Dr. Reid is a consultant to sanofi aventis. Dr. Ayres and Mr. Warmington reported no potential conflict of interest relevant to this article.
Managing chronic pain in an older adult can be a complicated task, with risks for adverse effects, under- or overmedication, and nonadherence. Pain can be alleviated in many cases, however, if you address potential complications and barriers to effective treatment when prescribing analgesic medications.
Pain is a part of daily life for many older adults
As many as 50% of community-dwelling older adults experience a chronic pain disorder, defined as pain on most days for at least 3 consecutive months.1 Prevalence rates are typically higher (49%-84%) among residents of long-term care facilities.2 Untreated chronic pain can lead to health consequences such as depression, decreased ability to socialize, impaired ambulation, impaired sleep, increased falls, malnutrition, and decreased quality of life.1,3 Among older women, pain is the most common reported cause of impairment in activities of daily living.4
Arthritis and arthritis-related diseases (such as back pain) are common causes of chronic pain in older adults.5 Other causes include neuropathies, vertebral compression fractures, cancer and cancer treatments, and advanced chronic diseases such as end-stage heart, lung, and kidney disease.6-10
Substantial literature documents that chronic pain is underdetected and undertreated with advancing age11,12 and strongly supports efforts to improve pain care in later life. Treatment guidelines recommend a multimodal approach, including evidence-based nonpharmacologic treatments such as cognitive-behavioral therapy, exercise, and physical therapy.1 At the same time, pharmacotherapies remain the primary treatment used by physicians,13 and studies indicate that older people use analgesics frequently:
- When 551 older black and non-Hispanic white adults with osteoarthritis were interviewed, more than 80% of each group reported regular use of prescription and over-the-counter (OTC) analgesic medications.14
- In a cross-sectional study of 272 community-dwelling older adults with chronic pain from diverse causes, 59% reported routine use of an analgesic medication.15
The following 6 steps can improve the likelihood of a successful analgesic trial when managing chronic pain in people ages 65 and older. They take into account barriers you are likely to encounter, including polypharmacy, multimorbidity, cognitive and sensory impairment, sociodemographic factors, specific health beliefs about pain and pain treatments, and age-related physiologic changes.
Refine your approach to chronic pain in older patients with these 6 steps
|1. Conduct a comprehensive pain history||Assess pain location and intensity, and ask how pain limits activity. What treatments have been tried? What worked best? Any intolerable adverse effects?|
|2. Review the problem list||Obtain a full medication list (OTC and supplements) to identify potential interactions. What chronic conditions (kidney or liver disease, movement disorders, neurologic problems) might worsen with analgesic medication or operate as a contraindication? Which drugs or comorbidities might affect treatment choices?|
|3. Establish treatment goals||Address potential unrealistic expectations (eg, complete relief of pain or no benefit from treatment). The patient’s goals might differ from yours; come to a mutual decision about the most important outcomes.|
|4. Identify barriers to therapy||Be aware of how cognitive or sensory impairment, sociodemographic factors, or health beliefs may limit medication adherence. Elicit the patient’s concerns about medications and discuss openly. Include the caregiver, as needed, when discussing treatments and monitoring outcomes.|
|5. Start low and go slow when initiating analgesia||Avoid “start low and stay low,” which can contribute to undertreatment. If treatment goals are not met and the patient is tolerating therapy, advancing the dose is reasonable before trying another intervention.|
|6. Assess for effects and outcomes||Make certain that the patient (or caregiver) understands what adverse effects might occur, and create a plan to address them. Establish how often and when communication should occur. Encourage telephone calls and/or e-mail to communicate questions or concerns.|
|OTC, over the counter|
Step 1. Conduct a comprehensive pain history
The first step in pain management is to perform a comprehensive pain assessment. Without a proper pain assessment, it will be difficult to effectively treat and monitor response to treatment. Whichever pain scale you decide to use, it is important to use the same pain scale consistently each time a pain assessment takes place.3 The numeric rating scale and verbal descriptor scales (or pain thermometer) are widely used and have been shown to be preferred in the older adult population.3,16 The numeric rating scale asks a patient to rate his or her pain on a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain imaginable. The verbal descriptor scale is a measure of pain intensity on a vertical scale (typically a thermometer) from “no pain” to “excruciating.”3