Introduction
In 2018, for the first time in history the number of persons aged 65 years or above exceeded the number of children under the age of 5 years on the planet. By 2050, it is predicted that one in four persons living in North America or Europe will be over the age of 65 years. , Health conditions and comorbidities, such as persistent pain, rise in prevalence within an aging population. Therefore it is vital to be aware of the nuances in geriatric pain assessment and management to meet the unique demands of this growing sect of the world population.
The differences in pain experience for older adults compared to their younger counterparts are related to higher prevalence of chronic illnesses, physiologic changes, polypharmacy, cognitive or communication deficits, frailty, and socioeconomic or psychosocial stressors. Despite these challenges, the approach to pain management for older persons is similar to the effective strategies used in younger cohorts. The multimodal approach includes accurate and thoughtful assessment and diagnosis, focus on optimal function and quality of life, individualized application of pharmacologic and nonpharmacologic interventions, continued monitoring of response and adherence, and adjustments to patient and caregiver needs.
Epidemiology
The prevalence of pain in older persons is difficult to estimate and reports differ greatly among countries, living settings (e.g., community vs. long-term care vs. hospital), pain duration (e.g., acute, chronic, intermittent), and type or site of pain. Pain prevalence estimates in community-dwelling older adults vary from 20% to 76% and long-term nursing care setting pain estimates vary from 28% to 93% (higher end of ranges reflect chronic pain). Despite this variability, several studies agree that approximately half of older adults report pain that interferes with their normal function. The overall prevalence of bothersome pain in the past month was 52.9% and the inability to do some activities of daily living (ADLs) was 70%–80% more common in American older adults with pain than in those who denied pain. These functional impacts are even more pronounced in those with pain in multiple sites.
Role of Aging in Types/Sites of Pain
Older adults may process pain differently, with decreased endogenous inhibition of noxious stimuli (particularly with the dopaminergic neurons in the basal ganglia) that could lead to greater bodily chronic pain. However, there is also evidence that older individuals are less sensitive to pain, which could indicate that the pain they feel is due to a more severe underlying pathologic condition. In the peripheral nervous system, the density of unmyelinated fibers can decrease considerably and be associated with nerve conduction slowing. However, mixed research study findings regarding pain perception in older adults underscore that their pain experience cannot be summarized as a simple “increase” or “decrease” in pain sensitivity.
Multisite and widespread pain are significantly more common in older adults, which likely reflects multiple underlying pain-associated conditions and physiologic mechanisms leading to their pain. Up to 75% of older adults report pain at three or more locations, which is associated with more severe disability and a higher risk of falls. , A sample of American adults aged 65–90+ years showed nearly a third of older adults reported back pain, while a quarter had knee pain. Shoulder, hip, foot, hand, and neck were the next most common set of pain sites; stomach and arm were the least common. The prevalence of neck pain actually decreased with advancing age. Curiously, some other common sources of pain such as myocardial infarction-related pain, migraine and severe headaches, and cancer pain appear to peak in the fifth and sixth decades of life but tend to decrease beyond the seventh decade.
Community-dwelling older adults with chronic pain who reported a combination of sensory pain (aching, throbbing, stiff, sore), cognitive/affective pain (troublesome, nagging, tiring, miserable), and neuropathic pain (sharp, penetrating, numb, shooting) had more severe pain and more interference with daily activities. Neuropathic pain, although least common, was associated with the widest variety of pathologic conditions.
Risk Factors Associated With Chronic Pain in Older Adults
Chronic pain is frequently associated with depressive symptoms; those with persistent pain have a higher risk of developing depression and those with depression are, interestingly, at higher risk of developing chronic pain. Older adults with both chronic musculoskeletal pain and depressive symptoms are at a significantly higher risk of developing disability than older persons with either condition alone.
Chronic pain is also associated with frailty (increased vulnerability to adverse health outcomes) leading to deterioration of physical and psychologic function. , The association appears to be bidirectional. In longitudinal studies, those with chronic pain had twice the risk of eventually developing frailty. In the surgical setting, those with preoperative frailty prior to elective noncardiac surgery had significantly more intrusive postsurgical pain than those who were not frail.
