, and now I can't do much of anything. I may have to go live with one of my children if I can't get some pain relief.”
Patients like Samantha can be found in any primary care clinic. She has several sources of chronic pain, one musculoskeletal and one neuropathic, and she is becoming increasingly disabled without adequate treatment. Her quality of life is diminished and depression is becoming an additional factor. Samantha's concerns are valid as are those of her healthcare provider and children. The following sections will examine how to assess pain in older patients and use these assessments to plan a multimodal plan of care for more effective pain relief.
Patients who can self-report pain
Most older patients can use the 0 to 10 numeric pain intensity rating scale: 0 is no pain and 10 is the worst possible pain. Even patients with mild cognitive impairment can understand how to use a number to represent pain and use the scale to reassess pain relief.2 Some patients prefer to use the verbal descriptor scale, which uses words such as mild, moderate, or severe to rate the severity of the pain. Each complaint of pain should have a thorough assessment work-up to determine the underlying cause.2 Some disorders with associated pain, such as Samantha's arthritis and diabetes, may require the assistance of specialists to determine which therapies would provide the most benefit for pain relief.
A key issue with older adults who can self-report pain is their reluctance to complain and report increased levels of pain. This is due to several factors:1
- many older patients think that pain is a normal part of aging
- they do not want to be a nuisance. They want to be seen as “good patients”
- they feel that if they acknowledge their pain, it will result in costly tests or hospitalization
- for patients with cancer, increased pain may be a result of disease progression.
Healthcare providers must perform a thorough examination, obtain a full health history, and perform a pain assessment on any patient with a potentially painful complaint (see Table: “Painful Complaints”).
A rapid pain assessment is useful for a busy practitioner, particularly for patients with chronic pain complaints. Using this set of brief questions can help pinpoint problem pain areas that may need a more focused assessment (see Table: “Rapid Pain Assessment”).
Copy the pain scale in a large font on a cream or beige background so that older patients with visual impairments can see the words or numbers easily. Make sure the patient is wearing hearing aides and/or glasses if necessary. A combined scale such as a thermometer scale can help patients point to the level of pain they are experiencing (see Figure: “Pain Distress/Intensity Scale”).
Patients who cannot self-report pain
The nonverbal or cognitively impaired patient can be difficult to assess for pain. In a study of 331 residents with dementia in assisted living facilities and nursing homes, 76% had pain, 21% had pain greater than 2 out of 5, and 42% were identified as depressed.12 Additionally, 25% were not assessed for pain by a healthcare provider, 60% had no standardized assessment, and 19% of the patients with pain were not receiving any treatment.12 This lack of assessment and treatment for pain can lead to depression, which further complicates a plan of care for these patients.
A new environment, such as a hospital, can cause a nonverbal patient to suffer increased agitation and confusion, making pain assessment more difficult.13 Although self-report is the best indicator of pain, patients who cannot self-report pain, such as those with dementia or cognitive impairment, may require a behavioral pain assessment tool to evaluate sets of behaviors that indicate pain.
The Checklist of Nonverbal Pain Indicators represents six of these behaviors, which were determined in a study comparing cognitively intact patients with cognitively impaired patients who had had hip repair surgery.14,15 These behaviors include:
- facial grimacing
- vocal complaints.
Other behaviors determined to indicate pain were identified by the American Geriatric Society2 and are more specific:
- verbalizations: moaning, calling out, asking for help, and groaning
- facial expressions: grimacing, frowning, wrinkled forehead, distorted expression
- body movements: rigid tense body posture, guarding, rocking, fidgeting, pacing, massaging the painful area
- changes in interactions: aggression, combative behavior, resisting care, disruptive, withdrawn
- changes in activity patterns or routines: refusing food, appetite changes, increase in rest or sleep, increased wandering
- mental status changes: crying, tears, increased confusion, irritability, or distress.
In addition, increased agitation can result from untreated pain, and physical or chemical restraints when used to help ease the patient and control unwanted behaviors.13 In this situation, a trial of pain medication may alleviate the agitation.
