Assessing pain in the older person

Managing pain in older patients can be very challenging, says Dr Sinead O'Mahony.

In the past 20 years, the population aged 85 and over has doubled in the UK.

Population ageing has huge implications for healthcare. Pain is common in older people, with up to half of older patients affected by it.

Impact of pain
Pain is associated with poor physical and mental well-being as well as interference with daily activities, poor global function, depression, sleep problems and reduced life satisfaction. It also has a detrimental effect on mobility among older adults.

Barriers of management
Barriers to effective pain management include failing to recognise pain, stoicism on the part of the patient and altered expectations of pain relief with advancing age.

Effective communication with older patients can be difficult in the presence of deafness, speech or cognitive impairment.

The majority of patients with mild-to-moderate dementia are capable of communicating effectively about their pain when asked.

However, patients with dementia are often not adequately assessed and what they say is not thought to be valid. Their behaviour and distress is assumed to be due to the dementia and the cause of the distress is not sought.

A pain history should be considered in all assessments of elder patients. The assessment should include the intensity, location and extent of the pain, and its impact on daily life. The intensity of the pain should be assessed using a standardised rating scale.

Observations
Observations play an important role in detecting the presence of pain. Several signs indicate pain in older adults, including: facial expressions such as grimacing, body movements such as guarding and verbalisation such as moaning.

Behavioural pain assessment tools have been developed for use in non-verbal older adults and older adults with dementia, for example the discomfort scale for dementia of Alzheimer type (DS-DAT), the Abbey pain scale, the pain assessment checklist for seniors with limited ability to communicate (PACSLAC), the NOPAIN tool and Doloplus-2.

Treatment
Older people are under-represented in clinical drug trials.

Extrapolating from evidence in middle-aged adults is not appropriate because of pharmacokinetic changes in older people.

Opioid dosages usually need to be reduced because of age-related decline in renal clearance, which can be quite variable across individuals.

As a result of reduced cognitive reserve, some older people are more prone to confusion as a side-effect of CNS-acting drugs.

Non-opioid analgesics are not without their problems. NSAIDs are associated with a much higher risk of GI haemorrhage in older people and can also cause renal impairment. The high age-related burden of cardiovascular and cerebrovascular disease means COX-2 inhibitors are inappropriate for many older people.

For moderate-to-severe pain, opioids may have fewer long-term risks in older people than other analgesic drugs. NSAIDs unfortunately still top the list of drugs causing acute hospital admission in the UK, with adverse drug reactions accounting for 6.5 per cent.

Several non-pharmacological interventions, including exercise and education programmes, have been shown to reduce pain in older patients.

Dr O'Mahony is a senior lecturer in geriatric medicine at Cardiff University

A longer version of this article was originally published in paineurope. To register to receive paineurope, email your details to paineurope@subscriptions.co.uk

REFERENCES

  • Kaasalainen S, Crook J. A comparison of pain-assessment tools for use with elderly long-term-care residents. Can J Nurs Res 2003; 35: 58-71.
  • Herr K, Bjoro K, Decker S. Tools for assessment of pain in nonverbal older adults with dementia: a state-of-the-science review. J Pain Symptom Manage 2006; 31: 170-92.
  • Zwakhalen S M, Hamens J P, Abu-Saad H H, Berger M P. Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools. BMC Geriatr 2006; 6: 3.
  • Pirmohamed M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18,820 patients. BMJ 2004; 329: 15-9.

KEY POINTS

  • Pain is common in older people, affecting up to half of community-dwelling older adults and 80 per cent of nursing home residents.
  • It is under-recognised and under-treated, especially in vulnerable older adults such as those with cognitive impairment.
  • Pain has multi-dimensional effects on older people, impairing physical and mental well-being, mobility and daily activities.
  • The best way of determining whether an older person is experiencing pain is to ask them.
  • Research is needed into effective pain management strategies in older people.

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