Some other risk factors associated with higher risk of chronic pain in the older population include female gender, osteoporosis, and obesity. Central abdominal obesity is a metabolic syndrome component shown to have a strong independent association with pain and is associated with nearly doubling the risk of chronic pain in the elderly.
According to numerous studies, race/ethnicity is another risk factor, with reports of higher pain intensity/prevalence and poorer pain management in minority adults aged over 60 years. In a study of more than 1.3 million US nursing home long-stay residents between 2011 and 2012, racial/ethnic minorities (non-Hispanic blacks vs. whites) and severely cognitively impaired residents had an increased prevalence of untreated and undertreated pain. Older adults with lower levels of education were more likely to report pain than those with higher levels of education. This may reflect the cumulative effects of social disadvantage on disease burden and the persistent effects of occupational, work-related injury.
Geriatric Pain Assessment
Barriers to Accurate Assessment
Older adults can exhibit several unique attitudes about health and function relevant to their perception of pain. They may downplay specific symptoms with stoicism because of the belief that pain and disability are normal and expected with age when in fact it is important for them to seek evaluation and relief whenever possible. They may avoid medical evaluation for pain and harbor fears of an unfavorable diagnosis; treatments with side effects or high-cost, ineffective treatment options; medication addiction; loss of independence; becoming a burden on others; or being labeled a “hypochondriac” or “bad patient.” ,
Patients who display high levels of pain catastrophizing have poorer pain outcomes, but there is evidence that optimism/hope can lessen pain perception via reduced catastrophizing. Therefore psychologic service referrals are prudent if negative attitudes and beliefs are detected.
Other barriers to geriatric pain assessment and management include communication and cognitive deficits, especially in the memory and language domains. This could potentially limit the reliability of self-reports of pain, but self-report scales for pain have still been shown to be meaningful for patients with mild-moderate dementia. ,
Tools to Evaluate and Diagnose Geriatric Pain
Self-report pain assessment methods are typically appropriate for older adults but are often inadequate for those with advanced stages of dementia. There are multiple alternative tools available to assess pain in patients with dementia, or who are otherwise unable to communicate their needs. These tools rely on assessment of nonverbal behavior, such as facial expressions and vocalizations. The Pain Assessment in Advanced Dementia (PAINAD) has been thoroughly validated and has good interrater reliability; conveniently, it also takes little time to complete (see Fig. 10.1 ). Other more thorough scales include the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Impaired Cognition (PAIC15), which may be more sensitive in detecting pain but have the disadvantage of requiring more time to administer.
Geriatric Pain Management and Special Considerations
General Principles
Safe and effective pain management in the older population requires an understanding of individual patient-centered factors such as comorbidities, risks of polypharmacy, potential drug-disease interactions, motivation for treatment adherence, financial burden, and expectations. An optimal treatment plan aims to reduce pain and disability and improve function and quality of life but should be based on realistic goals set in collaboration with the patient (and primary caregivers when indicated).
When nonpharmacologic treatments are considered, it is helpful to explore the biopsychosocial model of interdisciplinary pain management options using a heuristic approach. Treating the “whole” person is more important than focusing narrowly on a disease state. Providers can employ psychosocial support tools (e.g., psychologic counseling/coaching, cognitive behavior therapy, spiritual/religious guidance, meditation/mindfulness, community integration), physical interventions (e.g., therapy, modalities, bracing, assistive devices, massage), and procedural interventional strategies (e.g., epidural steroid injections and other spine interventions). Many of these approaches will be described later in this chapter.
