Senior Pain is Often Under Treated
Managing the pain of seniors is challenging. A key step in the treatment of pain in the elderly is actually recognizing the pain. The elderly patient may not always volunteer the information and therefore they must be asked routinely whether or not they are experiencing any pain. There are no specific biological markers or blood tests for the measurement of pain; therefore, the clinician must rely on the patient’s self-report as the best objective measure of the pain as well as of its severity
The AGS Panel on Chronic Pain in Older Persons (1998) noted that in one study of chronic pain in elderly nursing home residents, pain was associated with the inability to enjoy social activities in 54%, depression in 32%, impaired cognition in 12% and anxiety of 26% of residents.
Charles Argoff, M.D., writing for PainEDU.org, proposed that the under-treatment of chronic pain in general remains a significant public health issue.” In particular, even though there has been a plethora of new analgesics, even though there are numerous available non-pharmacologic approaches to pain management, and despite the fact there have been guidelines established for the treatment of chronic pain in the geriatric population, the under-treatment of chronic pain in the elderly persists.”
Dr. Argoff suggests that it is important to recognize that age by itself does not result in impaired pain sensitivity. In addition, age itself does not change the quality of the pain experience for an individual. Pain may be a source of or an exacerbating factor of depression in the elderly. The inability for an older person to perform basic activities of daily living as the result of the pain can be quite disturbing and depressing to the older person with chronic pain. Cognitive impairment in the geriatric population may limit the full assessment of pain as well as impair the ability to fully treat the condition.
Analgesics pose special risks
The elderly are likely to have other diseases/illnesses to contend with, increasing their frailty and at the very least complicating the treatment approaches. As a result, it is especially important when prescribing analgesic medications for elderly patients, that specific attention is paid towards choosing regimens that are least likely to cause organ toxicities, have significant drug-drug interactions or have other adverse effects.
Osteoarthritis is one of the most common pain disorders in the elderly
A National Health Nutrition Survey conducted several years ago proposed that osteoarthritis is one of the most common pain disorders in the elderly. Radiographic severity of osteoarthritis of the knee for example correlates well with increased pain, impaired function and psychological dysfunction. The prevalence of knee pain appears to be greater in older women compared with older men. Data from a national survey indicates that the prevalence of musculoskeletal pain affecting the neck, back, hip and knee is greater in older persons (mean age 75) than in younger persons (mean age 40). Of interest is that in this study, even when the prevalence of pain in a particular location was similar in the two groups, the effect of the pain on impairing activities of daily living and in disturbing quality of life was greater in the older group.).
Pharmacological treatment of pain in the elderly has some unique aspects to it
Dr. Argoff has noted that “The pharmacological treatment of pain in the elderly has some unique aspects to it. No single dose of analgesic is appropriate for all patients with chronic pain. The elderly may metabolize certain medicines more slowly than a younger patient would. It is therefore recommended in general that starting treatment with a low dose of medication and slowly increasing the dose is the best way to achieve satisfactory analgesia and minimize side effects. In general, using the least invasive route of administration and reassessing the patient’s complaint of pain frequently is advisable.”
“Non-opioid analgesics including acetaminophen and NSAIDs are commonly used to treat pain in the elderly. While the tolerability of acetaminophen may make it appear to be an ideal choice as an analgesic for mild to moderate pain, long-term use of acetaminophen must be very carefully monitored because of the potential for hepatic and renal toxicities – even with use of the recommended doses. In particular in managing pain in the elderly, care must be taken to maximize benefit and minimize harm; therefore, ideal analgesic choices might include topical therapies such as the lidocaine patch, Cox 2 specific drugs and certain anticonvulsants such as gabapentin.”
The administration of opiate analgesics has found increased acceptance as a treatment for chronic non-cancer related pain. Their use should be strongly considered in the elderly as single entity opiates do not have a ceiling effect with respect to organ toxicity and low doses of a variety of opiate analgesics can be extremely helpful in the management of pain in the elderly. Perhaps most important are the avoidance of medications which have come to be recognized as inappropriate in the elderly.
Fear of addiction and side effects impact pain control
The Albuquerque Veterans Administration Medical Center, New Mexico, issued a White Paper in which it noted that while much is known about opioid metabolism, which is critical in administering these agents to the elderly, fear of addiction and tolerance are the major barriers to their use among patients as well as health-care professionals. Addressing these issues early in the initiation opioid therapy will help to alleviate these concerns.
One concern about opioid therapy is a risk to renal function, due to its undesired side effects. It is critical to monitor renal function and make adjustments in dosage if renal problems are suspected.
Of all the unwanted effects of the opioids, the most difficult to deal with is that of constipation. Here, an aggressive approach using bowel stimulating laxatives is critical in order to prevent this problem. It is anticipated that a variety of newly formulated opioids will shortly be available for clinical use. Finally, as a better understanding of the neurophysiology of pain is gained, the clinician can anticipate having more analgesic opioids that target their receptors without agonist or antagonist effect on other opioid receptors. This will allow the clinician to better relieve pain with a minimum of unwanted side effects.
Treatment of pain challenges caregivers
The treatment of pain in the elderly poses certain challenges but these can be overcome and effective management can be realized. An eldercare navigator can develop a pain management program with caregivers to help manage pain and minimize side effects.
By Mardy Chizek, RN, FNP, BSN, MBA, AAS
President of Westmont, Illinois’ Charism® Eldercare Services