Pain Management Options for Seniors

How older generation can maintain quality of life

As people grow older, there is a universal belief that pain is a normal part of the aging process. Pain itself is an abnormal finding and should not be accepted as a part of our golden years. The incidence of chronic pain (defined as pain lasting longer than 3-6 months in duration) varies widely by geography, with Malaysians reporting a prevalence of 15.2 percent. Germany reports a higher prevalence of chronic pain at 69.8 percent, while residents in nursing homes may report up to an 83 percent occurrence. Although these figures appear significant, they may be underreported, as many elders expect pain to be a normal part of the aging process and decline to report it to caregivers.2

At least one in five Americans over the age of 65 report experiencing chronic pain daily. Pain, defined as an “unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” (IASP definition) can be a disruptive force at any age, but is especially so for seniors. Patients over the age of 65 may already be dealing with underlying physical conditions that limit functionality. Adding the challenge of physical discomfort can dramatically impact the quality of life for older Americans.

Dealing with Pain Myths

Getting past the idea that seniors expect to have pain is generally the first problem nurses and providers need to understand. The next myth is that patients believe most physicians and nurses have a comprehensive working knowledge of pain management, which is not always true. Patients may be hesitant to discuss pain, believing it is better to appear stoic than to come across as weak or struggling to control pain that others of their generation may be able to handle.1

Additionally, patients may believe people with osteoarthritis or with the same type of condition all fare the same on a pain and functionality scale. They may not understand that the experience of pain is unique to each individual seeking assistance. They may have compared notes with friends or neighbors and be fearful that “Betty” (who lives down the street) does quite well with long-acting Acetaminophen while they cannot. Consequently, they believe their pain could signal a worrisome diagnosis or that a known disease is progressing. Pain equals the unknown, which equals fear.1

Physicality of Aging and Pain

As the human body ages, there are various mechanisms that occur which lead to a propensity for chronic pain. The body has a decrease in various neurotransmitters that assist in reducing pain sensation, such as GABA (gamma-aminobutyric acid), serotonin, noradrenalin, and acetylcholine. The body also has reduced endogenous analgesic responses, and a decrease in the number of nociceptive neurons, which paradoxically, leads to an increase in overall pain sensitivity. Liver and renal function decline, as well as muscle mass, which leads to a body that is frailer in composition. As a result, patients are likely to suffer from trauma such as falls. These physiological factors increase the likelihood for acute and/or chronic pain as well as overall debility.2

Treating Seniors Safely for Pain

The most important part of a pain treatment plan for seniors is to consider safety. Renal and liver function may be slowed; therefore, drugs take longer to be cleared, resulting in longer half-lives. Any medication that is initiated should be started at the lowest possible dose until tolerance is understood. The caveat with seniors is always start low and go slow. Medication can always be added if the desired effect is not achieved, but it cannot be taken away once ingested, particularly for seniors who live alone/are independent. Their medication profile should also be studied carefully. Are they taking diuretics or stool softeners later in the day? They should avoid taking analgesics during the same timeframe!

Musculoskeletal and spinal disorders are the most common causes of pain in the elderly. Both conditions can be successfully treated with pharmacological as well as non pharmacological options. Topical Lidocaine and NSAIDS, as well as physical therapy, can be utilized for musculoskeletal pain. Injected steroids/numbing agents also work well for joint pain that is affecting mobility and/or interrupting sleep. A transcutaneous unit (TENS) is effective in diverting pain stimuli away from the noxious source of the pain, with the patient being able to increase current until the device proves effective. Ice and heat can also be used if suggested by their provider. Typically, ice is used to decrease swelling and inflammation after exercise, whereas heat is used to “warm up” a stiffened joint prior to movement.3

Utilizing Pain Scales

For many years, healthcare providers have been utilizing pain scales to assist in assessing the degree of pain felt by their patients. Pain scales are manufactured in many shapes and designs, but most are 0-10, with 10 signifying the most severe pain.4

Elderly patients do not always relate to pain scales, especially if they have a degree of cognitive impairment. Asking them to rate pain as mild, moderate, or severe works well over time, as opposed to defining a 6 or a 7. Asking them how they would describe the pain when they reach for an analgesic is more appropriate, as well as asking how many times a day that severity of pain occurs.

Opioids and Seniors

Using opioids or opioid analogs in seniors is generally not the best idea unless the patient has refractory cancer pain, and/or other options have proved to be of little use. One of the most worrisome challenges with using opioids in seniors is that they may have medication from 1984 (wow!) in the medicine cabinet just in case they need it for a random malady in the future. I have witnessed elderly patients practicing this type of pain treatment regimen in the home: taking a pill from several bottles depending on the hour, a round one on even hours and a square one on odd hours.

The only problem with this approach? A patient may mix long-acting opioids with short-acting agents. Add in a bit of renal dysfunction, and the result is a recipe for disaster, as it was for the patient I cared for in the ICU. Her family had no idea she had accumulated that much medication in the home until the mixture of pain medication nearly took her life. She recovered, and with her family’s assistance, they learned about returning narcotics and her additional medications through their local pharmacy.

Synthetic Opioids

One of the most widely used synthetic narcotics utilized with seniors is Tramadol (Ultram, ConZip). The medication requires a prescription for use, and doses start at 25 mg. All seniors should be started at the lowest dose until tolerance is observed. This medication is less potent than hydrocodone (Vicodin), as well as other opioids such as fentanyl and Morphine, but the potential for addiction and withdrawal still is present, so patients need to be closely monitored while they are on this medication. 

As far as driving, no senior should be driving when they are initially given an opioid medication. IF (and this is a big if) they are on a stable dose and tolerate the medication well, they may be able to make short trips after at least one full week on the medication. And, as with all pain medications, remember to instruct them to add a stool softener to their regime.

Conclusion

As people age, no one should believe that aches and pains are a normal part of life, or that everyone needs to accept chronic pain as part of their day. Pain options should be discussed with a healthcare provider to determine the origin of the discomfort, and then to formulate the most successful treatment options. The golden years really should be gilded, and as pain free as possible. Pain management for seniors can be accomplished with a variety of options, pharmacological and non-pharmacological, but most of all, safely. No one should sacrifice a moment of time feeling less than their best!

References

1. Geriatricpain.org “Common myths about pain – and the reality.” 2020. The University ofIowa.

2. Ncbi.nlm.nih.gov “Managing chronic pain in the elderly: an overview of the recent therapeutic advancements.” Ali, A., Arif, A., Ahmad, M. et al. National Institutes of Health, USA. gov.

3. Seniorliving.org “Effective pain treatment for seniors.” Hoyt, J., Updated February 6, 2018, Seniorliving.org.

4. Uptodate.com “Treatment of persistent pain in older adults.” Galicia-Castillo, M., Weiner, D., Literature review current through July 2020 @ UpToDate, Inc.

Definition of Pain

IASP-pain.org

1-202-856-7400

International Association for the Study of Pain

 

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