If medications are initiated, the general wisdom is to “start low and go slow” because of pharmacokinetic factors, but it is vital to monitor response and adjust the regimen when appropriate in a timely manner. Despite the risks associated with polypharmacy, it may be advantageous to use more than a single medication to achieve a synergistic effect or reduce adverse event risks associated with monotherapy dose escalation. The route of drug administration is also important because although the oral route is the most convenient, sometimes swallowing difficulties or cognitive/behavior issues in older adults warrant transdermal, rectal, transmucosal, intravenous, or other invasive alternative medication delivery methods. Intramuscular injections should be avoided when possible due to discomfort. The decisions to give immediate-release or modified-release formulations or provide scheduled medications versus on-request administration may rely on the nature of episodic or continuous pain or the older person’s level of awareness and cognition, respectively. Owing to the unpredictable age-related alterations in drug absorption, metabolism, or clearance, sometimes short-acting analgesics perform more like long-acting agents. Some important age-related physiologic changes and their associated clinical pharmacologic impacts are outlined in Table 10.1 .
| Physiologic Domain | Age-Related Change | Clinical Pharmacologic Impact |
|---|---|---|
| Volume of distribution | Decreased body water | Reduced distribution of water-soluble drugs |
| Increased body fat | Prolonged elimination and half-life of lipid-soluble drugs | |
| Lower plasma protein | Increased free fraction of drugs that are usually protein-bound with the potential for drug-drug interactions | |
| Hepatic function | Reduced hepatic blood flow | Decreased first pass metabolism |
| Reduced liver mass and functioning cells | Drug metabolism via conjugation is usually preserved, but half-life of drugs metabolized by oxidative enzyme reaction is prolonged | |
| Renal function | Reduced renal blood flow | Increased half-life of renal eliminated drugs and accumulation of the drug or metabolites |
| Gastrointestinal function | Delayed gastric emptying and reduced peristalsis | Increased risk of bowel dysmotility (e.g., constipation from opioids) |
| Skin/integumentary function | Reduced hydration, tissue thickness, surface lipids | Decreased predictability of transdermal penetration and drug distribution/retention |
Age-Related Physiologic Impacts on Drug Handling (Pharmacokinetics)
See Table 10.1 for a brief list of age-related physiologic changes that can impact pharmacokinetics.
Nonpharmacologic Treatments
Therapies (physical therapy, occupational therapy, others)
Broadly speaking, increased physical activity is associated with decreased pain due to endogenous pain modulation. Individuals with chronic pain tend to have higher sensitivity to painful stimuli and decreased capacity to endogenously inhibit pain. A similarly dysregulated modulation system is seen in older adults. Each level of physical activity (light and moderate to vigorous) affects a different mode of pain inhibition in older adults. This suggests that any degree of physical activity may have a unique impact on pain modulation. Physical activity and exercise are often prescribed for older adults with chronic pain with goals to prevent disuse muscle atrophy, to improve strength and joint range of motion, and to maintain or improve functional mobility. Additional benefits of attending various types of therapies include socialization, establishment of new social support networks, and empowerment through active symptom self-management. Low dose of moderate-vigorous activity was also shown to reduce mortality by 22% in adults aged over 60 years, and higher doses of activity improved all-cause mortality in a linear fashion. The 2018 Physical Activity Guidelines for Americans recommends multicomponent physical activities to include balance training and aerobic and muscle-strengthening exercises for older adults. However, caution regarding fall risk or cardiopulmonary adverse events is advised and appropriate precautions should be considered when prescribing therapy.
Alternative movement-based activities such as yoga or tai chi may also be appropriate options to enhance balance and flexibility, but the evidence base for people aged over 65 years is not very well established. One study of the efficacy of hatha yoga compared to aerobic/strengthening exercises showed equal if not superior benefits for function and knee osteoarthritis symptoms in older adults aged over 60 years. Another promising pilot randomized controlled trial of the effects of chair yoga on pain and function among community-dwelling older adults aged over 65 years and with lower limb osteoarthritis showed association with reduction in pain for up to 3 months after an 8-week “Sit ‘N’ Fit Chair Yoga” program compared to a standard Health Education program. The efficacy of tai chi in treating chronic pain conditions specifically in older adults remains unclear, but a systematic review and meta-analysis of 18 randomized controlled trials revealed some positive support regarding tai chi as a viable low-risk complementary and alternative medicine tool for immediate benefits for chronic osteoarthritis, lower back pain, and osteoporosis.
