Pain Management in the Elderly
The Importance of Understanding Pain in the Elderly
Pain currently is the most common complaint that motivates patients to visit a physician. Currently, elderly patients comprise the fastest growing segment of the world’s population. The number of people worldwide 65 and older is estimated at 506 million as of 2008 and by 2040 will increase to 1.3 billion.
Chronic geriatric pain is defined as “an unpleasant sensation and emotional experience associated with actual or potential tissue damage who have had pain for greater than 3 months.” The consequences of this pain include impaired movement and functioning on a daily basis and mental disturbances such as depression or anxiety. Pain is associated with complications including muscle deconditioning, walking abnormalities, accidents, and mental decline. Pain may also result in the physician prescribing large doses or many different medications which are sometimes difficult to keep up with.
The prevalence of persistent pain increases with age when increases in joint pain and nerve pain become more likely. A majority of elderly persons have significant pain problems and are undertreated. Moreover, detection and management of chronic pain remain inadequate. In one study, two-thirds of geriatric nursing home residents had chronic pain, but in almost half of the cases it was not detected by the treating physician.
The treatment of pain begins with the assessment of what started the pain, how that can be stopped, and what management modalities are most effective for that particular patient. In reality, however, assessment is rarely that simple. Clinical manifestations of persistent pain are often complex and involve many factors in the older population. Even the perception of pain may differ from that in those of less advanced years. Issues of access to treatment, cost of drugs, the presence of coexisting illness, the use of other medications, and even the ability to understand the complaints of the patient who has cognitive impairment are only some of those factors that contribute to the complexity of the situation. Without a thorough assessment, even pain that is causing severe impairment may not be revealed for an array of personal, cultural, or psychological reasons.
Evaluation of the patient’s level of function is also very important as it affects the level of independence, level of need for caregivers, as well as overall quality of life. After a diagnosis is made, a consensus treatment plan should be outlined that includes therapies to decrease pain perception and increase patient function. Loss of function and independence can many times be a trigger for mood disturbances and a source of depression if untreated.
The complexity of pain assessment in geriatrics often requires a multidisciplinary approach to diagnosis and management. The pain physician should work together with a psychologist or psychiatrist, as well as a physical therapist. Laboratory and imaging studies may be ordered to help pinpoint a diagnosis if a detailed history and physical is not enough. Improvement in a patient’s pain appears to be optimized when multiple therapies are available for treatment. These same results are not mirrored when only a single therapy is available (i.e. only procedures or only medication management).
Treatment modalities for pain in the elderly may be categorized into the following. A multidisciplinary approach is recommended to investigate all possible options for optimal management, including:
- Pharmacotherapy (most commonly employed)
- Interventional procedures
- Physical Rehabilitation
- Psychological support
Drug treatment is generally the first and most widely used treatment modality to control geriatric pain. It is relatively simple to implement and consists of NSAIDs, muscle relaxants, opioids, as well as other adjuvant therapy. Prescribing these medications is not without risks, however. The patient’s cognitive, physiological, and functional status may be affected and physicians need to be prepared for these issues.
Since pain is a complex sensory and emotional experience, psychological modalities should be employed in the pain management model. Pain coping strategies may include relaxation, prayer, and attention-diversion techniques. Depression and anxiety in the geriatric patient must be addressed with psychotherapy, meditation, and medication. A solid support system including relatives and caregivers should be established.
The rehabilitative aspect of pain management may help the patient live a more independent and functional life. Rehab may involve adapting to loss of physical, psychological, or social skills. The objectives of rehabilitation include stabilizing the primary disorder, preventing secondary injuries, decreasing pain perception via a multidisciplinary approach, treating functional deficits, and promoting adaptations to current disabilities.
Interventional pain modalities may help determine the underlying cause of pain and help to arrive at a precise diagnosis. It oftentimes alleviates the need for heavy medication use, thereby sparing the patient from unwanted side effects associated with larger doses. Nerve blocks are some of the most commonly used interventional procedures employed by pain physicians and help not only with diagnosis but also prognosis, preemptive analgesia, and sometimes definitive therapy. Many other interventions may be utilized when trying to decrease a patient’s pain.
Persistent pain is not an inevitable part of aging but is fairly common among the elderly. The treatment of pain may be complicated by multiple problems that are far less likely to occur in younger adults. Barriers to effective management include challenges to proper pain assessment; underreporting by patients; atypical manifestations of pain in the elderly; a need for increased appreciation medication effects and their changes with aging; and misconceptions about tolerance and addiction to opioids. Physicians can provide appropriate analgesia in geriatric patients through proper assessment, multidisciplinary approach, and appropriate use of treatment modalities. Dr. Jared Scott - Advanced Pain Medicine Associates in Wichita - Providing Hope for Pain Sufferers