Introduction

As the world increasingly greys, so too does the need for practitioners to gain competence in caring for older adults with a myriad of pain conditions. While many of these patients have suffered from pain for decades, others, because of the accumulation of degenerative pathology in their later years, are relative newcomers to pain. In either case, pain should never be considered normal and because older adults are not simply a chronologically older version of younger patients with pain, unique skills are needed to afford optimal treatment outcomes in these individuals.

This chapter focuses on chronic or persistent pain because of its greater clinical complexity and treatment challenges. Because aging in the absence of pain also may be associated with deterioration in each of these domains, aggressive treatment of chronic pain in older adults is especially important (Figure 13.1).

Figure 13.1 Multiple important functional domains that may be impacted by chronic pain.

Evaluation

The key to optimising treatment outcomes lies in careful and comprehensive evaluation (Figure 13.2).

Figure 13.2 Pain evaluation in older adults.

Step 1: Establish the Patient’s Treatment Expectations

The first step in evaluation is to establish what the patient expects from treatment and to set realistic goals. If the patient’s treatment expectations are unrealistic (e.g. a pain-free state), these must be reconciled to avoid frustration on the part of both patient and practitioner. Depending upon the setting of care and the patient’s cognitive status, involving the caregiver(s) may be critical at this stage.

Step 2: Identify All Treatment Targets

Once realistic treatment expectations and patient goals have been established, the next step is to explore the factors that need to be targeted to improve pain management. Chronic pain may be only one of multiple factors that increase the risk of disability and impair quality of life in older adults. For the older adult with good social support, financial resources, physical and emotional health, and who is independent in mobility and free of pain, the risk of disability is low (Figure 13.3).

Figure 13.3 Factors contributing to a low risk of disability.

For the individual who is socially isolated, indigent, burdened with multiple medical and psychological comorbidities, immobility and chronic pain, the risk of disability and poor quality of life is quite high (Figure 13.4). It is incumbent upon the practitioner, therefore, to prioritise and tailor chronic pain treatment according to the context in which it exists.

Figure 13.4 High risk of disability.

In the older adult with severe dementia, for example, it may be that the dementia itself is the main contributor to impaired function and overall distress. While such a patient’s pain requires treatment, the approach to pain treatment may be very different as compared with the treatment of chronic pain in a cognitively intact, highly functioning individual, as illustrated by the case history example in Box 13.1.

Box 13.1 Case History: Pain Management in the Elderly

82-year old woman:

Pain history: two years of low back pain after retiring; intensity increased by prolonged standing or walking; improved by local application of heat.

No associated fever, chills, weight loss, paresthesias, lower extremity weakness, or change in function of her bowels or bladder. She denied nocturnal symptoms.

Social history: had been working full time but retired due to company downsizing two years ago; lived alone – harder to do housework; frequent near-falls; passive suicidal ideations, and fear of going on the bus alone, so spending more time at home alone.

Medication: gabapentin, oxycodone CR, celecoxib, tramadol, acetaminophen, olanzapine, escitalopram, and lorazepam.

Examination: very impaired righting reflexes (i.e. inability to right herself in response to a gentle backwards tug at the waist) and performance on the clock drawing test (consistent with dementia); marked kyphoscoliosis, and tenderness on palpation of the right sacroiliac joint, tensor fascia lata (TFL) and erector spinae. Strength testing was limited by extreme guarding behaviour.

Management: admitted to a nursing home for detoxification; all medications were discontinued except regularly scheduled acetaminophen and prn tramadol; physical therapy for gait training and for treatment of her TFL myofascial pain and dysfunction. Her balance and cognitive function improved markedly and her pain complaints became infrequent.

Assisted living facility placement was recommended–social isolation and mild dementia were felt to have significantly contributed to her pain complaints–but the patient and her family refused.

Outcome:

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