Modalities (kinesiotaping, heat, ice, vibration, massage, electrotherapy)
For knee osteoarthritis in older adults, kinesiotaping may have at least short-term beneficial effects on gait, balance, and knee pain, which may in turn facilitate exercise and other more long-term beneficial effects for pain. , Physical modalities such as superficial heat, vibration, therapeutic massage, and transcutaneous electric nerve stimulation are intended to reduce pain intensity. Most of these modalities have limited evidence and are not practical for persistent pain relief but can provide relatively brief periods of comfort.
Superficial heat is generally well tolerated by older adults but has risk of burns if used in patients with impaired sensation or communicative/cognitive deficits. Product information and instructions should be closely followed to prevent thermal damage. Heat modalities should generally be avoided in acute injuries because they may promote edema or hyperalgesia.
Superficial cooling modalities may provide temporary pain relief via reduction in local inflammation. However, older adults may be less tolerant to cold-based treatments than to heat-based treatments. Vibration, massage, and electrotherapy modalities have mixed evidence supporting utilization but should be avoided over areas of broken skin, local malignancies, infections, or local trauma. Transcutaneous electric nerve stimulation (TENS) electrodes should not be positioned over the carotid sinuses or near metallic implants or cardiac devices.
Massage therapy has been shown to have positive effects on musculoskeletal and general chronic pain through a proposed mechanism of increased serotonin and dopamine levels, enhanced local blood flow, and acting through the gate control theory. Studies in older adults have shown slow-stroke back massage to reduce shoulder pain and anxiety in senior stroke survivors, with benefits observed up to 3 days after the massage. Another form of massage known as “Tender Touch” (gentle comfort massage) has improved pain and anxiety in older adults living in a long-term care facility and can improve patient-staff communication.
Psychologic and behavior therapies
Psychologic therapies have been shown to be well received by older adults, with improvements in self-reported pain. Cognitive behavior therapy in older adults living in the community and in nursing home settings has been shown to improve pain severity, self-rated disability, mood disturbance, coping skills, social engagement, and quality of life. Self-management strategies for pain control include relaxation, coping skills, exercise, adapted activities, assistive device use, and education. There is mixed evidence for the efficacy of self-management practices in the older adult population, but they are generally safe options to be offered in conjunction with other methods of pain management. Specifically, there is some evidence that assistive devices can reduce functional decline, care costs, and pain intensity and help older adults maintain community living.
Procedural (injections, manipulation, surgery)
Acupressure is a noninvasive technique that can be taught to laypeople without professional training. In frail older adults, acupressure resulted in decreased pain and increased quality of life compared with waitlisted controls, when applied continuously, almost daily, for 12 weeks.
For uncomplicated low-back pain, there is some retrospective evidence that chiropractic care may buffer against ADL and instrumental ADL decline, as well as increase self-rated health when compared with routine medical care. When comparing spinal manipulative therapy to exercise and physical therapy, both groups demonstrated improvements in pain and function over time, without significant differences between groups. However, when compared against sham therapy, spinal manipulative therapy does not consistently demonstrate improved pain outcomes, suggesting that there may be a nonspecific therapeutic effect of patient interaction itself.
Spinal stenosis due to degenerative changes narrowing the vertebral canal and/or neural foramina is a common cause of axial or radicular pain and limited functional mobility in older persons. There is some evidence to support the use of epidural steroid injections via fluoroscopic guidance, preferentially using the transforaminal approach, for short-term basis symptom benefit, but literature is mixed and limited in the older population. If conservative management fails or if neurologic deficits arise, surgical spinal decompression may be indicated.
