Rhonda J. Moore (ed.)Handbook of Pain and Palliative CareBiobehavioral Approaches for the Life Course10.1007/978-1-4419-1651-8_12
© Springer Science+Business Media, LLC 2013
12. Pain in the Older Person
(1)
University of California at San Diego School Medicine, San Diego, CA, USA
(2)
Shoals Hospital Senior Care Center, Muscle Shoals, AL, USA
Abstract
The US population is aging with those 65 years or older reaching 70 million (20% of the population) by the year 2030. Chronic conditions such as osteoarthritis, atherosclerosis, cancer, and diabetes prevalent in older Americans will contribute to the increasing costs of health care. Despite the frequency of pain and the suffering that occurs, it is often underreported and undertreated in older people. The incidence of undertreated pain ranges from 25 to 50% in adult communities, from 45 to 80% in nursing homes, and as high as 85% in long-term care facilities. Since cures for many of the chronic conditions manifesting in older patients are not always readily available, there must be a focus on the management of the pain associated with these conditions. There are multiple treatment modalities which have been shown to be effective for older people. The choice of pharmacologic treatment for an individual patient will depend upon multiple factors, including the source and pathophysiology of the pain, and the presence of comorbid conditions. Combining pharmacologic and nonpharmacologic options helps keep the drug effects lower. The growing number and types of analgesics available permit an individualized pharmacologic regimen that targets chronic pain while addressing the issues associated with treating older patients. The goal of this chapter is to explore the topic of pain in the older persons including neurophysiology, measurement of pain in the cognitively intact and nonintact patients, and psychosocial issues associated with pain. Complementary and alternative modalities and pain at the end of life will also be discussed. Suggestions will be made about the future research in the field of pain and aging.
By the year 2030, there well be 70 million Americans 65 years or older (20% of the US population) (Centers for Disease Control and Prevention 2001). The chronic conditions associated with older adults such as osteoarthritis, atherosclerosis, cancer, and diabetes are likely to contribute to the already escalating costs. About one-third of total US health care costs, $300 billion, are spent on older adults. In this population, pain is the most common symptom noted when consulting a physician (Otis and McGeeney 2001). The most frequently reported source of pain in one study was lower back pain (40%), arthritis (24%), previous fractures (14%), and neuropathies (11%) (Ferrel et al. 1990). Another study of long-term care residents found 45–80% had substantial pain from musculoskeletal origin that affected their functional status and quality of life (Helm and Gibson 1999). Almost half of older adults and 20% of those reporting no limitations in activities of daily living claim limited ability to walk one-quarter of a mile due to pain and fatigue (Hardy et al. 2010).
Pain is not a normal part of aging. Yet many conditions that commonly occur or worsen with aging also produce pain: diabetic peripheral neuropathy, postherpetic neuralgia, osteoarthritis, and cancer related pain, etc. Poor pain management can lead to deconditioning, gait disturbances, and falls. These can cause pain and aggravate preexisting pain. The cognitively impaired elderly are even more at risk. In a study by Won, 74% of a demented, elderly long-term care population suffered from inadequately treated pain (Won et al. 1999). Despite these patients being institutionalized and under the care of health professionals, the high prevalence of pain was overlooked, in part because identifying pain requires special assessment skills not used by many long-term care facilities. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased health care use have all been found to be associated with the presence of pain in older people (Parmelee et al. 1991).
Some of the best information on pain management in older populations comes from data generated in nursing homes and home care populations. Nursing homes vary greatly in the amount of formal or informal health care they may provide and differ dramatically from state to state and within states. Twenty thousand nursing homes provide care for almost two million older persons in the United States. Nursing homes account for more than twice as many beds compared to acute care hospitals and more than three times as many facilities with residents who are typically poor and disabled. It has been estimated that for every resident in a nursing home, there are three more with similar disabilities living at home or other long-term care facilities (Ouslander et al. 1997).
Elderly persons also present with multiple medical problems, many of which are irreversible, and cure is rare. The spectrum of complaints, manifestations of distress, and differential diagnosis are often different in elderly persons. The implications of functional impairment can be profound, and recovery from illness is often less dramatic and slower to occur. Despite this, relief of discomfort and disability modification can often be achieved. Without adequate awareness of the nuances of elderly patients’ pain management, care is less than optimal.
For example, osteoarthritis is the most common painful disorder in older individuals with over 80% of people older than 75 having symptomatic osteoarthritis, and 80% over the age of 50 have radiologic evidence of osteoarthritis (Sharma 2001).Despite the prevalence and suffering precipitated by pain, it often remains under reported and under treated especially in the elderly. The incidence of under treatment of pain in older patients ranges from 25 to 50% in adult communities (Ferrell 1991). It ranges from 45 to 80% in nursing homes (Ferrell et al. 1990), and as high as 85% in long-term care facilities (Mobily and Herr 1996).
Multiple reasons for inadequate care have been cited in the literature. Older adults often express that pain is inevitable and that the treatment is worse than the symptom. They fear underlying causes, such as cancer, and the side effects of the analgesics. Health care providers lack adequate education in pain management and some believe, mistakenly, that older patients have a higher pain tolerance. Treatment is also often withheld because of concerns about falling, diminished cognition, addiction, and constipation. The elder patient may contribute to this problem by failing to report when pain is present. In one study, up to 56% of health symptoms are regularly underreported in our aging population (Ferrell 1995). In this chapter, we highlight issues related to pain in older patients.
