Elder Care Interprofessional Provider Sheets

Pain - Management of Persistent Pain in Older Adults

Sathish Karmegam MD, FACP and Jeannie Kim Lee, Pharm D, BCPS, CGP, FASHP, University of Arizona

May 2015

TIPS FOR MANAGEMENT OF PERSISTENT PAIN IN OLDER ADULTS

  • Ask older adults about pain, as patients may not tell you about their pain, and it often goes unrecognized. 
  • Establish a way to quantify the severity of a patient's pain so you can judge whether treatment is effective. Use a visual analog scale in patients who are cognitively intact. In patients with cognitive impairment, rely on behaviors, facial expressions, crying, and caregiver reports.
  • Don't be afraid to prescribe opioids if a patient's pain is not relieved by non-opioid analgesics. But, be alert for side effects ranging from constipation to delirium, and reduce the dose or discontinue opioids if needed.

Pain is estimated to affect 25-56% of older adults in the community and between 45-80% of those in long-term care facilities. More than half of older adults who are dying suffer from pain.

Pain can be broadly classified as acute or persistent. Persistent pain, which is the topic of this Elder Care, is defined as a painful sensation that continues for a prolonged period of time. It may or may not be associated with an identifiable disease process.

About 30% of females and 19% of males older than age 75 report persistent pain in three or more sites. The most common types of persistent pain in these individuals are musculoskeletal, neuropathic and cancer-related pain.

Persistent pain in older adults is often not identified or adequately treated, resulting in unnecessary suffering, depression, anxiety, impaired ambulation, sleep disturbances, impaired cognition, poor appetite, weight loss, decreased social interaction, and increased use of health care services. Unrelieved pain is also associated with a 9-fold increase in the rate of delirium.

Challenges

Effective management is important to improving quality of life for individuals with persistent pain. But, there are challenges to assessing and treating pain in older adults.

From the point of view of assessment, one challenge is that many older adults are concerned about addiction to, and side effects of, pain medications, making them reluctant to bring pain to their clinician's attention. They may also not want to be seen as a "complainer." Another challenge is that the presentation of pain syndromes in older adults may be atypical, making it difficult to identify potentially reversible causes of pain. Furthermore, some older adults have cognitive or sensory impairments that make them unable to explain the degree and nature of their pain.

From the point of view of treatment, older adults are at increased risk for analgesic-related adverse effects for a variety of reasons. One is that they have an increased sensitivity to pain medication, making them more susceptible to sedation and other side effects. Another is the potential for drug-drug interactions in those taking multiple medications. And, while inadequately treated pain is a risk factor for delirium, treatment of pain (e.g., with opioids) can also cause delirium.

Pain Assessment

For patients with good cognitive status, pain assessment often relies simply on the patient's self-report. Their pain can be quantified by having patients rate pain severity with an image-based visual analog scale (Figure).

 

 

For patients with cognitive impairment, the presence of pain must often be inferred from non-verbal indicators such as wincing, moaning, tears, or immobility, as well as caregiver reports and responses to empiric therapy. If pain is thought to be present, the best course of action is to assume that it is.

Pain Treatment

Pain treatment begins by establishing a method, such as the pain scale noted above, for assessing pain severity at baseline so that comparisons can be made after treatment is instituted. If a pain scale cannot be used because of the patient's cognitive status, establish the words or signals that the patient uses to express pain. Teach caregivers to identify those words or signals so they can administer pain medications when a patient has pain.

When appropriate, consider non-drug approaches to pain management. These include physical therapy, exercise programs, cognitive behavioral therapy, acupuncture, and education of caregivers about helping patients to avoid pain. Topical analgesics are also a good alternative to systemic drugs for treatment of localized pain (e.g., arthritis).

But, many patients require a trial of systemic analgesic medication. There is strong evidence that a trial of analgesic medication (Table 1) helps older adults who have pain. Even nursing home residents will experience significant benefit, including improved social interactions.

The Analgesic Ladder 

Medication regimens are often based on the World Health Organization's (WHO) Analgesic Ladder. A special version of the ladder has been developed for use in geriatric practice (see resource list).

For patients with mild-to moderate pain, the first step on the ladder is a non-opioid analgesic, such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs), with or without an adjuvant. NSAIDs should only be used short term in older adults because of concerns about renal and gastrointestinal side effects, and fluid retention in heart failure.

If pain persists or increases despite treatment, the next step on the ladder is adding an opioid intended for treating moderate pain, such as hydrocodone. The original adjuvant medications can be continued if they have been helpful.

The third step is use of a stronger opioid medication such as oxycodone. Adjuvant medications can be continued if they have been helpful.

Assuming pain is continuous, medications should be administered around the clock, often with long-acting agents once a patient's dose requirements have been determined and do not cause undo sedation. There should also be a short-acting agent available for breakthrough pain.

Special Considerations for Episodic Pain

When pain is episodic, medications can be prescribed on an as-needed basis, though as-needed treatment is not a good choice for patients with cognitive impairment who cannot request medications. Scheduled administration before anticipated pain episodes is a better approach for them.

Special Considerations for Prescribing Opioids

Initiate opioid therapy at a dose 25-50% lower than what is recommended for younger adults. Carefully titrate the dose upwards with frequent assessments of the need for dose adjustments based on pain relief and side effects.

Many clinicians avoid opioids in older adults for fear of causing delirium. Keep in mind, though, that while opioids can cause delirium, delirium is more often caused by unrelieved pain than by opioid therapy. But, if delirium occurs in a patient taking opioids and no other causes are identified, then consider decreasing or discontinuing the opioid.

Fentanyl is ill-advised for chronic pain management in older adults. Patch and buccal absorption are unpredictable.

Finally, opioids are a major cause of constipation in older adults. Bowel regimens containing a stimulant laxative (stool softeners alone are inadequate) should be started concomitantly with opioid therapy.

Table 1.  Examples of Analgesics Used and Studied for Treating Persistent Pain in Older Adults
Medication Class Medications Medication Class Medications
Non-Opioids
 
  • Acetaminophen
  • Non-Steroidal, Anti-Inflammatory Drugs 
    (long-term use not recommended): Diclofenac, Ibuprofen,                                                          Naproxen
Adjuvants

 
  • Serotonin-Norepinephrine Reuptake Inhibitors:  Duloxetine, Venlafaxine
  • Anticonvulsants for neuropathic pain:  Gabapentin, Pregabalin
Opioids

 
  • Weaker Opioids:    Hydrocodone
  • Stronger Opioids:  Oxycodone
Others with Special Indications

 
  • Muscle Relaxants:    Baclofen, Tizanidine
  • Cannabinoids:           Dronabinol, Nabilone
  • Local Injections:      Corticosteroids
  • Topical agents:        Capsaicin, Lidocaine, NSAIDSs

Other medications in each class, not listed in this table, can be considered for use in patients refractory to the listed medications after considering benefits vs risks.

 References and Resources

  • Abdulla A, et al . Guidance on the management of pain in older people. Age and Ageing. 2013; 42 Suppl1:1-57.
  • American Geriatrics Society. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009; 57:1331-1346.
  • Herr K, et al.  Pain assessment in the nonverbal patient: Position statement with clinical practice recommendations. Pain Manag Nurs. 2006; 7:44-52. 
  • Makris LE, Abrams RC, Gurland M, et al. Management of persistent pain in the older patient. A clinical review.  JAMA. 2014; 312:825-836.
  • Wenger, NS, et al. Introduction to the assessing care of vulnerable elders -3 quality indicator measurement set. J Am Geriatr Soc. 2007; 55:S247-S252.
  • World Health Organization Ladder