Elsevier

Clinical Therapeutics

Volume 35, Issue 11, November 2013, Pages 1659-1668
Clinical Therapeutics

Review Article
Pain Management in Older Adults

https://doi.org/10.1016/j.clinthera.2013.09.026Get rights and content

Abstract

Background

Chronic pain is prevalent among older adults but is underrecognized and undertreated. The approach to pain assessment and management in older adults requires an understanding of the physiology of aging, validated assessment tools, and common pain presentations among older adults.

Objective

To identify the overall principles of pain management in older adults with a specific focus on common painful conditions and approaches to pharmacologic treatment.

Methods

We searched PubMed for common pain presentations in older adults with heart failure, end-stage renal disease, dementia, frailty, and cancer. We also reviewed guidelines for pain management. Our review encompassed 2 guidelines, 10 original studies, and 22 review articles published from 2000 to the present. This review does not discuss nonpharmacologic treatments of pain.

Results

Clinical guidelines support the use of opioids in persistent nonmalignant pain. Opioids should be used in patients with moderate or severe pain or pain not otherwise controlled but with careful attention to potential toxic effects and half-life. In addition, clinical practice guidelines recommend use of oral nonsteroidal anti-inflammatory drugs with extreme caution and for defined, limited periods.

Conclusion

An understanding of the basics of pain pathophysiology, assessment, pharmacologic management, and a familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Introduction

Pain is a subjective experience that can be challenging to assess and treat.1 This is particularly true for older adults, many of whom live with serious illness accompanied by significant pain and symptom burdens.2, 3, 4 The approach to pain assessment and management in older adults differs from that in younger adults. Older adults may underreport pain or may have difficulty communicating, and physicians may undertreat pain because of inherent biases and concerns about use of medications in older patients. Concurrent illness and comorbid conditions make pain evaluation and treatment more difficult and patients more likely to experience medication adverse effects.5, 6 In this article, we review overall principles of pain management in older adults and then specifically focus on common painful conditions and approaches to treatment based on a review of literature and 2 major pain guidelines.5, 7

Section snippets

Physiologic Changes Associated With Aging

The physiologic changes observed through aging are well described and are important when considering the pharmacologic management of pain. The body’s total water and lean mass decrease, whereas body fat increases, affecting volume of distribution, plasma concentration, and elimination of drugs. Bones and viscera shrink, and the basal metabolic rate decreases. These changes can be difficult to quantify and vary from person to person.8 Additional important changes in renal function, hepatic

Pain Assessment

A comprehensive pain assessment is key to effective pain management. Self-report provides the most accurate and reliable information. In studies that examine patient reports of pain, both clinicians’ and family members’ perceptions underestimate pain severity as reported by patients.14, 15, 16 There are indeed challenges in assessing pain in older adults, but these can be circumvented. Visual scales and assistive hearing devices can be used in patients with hearing impairment, whereas larger

Traditional Analgesics

The World Health Organization’s pain ladder is the most widely known model for pain management and provides a stepwise approach. The first step, for patients with mild pain, is the use of nonopioid medications, such as acetaminophen or NSAIDs with or without an adjuvant agent. The second step, for patients with moderate pain, involves adding a weak opioid medication alone or in combination with a nonopioid, with or without the use of an adjuvant agent. The third step, for patients with severe

Heart Failure

Heart failure is primarily a disease of older adults. Its prevalence increases with age, and 80% of heart failure patients are age >65 years.26 Not surprisingly, an increasing number of patients with heart failure have multiple comorbidities and high symptom burden.26, 27 Dyspnea and fatigue are the hallmarks of heart failure; however, data from the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT) of >9000 seriously ill adults 15% of whom had a

Conclusion

Pain is difficult to treat and a task made all the more challenging in older adults with chronic illness. An understanding of the basics of pain pathophysiology, assessment, and pharmacologic management and familiarity with common pain presentations will allow clinicians to effectively manage pain for older adults.

Conflicts of Interest

The authors have indicated that they have no conflicts of interest regarding the content of this article.

Acknowledgments

This work was supported by the National Palliative Care Research Center. Dr. Morrison is the recipient of a Mid-Career Investigator Award in Patient Oriented Research from the National Institute on Aging (grant K24 AG022345). All authors contributed equally to the literature search, data interpretation, figure creation, and writing of the manuscript.

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