Pharmacologic Treatments (see Table 10.2 )
Older adults with moderate and severe pain are more likely to use daily oral analgesics, often multiple medications concomitantly, and are more likely to feel they need a stronger pain medication. Owing to age-related pharmacokinetics, oral analgesic medication recommendations can differ for older people.
| Medication | Indications | Starting Dose | Maximum Dose | Renal Adjust | Hepatic Adjust | Comments |
| Acetaminophen | Mild-moderate pain Nociceptive pain Tension headache | 325 mg q4–8h | 3 g per day | CrCl 10–50: q6h CrCl <10: q8h | 2 g per day max | First line, but minimal effect on knee/hip OA, no effect on chronic low-back pain. Avoid with alcohol. Monitor OTC use. Low therapeutic index → overdose. |
| NSAIDs | Inflammatory pain Nociceptive pain | Risk of GI bleed, kidney damage, and cardiovascular adverse events in susceptible patients. | ||||
| Ibuprofen | Mild-moderate pain | 200 mg q6–q8h | 2400 mg per day | Avoid in CKD or AKI | None | Short-term trial. Give with food. Consider GI PPx (H 2 blocker or PPI) to prevent GI ulcer. Caution with antiplatelet or anticoagulation therapy. Avoid in cardiovascular disease. |
| Naproxen | Mild-moderate pain | 250 mg q12h | 500 mg q12h | CrCl <30: avoid | Avoid in liver disease | Similar profile to ibuprofen but easier to take because of bid dosing. |
| Celecoxib | Mild-moderate pain | 100 mg qd | 200 mg bid | Avoid in CKD or AKI | Avoid in liver disease | Reduced risk of gastroduodenal toxicity and minimal platelet inhibition (can take with aspirin). Equivalent cardiovascular risk as other NSAIDs. |
| Meloxicam | Osteoarthritis | 7.5 mg qd | 15 mg qd | Hemodialysis 7.5 mg qd | Unknown | Low risk of gastroduodenal toxicity at 7.5mg (mostly COX-2), higher risk at 15 mg (mostly COX-1). Increased risk of hemorrhagic stroke. |
| Salsalate | Mild-moderate pain | 500 mg bid | 3 g per day | Avoid in CKD or AKI | Avoid in liver disease | Minimal GI side effects and minimal effect on platelet function. Old drug, but few studies in geriatric population. |
| Anticonvulsants | Central/peripheral neuropathic pain | |||||
| Gabapentin | Postherpetic neuralgia Diabetic peripheral neuropathy Fibromyalgia | 300 mg qd ×1d, then bid ×1d, then tid | 1200 mg tid | CrCl <60: reduce dose proportionately to CrCl, administer bid | No adjustment | Titrate up dose as tolerated. To discontinue drug taper over 7 days. Increased risk of falls due to common side effects: dizziness and somnolence. Consider qhs dosing. |
| Pregabalin | Postherpetic neuralgia Diabetic peripheral neuropathy Fibromyalgia | 150 mg/day divided bid or tid | 300 mg/day, divided bid or tid | CrCl <60: reduce dose proportionately to CrCl | No adjustment | Titrate up dose as tolerated. To discontinue drug taper over 7 days. |
| Antidepressants | Neuropathic pain Off-label: chronic pain | |||||
| Duloxetine | Chronic MSK pain Diabetic peripheral neuropathy Fibromyalgia | 30 mg qd | 120 mg/day | CrCl <30: avoid | Avoid in liver disease | Preferred SNRI in older adults. Tolerable side effect profile. Caution for hyponatremia. To discontinue drug taper gradually. |
| Venlafaxine ER | Off-label: same as duloxetine | 37.5 mg qd, increase by 75 mg qwk | 225 mg qd | CrCl 10–70: decrease dose by 25%–50% | Mild-moderate impairment: decrease dose by 50% | Second-line SNRI. Recommend trial of duloxetine first. Side effects: hypertension, anxiety, insomnia, and hyponatremia. Can impair platelets → bruising and bleeding. To discontinue drug taper over 2 weeks. |
| Nortriptyline | Off-label: diabetic peripheral neuropathy Fibromyalgia | 10 mg qhs, increase by 10 mg q5d | 160 mg qhs | No adjustment | Caution | Preferred over amitriptyline because of fewer anticholinergic side effects, but still must monitor. On Beers list. |