Older patients with dementia can be very vulnerable to pain and its subsequent results and may perceive it differently. These differences include:
- higher pain threshold, diminished warning, decreased tolerance
- no difference in peripheral pain sensation or transmission
- central nervous system changes that may affect how the pain is interpreted.5
Using a behavioral pain scale consistently can help ensure that nonverbal patients are assessed for pain and that behaviors indicating pain are recorded regularly. This technique also allows the healthcare provider to track results of pain medication if behaviors resolve or lessen.
One of the simplest behavioral pain scales for older patients with cognitive impairment is the Pain Assessment in Advanced Dementia (PAINAD) scale (see Table: “PAINAD Scale”). This scale uses five common pain behaviors that include breathing, negative vocalization, facial expression, body language, and consolability. Each behavior is ranked and then added together; the higher the number, the more severe the pain.
Although some may consider the scale inaccurate because it relies on a caregiver's opinion,11 these patients may be overlooked and untreated, making it the best option to date to ensure consistent, standardized pain assessment in this population. It is anticipated that the PAINAD and many additional tools will be further developed in the future to improve reliable pain assessment in older patients with dementia.
Pain assessment should lead to an appropriate treatment in any patient. Whether it is medication, an intervention such as epidural steroid injection or kyphoplasty, or an alternative treatment such as acupuncture, will depend on the assessment findings. In the case study, Samantha will be given a combination of treatments involving medication for osteoarthritis and neuropathic pain. Using other pain relief options such as physical therapy, swimming programs, pool therapy, and acupuncture may provide enough pain relief to allow her to maintain her quality of life and independence.
Medication Management in Older Patients
The following tips are helpful when deciding on a medication regimen for an older patient:
- Older patients commonly have many medications and many prescribers. Ask the patient to bring all prescribed medication to the visit.
- Is the patient taking a medication that may cause a harmful interaction if taken with a medication you are prescribing? One example is combining aspirin used for prophylactic cardiac treatment with a nonsteroidal anti-inflammatory drug (NSAID). In the CLASS study, the risk of gastrointestinal (GI) ulceration and bleed was five times greater than the rate for nonaspirin users.16
- Does the patient use alcohol or illicit substances regularly? If so, they are not good candidates for opioid therapy or regular acetaminophen use.
- Frequent reevaluation is necessary to ensure the patient is taking the pain medication as ordered and to monitor side effects. A pill count at a follow-up visit may reveal the patient is not taking the medication at all, does not understand how to take it, or is taking too many doses.
Prescribing medications for older patients involves some trial and error; starting low and going slow is still the best approach. The older patient has a variety of factors that affect the way medications are utilized, including body fat composition (muscle to fat ratio), protein binding affected by poor nutrition, slowed gastric motility, decreased cardiac perfusion, and renal impairment.1
On the World Health Organization's analgesic ladder, possible medication options are arranged by steps:
- Step 3- severe pain: strong opioids such as morphine, fentanyl, hydromorphone, methadone
- Step 2- moderate pain: combination medication containing acetaminophen and oxycodone or hydrocodone
- Step 1- mild pain: acetaminophen, NSAIDs
Adjuvant medication like antiseizure drugs and antidepressants can be started and continued on any step.
Acetaminophen is the first option for mild-to-moderate pain complaints, and many older patients tolerate it very well. If the patient has a history of alcohol abuse or liver or renal impairment, the maximum daily dose of acetaminophen should be decreased by 50% to 75% from 4 grams per day or not used at all.2
The next level of medication for older patients is NSAIDs, such as ibuprofen, naproxen, or celecoxib (Celebrex). The most recent information from the Food and Drug Administration states that NSAIDs should not be used for patients with a history of transient ischemic attacks, recent cardiac bypass surgery, heart disease, or any patients with increased cardiovascular risks.17 The risk from NSAID use involves increased potential for myocardial infarction, stroke, and Stevens-Johnson syndrome. The increased GI bleeding and ulceration from NSAIDs cause 2,100 deaths per year.18 Although many prescribers attempt to limit GI effects by using a proton pump inhibitor such as omeprazole, recent capsule endoscopy studies found 30% of the patients started on NSAIDs had asymptomatic gastric ulceration after 3 weeks of NSAID therapy, and the incidence of lower GI mucosal breaks was 25.9% with ibuprofen use, 6.4% with celecoxib, and 7.1% with placebo.19
A topical NSAID patch that can provide localized pain relief from strains and sprains has been developed in an attempt to circumvent these serious adverse events.