Neurophysiology of Aging
Excitatory and inhibitory mechanisms in the nervous system exert differential effects contributing to the experience of pain and depend on complex communications among many neural systems. The effects of age on the human brain are known to be extensive, involving changes in structure, neurochemistry, and function (Hunskaar et al. 1985). Cellular and neurochemical substrates change thereby altering the pain sensation (nociception). There is strong evidence of a progressive, age-related loss of serontonergic and noradrenergic neurons in the dorsal horn suggesting impairment of the pain inhibitory system (Ko et al. 1997; Iwata et al. 2002). Peripheral nerves decrease with age, both unmyelinated and myelinated, and increasing age shows signs of related damage or degeneration of sensory fibers (Knox et al. 1989; Kakigi 1987).
There are so many integrated processes involved in pain, it is difficult to determine what effects these changes have. An increased pain threshold has been shown with age. Decreased acuity for pain may place older people at a greater risk of tissue damage (Birren and Schroots 1995). Age is not associated with substantive functional change over much of the pain stimulus–response curve (Chakour et al. 1996). Increasing pain reports with age occur when stimuli are intense or persist for longer periods.
It is widely believed that elderly persons do not experience pain with the same intensity as a younger population and this is not borne out in the literature (Mobily and Herr 1996). Nerves that have been injured by trauma or disease can become more sensitive. Older persons are more likely to have slow resolution of peripheral sensitization despite tissue healing leading to prolonged pain states not seen in younger populations. Under circumstances where pain is likely to persist, older people are especially vulnerable to the negative impacts of pain.
Assessment
There are many diagnostic challenges in assessing pain in the elder person. Aggressive testing or implementation of complicated treatment is less important than providing comfort and effective symptom management for many patients (Ferrell 1996). Incomplete medical records and unavailability of consultants often hamper initial assessment. Diagnostic laboratories, radiographs, or other resources common in ambulatory settings may not be available because of lack of convenient transportation. Testing or consultations disrupt the frail elderly’s schedules, resulting in missed medication and meals.
Pain descriptor may not be accurate, the location and onset of the pain may not be precise or remembered. A diagnosis of neuropathic pain may be missed if the signs and symptoms of neural dysfunction are not recognized. Neuropathic pain (diabetic peripheral neuropathy, post herpetic neuralgia, etc.) may arise from many neurologic levels, manifesting with negative neurosensory symptoms, such as loss of sensation, or with positive sensory symptoms such as paresthesia, hyperalgesia, dyesthesia, or allodynia. Elderly persons in long-term care settings can present unique challenges to pain assessment with as many as 50% of the residents likely to have significant cognitive impairment and psychological illness (Ferrell 1995).
Nociceptive pain (arthritis, surgery, fracture, etc.) usually relates to known pathology, is more precisely localized, and pain levels often represent level of tissue damage. There can be considerable overlap in the symptoms between neuropathic and nociceptive pain. The symptoms that are more suggestive of neuropathy include burning, electrical sensations, sharp, stabbing, shooting, knife-like, numbness, and pins/needles often with a sudden paroxysmal pattern.
Commonly used tools for measuring pain – for example, the Visual Analog Scale (VAS), the McGill Pain Questionnaire (MPQ), and the Verbal Descriptor Scales (VDS) – are reliable and valid measures of pain, especially nociceptive pain.
Two scales developed specifically to assess neuropathic pain include:
Neuropathic Pain Scale (NPS): Galer and Jensen (1997) includes two items that assess the global dimensions of pain intensity and pain unpleasantness, and eight items that assess specific qualities of NP. An eleventh item assesses the temporal sequence of pain.
Leeds assessment of neuropathic symptoms and signs (LANSS) (Bennett 2001) Pain Scale: a seven-point scale based on an analysis of sensory description and bedside examination of sensory dysfunction. An advantage of using the LANSS is that it provides immediate information in clinical settings.
Mood, physical functioning, pain-coping strategies, and social support can have a significant impact on both the patient’s ability to adjust to pain and the effectiveness of treatment. Depression has been associated with the pain of postherpetic neuralgia, spinal cord injury, and HIV-AIDs. A number of psychological assessment tools are available, including the Beck Depression Inventory (Beck et al. 1961), the Pain Disability Index (Pollard 1984), and the Coping Strategies Questionnaire (Rosenstiel and Keefe 1983).
Incomplete medical records, failure to disclose use of alcohol or recreational drugs, lack of appropriate diagnostic tests, and undisclosed medications may complicate initial assessment in older adults. Loss of vision, hearing, and cognitive impairments contribute to the difficulty. Even patients with moderate cognitive impairment can provide useful and reliable information if the provider is patient and allows adequate time. Concrete questions with yes or no responses are helpful. Pain can wax and wane, making frequent assessments more valid than relying on patient memory. Observing patient behavior and obtaining information from family or other caregivers can be valuable sources of information when the patient lacks optimal communication skills (see also Kovach 2011). At times an analgesic medication trial may provide useful information. Providing comfort, maintaining cognitive function, and effective symptom management is more important than aggressive testing for a definitive diagnosis, especially near the end of life (Bennett 2001).
Self-Management: What Can Older Adults Do to Manage Their Own Pain?
Since age cannot be controlled, as adults grow older, additional strategies may be used to lessen the severity and frequency of pain. These approaches range from weight stabilization (after weight loss if necessary), smoking cessation, maintenance of blood sugar in the normal range (if diabetic to prevent worsening of diabetic peripheral neuropathy related pain), correction of abnormal physiological markers (e.g., lipids predisposing one to increased risk of cardiovascular and cerebrovascular disease), treatment of depression, daily exercise program, proper nutrition, adequate sleep, and daily cognitive activity. While controlled studies do not absolutely establish that these approaches significantly prevent or reduce pain, from a common sense perspective it seems reasonable to provide patients with information that helps them maximize their potential, better anticipate painful circumstances, use proper body mechanics to limit or prevent injury, and to optimize overall fitness and health status.
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Chronic Low Back Pain
Hope in the Context of Pain and Palliative Care
Suffering, Hope, and Healing
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