Pain management - Pain in the elderly

Treating pain in the elderly patient poses a particular challenge. Dr Deane Halfpenny explains how success can be achieved.

Manage pain with pharmacological and non-pharmacological strategies (Photo: Science Photo Library)
Manage pain with pharmacological and non-pharmacological strategies (Photo: Science Photo Library)

As the elderly population continues to increase, certain pain conditions become more prevalent. Typically, these are associated with degenerative joint conditions such as osteoarthritis and back pain, but they can arise from other sources, leading to neuropathic pain commonly found in shingles and diabetic neuropathy.

Improved management of pain in the elderly can significantly reduce disability and improve quality of life. Pain should not be overlooked as a significant contributing factor in depression, disability, social isolation and overall functioning. It should be actively investigated and treated.1

Why is pain so frequently underdiagnosed and poorly managed, and what are the barriers to its effective management? In part there is a general under-reporting by patients, as many simply acknowledge that a degree of pain is an inevitable consequence of ageing; however, practitioners need to be more vigilant.

Diagnosis

A comprehensive assessment of the patient should be undertaken, with appropriate investigations where necessary. It is helpful to determine what instigated the pain, how much of it can be eliminated and how much needs to be managed.

Pain from an osteoarthritic joint can be eliminated where arthroplasty is routinely carried out, such as in total hip replacement, whereas pain from degenerative spinal conditions needs continuing management.

Pain should be actively investigated, with a diagnosis established wherever possible. This is particularly helpful in long-term management, where ruling out certain conditions ensures that patients can engage with strategies to alleviate pain.

There are no objective biological markers for pain, so self-reporting is accepted as evidence for its presence and perhaps the best way to assess its intensity. Pain has been described as the 'fifth vital sign' and physicians need to ask regularly about the presence of pain in their evaluation of older patients.2

An evidence-based treatment plan should be formulated. This should employ pharmacological and non-pharmacological strategies wherever possible. Despite the high risk of adverse drug reactions, pharmacological interventions remain the primary modality for treating pain in the elderly.

Pharmacotherapy

When prescribing pharmacotherapy, the physician must consider age-associated changes in drug metabolism, increased incidence of adverse drug reactions with age, and the increased likelihood of drug-drug and drug-disease interactions.

Despite these obstacles, chronic pain in older adults can be well-controlled, although achieving this often requires trial and error and titration of medication dosages. This is particularly true of opioid analgesics and antineuropathics.

Understandably, there are concerns when introducing these agents to patients with cognitive impairment or falls, for example, but the concept of starting 'low and slow' can avoid complications. Careful monitoring is important, not only in determining effectiveness, but also in detecting any complications.

Interventional therapy

Interventional pain modalities may help to determine the underlying cause of pain and elucidate a precise diagnosis. Intervention often reduces overall dependence on analgesics, thereby sparing the patient from unwanted side-effects associated with larger doses of drugs.

Nerve blocks are some of the most commonly used interventional procedures employed by pain physicians; these help with diagnosis, prognosis, pre-emptive analgesia and definitive therapy.

An epidural steroid can maintain mobility and functioning in selected patients who may not be suitable for surgery in spinal stenosis. Other interventions include chemical neurolysis, radiofrequency lesioning, cryoneurolysis, neuroaugmentation and neuraxial drug delivery.

Exercise and education

Targeted exercise programmes as a means of pain management by enhancing functioning and avoiding deconditioning are helpful, but may not be suitable for patients with significant cardiovascular risk.

Assessment by a physical or occupational therapist may be helpful, not only in recommending ways to improve muscle strength and avoid dysfunction, but also to identify appropriate use of heat, cold, or massage therapy alongside TENS or acupuncture.

Patient and carer education is extremely important and the effectiveness of patient education programmes in improving pain management has been documented.3

It can be achieved through group education, one-on-one training, or provision of written material enabling patients and carers to understand that approaches to pain management include pharmacological and non-pharmacological strategies.

Patient selection is important, as clearly those with a degree of cognitive impairment will not be suited to this modality of treatment.

Dr Halfpenny is a consultant in musculoskeletal pain medicine at the London Orthopaedic Clinic and Homerton University Hospital

References

1. Cavalieri TA. Pain management in the elderly. J Am Osteopath Assoc 2002; 102(9): 481-5.

2. Herr KA, Garand L. Assessment and measurement of pain in older adults. Clin Geriatr Med 2001; 17(3): 457-78.

3. Ferrell BR, Ferrell BA, Ahn C et al. Pain management for elderly patients with cancer at home. Cancer 1994; 74(7 Suppl): 2139-46.

4. Kaye AD, Baluch A, Scott JT. Pain management in the elderly population. Ochsner J 2010; 10(3): 179-87.

Key points

Persistent pain is not an inevitable part of ageing, but is fairly common among the elderly.

It is frequently inadequately treated because of barriers to assessment, under-reporting, fear of drug addiction and side-effects.

Physicians can provide effective analgesia in elderly patients through proper assessment, a multidisciplinary approach and appropriate use of treatment modalities.4

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