Opioids, used for moderate-to-severe pain, provide excellent pain relief and are easier to metabolize, but have the unwanted effects of sedation, nausea, confusion, and delirium. They have no ceiling dose when not combined with acetaminophen. Depending on the results of the pain assessment, using a midlevel short-acting pain medication such as hydrocodone-acetaminophen (Vicodin) can provide acceptable pain relief. For some patients with more severe chronic pain, higher level opioid drugs such as oxycodone or morphine are beneficial. Some older patients with chronic persistent pain require extended-release medications such as MS Contin or OxyContin. When prescribing an opioid for an older patient, careful monitoring and dose titration will be the best protection for unwanted adverse effects such as sedation, nausea, itching, and confusion. Patients prescribed an opioid should be informed of the adverse side effects and given a bowel regimen of a laxative and stool softener.
If the patient has a neuropathic pain complaint, gabapentin (Neurontin), pregabalin (Lyrica), or duloxetine (Cymbalta) are options for pain relief. Extreme care should be taken when starting these medications because sedation and confusion are common. Starting with low doses and careful titration can minimize these adverse effects. A topical option is the 5% lidocaine patch that can be placed over the painful area. Research data support the use of this patch in postherpetic neuralgia, osteoarthritis of the knee, and low back pain.4 Tricyclic antidepressants such as amitriptyline should be avoided in older patients because of the high potential for orthostatic hypotension.2
Other Options for Pain Relief
There are other pain relief options that older patients can combine with medications or use alone. Any type of exercise can help keep joints moving and muscles strong. Acupuncture has proven effective for back pain, neck pain, osteoarthritis, and fibromyalgia.20 Meditation, imagery, relaxation, and hypnosis are useful for patients with recently diagnosed rheumatoid arthritis.20 Capsaicin (the active ingredient in cayenne pepper), devil's claw, and Phytodolor also provide limited pain relief in patients with rheumatoid arthritis.20
If all treatment options fail or a condition presents itself as conducive, interventional methods for pain management can be used. For radicular back pain, an epidural steroid injection into the area of the nerve serving the painful area can be effective.10 For patients with compression fractures, kyphoplasty or vertebroplasty is an option.
There are approximately 700,000 painful spinal fractures every year caused by osteoporotic weakening of the vertebrae.21 Theses fractures are extremely painful, and the pain is difficult to control with standard measures. Once the fracture has been confirmed, a vertebroplasty—which is a percutaneous injection of polymethylmethacrylate (PMMA)—is used to stabilize the collapsed vertebral body. The PMMA is placed directly into the fractured vertebra and can provide stability and excellent pain relief.21 To correct a vertebral fracture with a kyphotic deformity, a kyphoplasty can be performed. This involves placing a bone tamp into the vertebra, creating a hollowed out area in the vertebral body, and filling the space with PMMA.21 As with the vertebroplasty, the kyphoplasty can provide excellent pain relief and reduce the spinal kyphosis. The reported level of pain relief with these procedures is 87% with vertebroplasty and 92% with kyphoplasty.22
Considering All Options
Although there are many options for treating pain in the older patient, there are also many potential pitfalls. The best approach is to consider the diagnosis, preference, and tolerance of the patient, and the patient's ability to comply with the selected treatment option.1 Most primary care providers have an established relationship with their patients. Using a good pain assessment to drive treatment options is very beneficial, and electing an adequate medication paired with a complementary or interventional technique can provide excellent pain relief and preserve good quality of life for the older patient.
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