| Amitriptyline | Off-label: diabetic peripheral neuropathy Fibromyalgia | 10 mg qhs, increase by 10–25 mg qwk | 75 mg qhs | No adjustment | Caution | Recommend avoiding because of anticholinergic side effects in older adults. On Beers list. |
| Muscle relaxants | Nociceptive pain | |||||
| Baclofen | Chronic spasticity off-label: MSK pain | 5 mg bid/tid | 80 mg/day | No adjustment | No adjustment | Can use long term. Risk of withdrawal. To discontinue drug taper gradually. |
| Dantrolene | Chronic spasticity off-label: MSK pain | 25 mg qd, dose/frequency q7days | 100 mg qid | Not defined | Contraindicated in liver disease | Monitor hepatic function because of risk of hepatotoxicity. Can cause sun sensitivity. |
| Cyclobenzaprine | MSK pain Fibromyalgia | 5 mg qd (IR tablet only) | 10 mg tid 3 weeks max | Not defined | Avoid in moderate-severe impairment | Avoid extended release in older adults. Almost identical structure to amitriptyline; caution for anticholinergic side effects. Short-term use only. |
| Methocarbamol | MSK pain | 500 mg qid | 1000 mg qid (max 4 g/day) | Not defined | Not defined | Very short half-life. Also has IM/IV formulation. Can change urine color to brown/black/green. |
| Carisoprodol | MSK pain | 250 mg qhs | 350 mg tid 3 weeks max | Caution | Caution | Avoid in older adults. Increases risk of fall. Risk of withdrawal. Monitor for orthostatic hypotension. To discontinue long-term use taper gradually. |
| Topical analgesics | Nociceptive pain Inflammatory pain Neuropathic pain | Consider as first line in older adults because of the superior side effect profile compared with oral medications. | ||||
| Diclofenac 1% gel | OA off-label: MSK pain | 2 g Upper Extremity joints 4 g Lower Extremity joints | 8 g/joint 32 g/day | Caution, monitor | Caution | Minimal (∼7%) systemic absorption, low incidence of typical NSAID adverse reactions. Enhanced tissue penetration with ultrasonography/iontophoresis. Efficacy may subside after 6–12 weeks. |
| Lidocaine 5% patch | Peripheral neuropathic pain off-label: MSK pain | 1 patch | 3 patches | Not defined | Not defined | Apply patch 12 h on and 12 h off. Monitor for skin reaction. Can also consider lidocaine gel for short duration. Minimal systemic absorption, minimal penetration into soft tissue. |
| Capsaicin <1% cream | Peripheral neuropathic pain Fibromyalgia | Apply tid to qid | Apply tid to qid | Not defined | Not defined | Works by exhausting peripheral nerve substance P. Takes multiple applications (up to 3 weeks) before achieving analgesic benefit. Transient burning pain, erythema, itch. |
| Capsaicin 8% patch | Peripheral neuropathic pain | 1–4 patches for 30 min (feet) or 60 min (other) | 1 treatment every 3 months | Not defined | Not defined | High concentration 8% patch more effective in peripheral neuropathy, with only 1 application every 3 months. |
| Opioids | Adjunctive therapy for severe pain refractory to nonopioid analgesics and nonpharmacologic modalities. | |||||
| Tramadol | Moderate-severe pain | 25 mg bid | 50 mg q6h | CrCl <30: q12h, max 200 mg/day | Cirrhosis: 50 mg q12h, max 100 mg/day | Lowest effective dose for shortest duration. Avoid extended release in older adults. If long-term use taper gradually to discontinue. Dose-dependent QT prolongation. |
| Oxycodone | Severe pain | 2.5 mg q6h | 10 mg q6h | CrCl <60: titrate slowly | Impairment: 50% starting dose | Lowest effective dose for shortest duration. Consider extended release for maintenance of chronic pain. |
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