Managing the Burden of Pain in Older Patients

The burden of pain among older patients is great, and its consequences can be "serious and significant," according to Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population and increases with age, he said.

In fact, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous identified barriers to the management of pain in older patients, including language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions. Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain. 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 "universal precautions" in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain. Med. 2005;6:107-12). These include the following:

• Making a diagnosis with appropriate differential diagnoses.

• Performing psychological assessments, including evaluation for risk of addictive disorders.

• Obtaining informed consent.

• Developing treatment agreements.

• Performing pain and function assessments.

• Using pain medication – and particularly opioids – on a trial basis.

• Reassessing pain, function, and behavior.

• Regularly reassessing the "Four As" (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

• Periodically reviewing diagnosis and comorbidities.

• Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010;31:494-503; Clin. J. Pain. 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

• Titrate according to individual circumstances.

• Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

• Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

• Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, consider alternatives to standard numeric rating scales for pain assessment. Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600) or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.

The burden of pain among older patients is great, and its consequences can be "serious and significant," according to Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population and increases with age, he said.

In fact, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous identified barriers to the management of pain in older patients, including language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions. Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain. 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 "universal precautions" in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain. Med. 2005;6:107-12). These include the following:

• Making a diagnosis with appropriate differential diagnoses.

• Performing psychological assessments, including evaluation for risk of addictive disorders.

• Obtaining informed consent.

• Developing treatment agreements.

• Performing pain and function assessments.

• Using pain medication – and particularly opioids – on a trial basis.

• Reassessing pain, function, and behavior.

• Regularly reassessing the "Four As" (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

• Periodically reviewing diagnosis and comorbidities.

• Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010;31:494-503; Clin. J. Pain. 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

• Titrate according to individual circumstances.

• Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

• Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

• Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, consider alternatives to standard numeric rating scales for pain assessment. Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600) or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.

The burden of pain among older patients is great, and its consequences can be "serious and significant," according to Dr. Perry G. Fine.

The prevalence of pain ranges from 25% to 50% in the older population and increases with age, he said.

In fact, among older nursing home residents, the prevalence is estimated at 45%-80%. In one study, 20% of individuals aged 65 and older admitted to having a day-long bout of pain in the past month, and about 60% said they had experienced pain for a year or more, said Dr. Fine, professor of anesthesiology at the University of Utah, Salt Lake City.

The sources of pain in these patients are many and varied, and the consequences can include mood disorders, sleep disturbances, decreased socialization, increased health care utilization and costs, limitations in activities of daily living, comorbidities, and polypharmacy, all of which can lead to diminished function and quality of life.

Further complicating the problem is the fact that studies have repeatedly shown that pain in older adults is frequently undertreated, Dr. Fine said.

This may be the result of one or more of the numerous identified barriers to the management of pain in older patients, including language and cultural barriers, fear of judgment, fear of addiction, cognitive impairment, sensory impairment, and adverse effects such as fear of falling, constipation, sedation, and drug-drug interactions. Barriers for clinicians can include the lack of objective measures of pain and pain response, concerns regarding addiction and/or drug seeking, fear of causing harm from medication-related adverse effects, lack of time in the office setting, and lack of pain management training, according to findings from two studies on the topic (Clin. J. Pain. 2007;23[suppl. 1]:S1-43; J. Adv. Nurs. 2009;65:2-10).

Following a list of 10 "universal precautions" in pain management can help with overcoming some of these barriers, Dr. Fine said (Pain. Med. 2005;6:107-12). These include the following:

• Making a diagnosis with appropriate differential diagnoses.

• Performing psychological assessments, including evaluation for risk of addictive disorders.

• Obtaining informed consent.

• Developing treatment agreements.

• Performing pain and function assessments.

• Using pain medication – and particularly opioids – on a trial basis.

• Reassessing pain, function, and behavior.

• Regularly reassessing the "Four As" (analgesia, activities of daily living, adverse events, and aberrant drug-taking behaviors).

• Periodically reviewing diagnosis and comorbidities.

• Documenting thoroughly.

Also, keep in mind that aging results in a number of physiological changes that will influence both pharmacokinetics and pharmacodynamics, including changes in body composition; decreases in gastrointestinal motility, hepatic metabolism, renal clearance, and protein binding; and increased central nervous system sensitivity to noxious stimuli and medication effects, Dr. Fine said (Neurobiol. Aging 2010;31:494-503; Clin. J. Pain. 2004;20:220-6).

While speaking at the Congress of Clinical Rheumatology, Dr. Fine listed the following general principles to follow when it comes to pharmacotherapy in light of these changes and the needs of older adults:

• Titrate according to individual circumstances.

• Anticipate and monitor for adverse effects, prevent them when possible, and treat them when necessary.

• Practice synergy by combining lower doses of drugs that mediate analgesia via different mechanisms.

• Know and understand the distinctions among tolerance, dependence, addiction, and pseudoaddiction.

In those with cognitive impairment, in whom pain assessment can be particularly challenging, consider alternatives to standard numeric rating scales for pain assessment. Patients who have difficulty reporting pain based on these types of scales may do better with the Iowa Pain Thermometer, which allows a patient to rate pain using increments on a picture of a thermometer (Pain Med. 2007;8:585-600) or with the Brief Pain Inventory. Reports from caregivers may also be useful, Dr. Fine said.

Dr. Fine reported having no conflicts of interest that were relevant to his presentation.