Primary Care Resources - Pain

Pain is a subjective, unpleasant sensory and emotional experience.(2) Acute pain usually results from trauma or surgery and is time-limited.  Persistent pain lasts for more than 3-6months and is typically found with chronic conditions or injury. This type of pain is associated with functional loss, mood disruptions, behaviour changes, and reduced quality of life.(2) Other categories of pain include nociceptive pain (pain caused by stimulation of specific peripheral or visceral pain receptors) and neuropathic pain (pain caused by damage to the peripheral or central nervous system).(2)

Why is it important?

  • 50% of older adults in community-dwellings and up to 80% of nursing home residents/long-term care residents experience some form of pain (3)
  • Elderlyare often untreated or undertreated for pain (1)
  • Consequences of under treatment for pain can have a negative impact on the health and quality of life of the elderly: depression, anxiety, social isolation, cognitive impairment, immobility, and sleep disturbances, impaired immune function  and increased dependency (2)(1)

Common Causes

  • Frailty and chronic diseases are prominent among the elderly; they are more likely to have arthritis, bone and joint disorders,cancer, and other chronic disorders associated with pain (1)
  • Other reasons for pain include trauma, injury, and surgery
  • Misbeliefs (e.g. part of old age), hearing loss, vision loss, and cognitive impairment due to dementia or delirium can hinder an older adults attempts at communicating pain severity and duration; therefore, extending the experience
  • Reasons for inadequate pain control include lack of training, inappropriate pain assessment, and reluctance to prescribe medication or treatment, pain management being seen as low priority by health professionals, and lack of time for proper assessment/follow-up (3)(1)

Key Considerations

  • Comprehensive assessment should include a history and physical examination; diagnostics to identify etiology of pain; a recording of intensity, frequency, and location;  and use of standardized geriatric assessment tools to assess function, gait, affect, and cognition (1)
  • Assess intensity with pain scales such as a verbally administered 1-10 scale (on a scale of 1-10, one being no pain and ten being the worst pain, how much pain do you have?); a visual analog scale, a numerical scale, a pain thermometer scale, or a pain faces scale (1)
  • An increase in agitation, changes in functional status, altered gait, and social isolation may be signs of pain in patients with dementia (1)
  • The process: use patient-centered, interdisciplinary team approach to assess and manage pain, keep a pain log to assess effectiveness of treatment, reassess and evaluate compliance and presence of adverse drug effects (1)

Pharmacologic Pain Management:

  • Always consider age-associated changes of pharmacokinetics and pharmacodynamics , drug-drug, and drug-diseaseinteractions (1)
  • Older patients may have increased sensitivity to analgesic medications, lesser dosages and slower titration may be effective - especially true when using opioid analgesics (1)
  • Use equianalgesic dosing and the WHO three-step ladder to obtain optimal pain relief with fewer side effects (2)
  • Choose correct analgesic: start with non-opioid medications for patients with mild pain, advance to opioids for those with moderate to severe pain (consider underlying pathophysiology,medical history, comorbidities, drug interactions, heptic and renal functioning) (2)(1)
  • Anticonvulsants, steroids, topical local anesthetics, and antidepressants are adjuvant agents that may be used alone or in combination with non-opioid or opioid analgesics (1)

 Non-pharmacologic Pain Management:

  • Patient and caregiver education: information on nature of pain, medication use, coping skills, cognitive-behavioural therapy: therapist support, coping skills (1)
  • Osteopathic manipulative treatment: chronic pain management, holistic approach to care (1)
  • Physical therapy, occupational therapy, and participation in physical activity may be beneficial 

References

1.      Cavalieri, T. (2005). Management of Pain in Older Adults. JAOA, Supplement 1, 105(3), S12-S17. 
         Retrieved March 2014 from:  
         http://www.jaoa.org/content/105/3_suppl/12S.full.pdf+html

2.      Horgas, A., Yoon, S., Grall, M. (2012). Nursing Standard of Practice Protocol: Pain Management in Older Adults.
         Retrieved March 13, 2014 from:
         http://consultgerirn.org/topics/pain/want_to_know_more

3.      The Canadian Pain Society (2013). Pain in Canada Fact Sheet. Retrieved March 13, 2014 from:
         http://www.canadianpainsociety.ca/pdf/pain_fact_sheet_en.pdf

Additional Resources

1.     American Geriatrics Society. (2009).  Pharmacological Management of Persistent Pain in Older Adults.
        Retrieved March 13, 2014 from:
        http://www.americangeriatrics.org/files/documents/2009_Guideline.pdf

2.     Center for Nursing Excellence in Long-Term Care. (2014). Geriatric Pain. Retrieved March 13, 2014 from:  
        http://www.geriatricpain.org/Pages/home.aspx

3.     Molton, I., and Terril, A. ( 2014). Overview of Persistent Pain in Older Adults.  American Psychologist, 69(2),
        197-207. Retrieved March 2014 from:
        http://www.apa.org/pubs/journals/releases/amp-a0035794.pdf